Dr Dilip Mahalanabis (1934-2022): The Underappreciated Breakthrough Use Of A Simple Oral Solution That Saved Countless Lives

A stalwart of Indian public health is no longer with us.

Dr Dilip Mahalanabis passed away 16 October 2022, a month shy of turning 88 years old.

He pioneered the proper practical, emergency use of oral rehydration solution, commonly known by its abbreviation “ORS,” for diarrhoeal diseases.

Diarrhoea is defined as the passage of three or more loose or liquid stools per day.

Because it can lead to life-threatening dehydration and electrolyte loss, the dangerous loss of fluids from the body needs to be averted fast. Otherwise, it can quickly turn into a death sentence, as it often did in the past. 

Diarrhoea was among the leading causes of child deaths in developing countries in the twentieth century. In 1975, for instance, it was estimated that 500 million episodes of diarrhoea in children below age five in Asia, Africa, and Latin America resulted in five to 18 million deaths.

It is here that ORS came to the rescue, and remarkably so.

An estimation of lives saved, particularly of kids, by the use of ORS often runs into tens of millions. One estimate pegs it at 70 million since the 1970s.

“We may never know the true number of deaths averted from ORS, an incredibly cost effective health intervention. But it’s certainly substantial,” Brian Wahl, an epidemiologist with The Johns Hopkins Bloomberg School of Public Health's Department of International Health, said in a tweet.

It was substantial enough that in August 1978, just over a decade after the original discovery in 1964, ORS was already hailed as “the greatest medical discovery of the 20th century” in the premier medical journal The Lancet.

The development of ORS therapy emerged from an effort, in 1962, to treat cholera-induced diarrhoea, which was claiming thousands of lives globally during seasonal epidemics.

Although a treatment did exist since the 1920s — in the form of rehydration with hospital-administered intravenous solutions, it necessitated hospital infrastructure and wasn't spot on with respect to what the body lost due to diarrhoea and what and how much was replenished in turn.

The treatment was also expensive, and was away from the reach of regions where diarrhoea wrecked most havoc.

The 1960s effort sought a more effective and, more importantly, accessible solution.

After the work took off early in the decade, it took less than six years to “overturn the medical establishment's paradigm for diarrhoeal treatment,” as Joshua Nalibow Ruxin writes in his history of the therapy.

The medical innovation was built on prior research work carried out by such scientists as Dr Daniel Darrow of Yale University, several sugar-sodium physiologists like E Riklis, J H Quastel, and Robert K Crane, and Dr Robert A Phillips.

Dr Phillips was the first to show that oral therapy would work on cholera patients.

While much of the 1950s and 1960s hosted efforts more academic in nature, researchers began to find success in field trials in 1968.

East Pakistan’s Matlab Bazaar was in the middle of a cholera epidemic and did not have the means to counter it. An oral rehydration therapy (ORT) protocol, written by Doctors Richard Cash and David Nalin, was then put to work against much headwind. It yielded very good results.

“Most significant was their proof that oral rehydration therapy was a practical treatment which could be used to treat large numbers of patients in primitive conditions where little intravenous therapy was available,” Ruxin writes.

In Matlab, ORT turned out to be effective in adults as well as children, in non-cholera diarrhoeal patients as well as cholera patients.

The ground was, thus, laid for Mahalanabis to step in and pull off an extraordinary feat.

It was the time of the 1971 Bangladesh War of Independence, where refugee camps were filled to the brim.

A full monsoon season in between meant that the situation was even more complicated. Cholera had broken out, and the refugee shelter areas were overrun with vomit and faeces, especially on the Bongaon border area.

In this most trying of circumstances, while physicians scrambled to save lives, ORS was administered in very large numbers — and, remarkably, by family members of the patients themselves!

The ORS delivery was Mahalanabis’ second line of attack after supplies had run dry and the administration of intravenous solution, which at the time was the go-to method in such a crisis scenario, had hit a dead end of sorts.

Since ORS was yet to receive global acknowledgement — and this would surprisingly take a while — the government medical team was sceptical and even tried to stop Mahalanabis.

But he took a risk — “if even one person could be saved,” as reported by Dipankar Bhattacharya in the Bengali-language newspaper Anandabazar Patrika (16 June 2019).

More than 3,000 people with cholera received ORT in this way.

It worked! And that it did in a public health emergency where so many lives were at stake paved the way for ORS to be taken more seriously — especially by global public health organisations — and later adopted on a larger scale.

The simple solution consisting of sugar, salts, and water had helped save the lives of severely dehydrated adults, children, and infants in Dacca, East Pakistan (now Dhaka, Bangladesh), and Calcutta (now Kolkata), India.

“...in just a few months the case-fatality ratio from cholera and cholera-like diarrheal diseases fell below 4% among the people treated with ORT, as compared with the 30% ratio observed previously,” researcher Bernadeta Dadonaite writes for the website ‘Our World in Data’.

There was no looking back for ORS thereafter. The use cases only expanded. Though there is a long line of researchers and physicians to whom credit is due, Mahalanabis is definitely near the top of that line.

“Cash and Nalin's work is tremendous, and I'm not denigrating that at all, but the Mahalanabis one turned me on,” Dr Alex Langmuir, who provided crucial support to the Matlab study, said in an interview in February 1992.

Mahalanabis’ work was taken forward in the 1970s by physicians like Norbert Hirschhorn. Though delayed, ORT came to be acknowledged eventually as superior to intravenous treatment.

Contrast the ease of orally administering a simple solution at home to the administration of saline solution intravenously in hospital settings. Looking at it another way: what’s better than a parent being able to administer a quick and simple solution to their sick child?

Yet the West scratched their heads for at least two decades about whether to embrace oral therapy. The "developing" world was smarter.

From 1980 to 2000, a period which corresponded with the rise in ORS use worldwide, deaths from diarrheal diseases in children fell from 4.8 million deaths every year to 1.2 million.

Though the number of children dying from diarrheal diseases — close to half a million yearly — would still count as high, it has actually fallen by a substantial two-thirds since 1990.

Even now, there’s potential to further maximise ORS adoption worldwide.

The Highlights

Mahalanabis was born on 12 November 1934 in East Bengal (now Bangladesh). He studied medicine and specialised in paediatrics in Calcutta (now Kolkata) before continuing his academic journey in the United Kingdom (Queen Elizabeth Hospital for Children, London) and United States (Johns Hopkins University).

His work with Johns Hopkins researchers continued back home in Calcutta, India, and it pertained to ORT for diarrhoeal diseases.

This early work became a cornerstone of public health over the next couple of decades, saving children’s lives through the use of 500 million ORS packs annually in over 60 developing countries.

Mahalanabis founded the research organisation Society for Applied Studies (SAS) in West Bengal in 1990. With a vision of better health and quality of life, especially for women and children, the institution later expanded to include the New Delhi-based Centre for Health Research and Development, Society for Applied Studies (CHRD-SAS).

Prior to establishing SAS, Dr Mahalanabis worked on the World Health Organization’s Diarrheal Disease Control Programme and thereafter served as the Director of Clinical Research at Bangladesh-based International Centre for Diarrhoeal Disease Research.

Mahalanabis became a member of the Royal Swedish Academy of Sciences, which is directly responsible for awarding three of the five Nobel prizes, in 1994.

He received first-ever Pollin Prize for Pediatric Research (2002), administered by NewYork-Presbyterian Hospital, along with other ORT pioneers.

Four years later, he received the Prince Mahidol Prize along with Drs Nalin and Cash for their work on oral therapy.

The public health legend passed away in Kolkata on 16 October, but he lives on through his legacy of saving countless lives.