Cholera like typhoid is restricted to humans, spreads through fecal oral transmission, and is endemic in Nepal. The bacteria, vibrio cholerae, produces a potent toxin which may lead to severe dehydrating diarrhoea and death within 12 hours. Clinically, however, a cholera-bug infected person may span a spectrum from being an asymptomatic carrier to a severely debilitated patient.
During the 19th century, cholera pandemics killed millions across Asia, Europe, Africa, and North America. The disease was given the nickname ‘Blue Death’ because extreme dehydration caused the skin to turn grayish-blue. Even today Africa and Asia have the highest numbers of reported cholera cases. In January 2010, the disease resurfaced in Haiti after more than a century following the devastating earthquake. The outbreak claimed more than 8,000 lives in Haiti and was embarrassingly traced back to the Nepali peacekeeping base.
Almost 70 per cent of cholera patients succumb to the disease and the main reason for this is volume depletion brought on by the vibrio toxin which triggers a rapid outpouring of fluid into the intestine from the cells lining the gut. Because our bodies are 60 per cent water, cholera diarrhoea feels like a sponge being wrung out. The watery diarrhoea called ‘rice water’ (‘chaulani’) refers to the appearance of water after soaking rice. Because we are voracious rice eaters, most Nepalis have no problem in recognising ‘chaulani’. However, drinking water to replace fluid loss is no good because the intestine in a patient with cholera won’t absorb plain water.
Beginning in the early 1900s, the administration of intravenous fluids helped slash mortality rates to 30 per cent. But it was engineers like Joseph Bazalgette from the UK, who really made a difference in lowering death rates in the western world. Bazalgette built interceptor sewers along the banks of the Thame in the late 1800s that took care of fecally transmitted diseases like cholera.
But how did poorer countries deal with cholera at the time? Unfortunately, millions of people especially children continued to perish globally even when patients made it to hospitals or clinics because intravenous tubings, volumes of sterile fluid, and needles were unavailable or expensive. The work of Bazalgette and others had not yet started to make an impact in the developing world.
Almost six decades late in the 1960s two resourceful American researchers, David Nalin and Richard Cash, based in Dhaka (in what was then East Pakistan) during a cholera epidemic revolutionised treatment. At this time other scientists had discovered that sugar helps the gut absorb water. Nalin and Cash decided to test this hypothesis by giving patients an oral rehydration solution containing sugar as well as salt, effectively ‘noon chini pani’ as we know it in Nepal. Many people doubted this would work because the victims would have to drink many litres of this solution every day. Amazingly, after the patients consumed vast quantities of the fluid, they no longer required intravenous fluids. This solution provided a crucial breakthrough in the treatment of cholera, but the story gets even more interesting.
After Bangladesh’s war of independence in 1971 caused thousands to be displaced, a cholera epidemic broke out at a refugee camp of 350,000 in West Bengal, India. Due to the severe shortage of intravenous supplies in the camp, medical director Dilip Mahalanabis had no choice but to try the ‘noon chini pani’ Dhaka solution. The results from the oral rehydration were startling: instead of the usual 70 per cent casualty rate, only 3 per cent died. The take home message: if cholera victims are alert, able to drink ‘noon chini pani’ in large quantities, they can save their own lives.