A pinch of salt. A fistful of sugar. A half liter of water. It's a recipe 8-year-old Mee Akter recites easily while squeezing and scooping her tiny fingers through the air with precision, pretending to measure just the right amount of each ingredient. “You take the salt with three fingers,” says the little girl in a pink- and blue-ruffled dress, smiling shyly. “I learned it in school last year.” Over the past 30 years, this simple `poor man's Gatorade' has become a cheap, trusted home remedy passed down to generations of Bangladeshi moms nationwide. It is bought or whipped up and sipped down at the first signs of diarrhea to stave off dehydration, which can drain a weak child of life in just hours. Bangladesh, one of the world's poorest countries, is a leader in the fight against diarrhea, which is the number two killer of children under age 5 worldwide after pneumonia. Diarrhea claims 1.5 million kids annually -more than AIDS, malaria and measles combined - and the United Nations has projected the number of deaths will rise by 10 percent each year over the next decade. “When I talk to people in developed countries about diarrhea, they don't believe me when I tell them it's killing children,” says Dr. Olivier Fontaine, a diarrhea expert at the World Health Organization in Geneva. “We have the magic bullets, and now we need to apply them to make sure every kid has access. What we need is money to implement what we have seen in Bangladesh.” Rahima Begum, 45, was among the first to teach the homemade recipe to mothers 26 years ago in Borungo Khola village, a bucolic farming community down a dirt road about 40 km outside the capital, where little Akter is a neighbor. It was a time when parents had no idea what to do when diarrhea struck. If there was no hospital nearby, and usually there were not, many children simply died. “Spreading the message is very important,” Begum says. “We didn't know it, but now we do. Maybe people from Bangladesh can teach this to other countries.” At first glance, Bangladesh would appear to be an unlikely instructor. Bangladesh is a young democracy plagued by corruption and natural disasters, where nearly half the population lives on less than $1 a day. Yet the Muslim nation has vast experience beating back diarrhea tied to annual monsoon flooding, unclean drinking water and poor sanitation. Over the past two decades, its overall child death rate has dropped threefold to 5 percent today. Bangladesh is the birthplace of ORS, the lifesaving oral rehydration salt-sugar solution. Today, the concoction is so woven into the culture that it is not only mixed up or purchased for pennies to treat diarrhea and tummy aches, but guzzled by children and adults alike after working or playing outside in the sweltering heat. Bangladesh also is home to the International Center for Diarrheal Disease Research, which treats more than 100,000 patients a year at its hospital filled with hundreds of brightly colored diarrhea cots with holes in the middle opening to clear buckets beneath. Some 27,000 health workers have trained here from about 70 countries, and WHO regularly calls on its experts to help with global outbreaks of cholera, a fast-spreading watery diarrhea. “Almost everybody starts rehydration at home,” says Cathrine Costa, a nurse at the hospital where mothers, rich and poor, sit beside one another in open wards shoveling spoonfuls of a special rice gruel into the mouths of bare-bottomed babies, many malnourished. “If they don't, the dehydration is much, much worse.” Oral rehydration solution was first tested in the late 1960s in East Pakistan, which would later become Bangladesh. But the real experiment came in 1971 during a cholera outbreak in the refugee camps of West Bengal, India, which were crammed with families who had fled the war between East and West Pakistan. With a scarce supply of intravenous drips, doctors proved that by drinking the formula, the death rate could be reduced to below 5 percent. “These people were not getting drugs. They were not getting IVs. They were dying,” recalls Dr. Richard Cash, a Harvard University professor who conducted the first ORS clinical trials at the diarrheal research center. “We were not looking at failure. We were looking at measures of success.” Diarrhea is caused by viruses, parasites, bacteria and toxins. Rotavirus, spread through contaminated hands and surfaces, is the most common cause of diarrhea, killing half a million children annually. A vaccine is now available in the West, where the disease is a mere irritation, but it will not reach the poor for several years. Measles is another vaccine-preventable disease that causes severe diarrheal deaths. The ORS solution helps the gut absorb fluids and electrolytes that are rapidly being purged, bringing life back to children's sunken eyes and dehydrated skin. The recent addition of zinc further decreases the length and severity of the attack. Breast-feeding and continuous eating also are encouraged. The Bangladesh discovery was hailed by The Lancet medical journal three decades ago as “potentially the most important medical discovery of the 20th century.” Some 800 million ORS packets are produced worldwide today, saving more than an estimated 50 million lives. “You have a child that's almost dead, you give them ORS and within a few hours they are running all over the place. It's really a miracle,” says WHO's Fontaine. “We don't find anyone who would come as a champion for diarrhea. Many people are willing to go on TV and talk about AIDS, tuberculosis and malaria but when it comes to diarrhea, no one is interested.” Today Bangladesh has one of world's highest ORS packet usage rates, with nearly 70 percent of children drinking the solution during diarrhea. Yet WHO estimates the disease still kills more than 50,000 kids in Bangladesh annually, where ORS still does not reach everyone and malnutrition is rampant. Globally, about 60 percent of children do not have access to the formula. And in countries, mainly in Africa, where bouts of diarrhea are common, that rate is even lower. Last year, Zimbabwe experienced Africa's worst cholera outbreak in 15 years, killing more than 4,000 people. It is a statistic that makes Fazle Hasan Abed cringe. As founder of Dhaka-based BRAC, one of the world's largest non-governmental aid organizations, Abed trained a small army of women to spread the ORS recipe to millions of households across Bangladesh in the 1980s. “I know of nobody else who's tried to do this. Everybody came here and looked at the problem, and it was mind-boggling for them to think that one could go to every household and do it,” says Abed, who was recently knighted in England for his development work. “I think this could have a similar kind of impact in Africa.” He says the method of teaching mothers about ORS could be tried in a country like Uganda, where his organization already has a presence. But he adds that Bangladesh does have some advantages. Roughly the size of the US state Iowa, the low-lying nation is one of the world's most densely populated countries, crammed with about 150 million people, or half of the entire US population. That makes the task of spreading a message from community to community easier and cheaper as opposed to reaching sparse, spread-out villages dotting many African countries. Another obstacle in Africa to the community-based approach is the belief in some places that only health workers can provide medical care. WHO is working to distribute packets of ORS to every market in Tanzania, as is done in countries such as Mexico. In many cases, the sachets are cheaper than coveted sugar in African countries, making the pre-made pouches a smarter choice than the homemade sugar-salt solutions, which can kill children if too much salt is given. In Bangladesh, mothers were taught that the oral formula was not a cure, and if a child continued to suffer severe diarrhea after a day of drinking the ORS, a trip to the hospital was urgent. It is a message that has been retained and transferred to even the youngest members of the village, where the sugary drink is lapped up like Kool-Aid. “My 7-year-old little boy was sick with diarrhea one month ago,” says Taslima Akter, 28, who demonstrated how to make ORS in Borungo Khola village, where three generations know how. “I mixed it up at home. It was not serious, just one day. I used to take it when I was a kid.”
