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Lost in translation-lessons from cholera

Ami Banerjee
Last edited 10th June 2009
The recent cholera outbreak is the worst in Zimbabwe's history, infecting 66,000 people with over 3,300 deaths [1, 2]. Last week, a Red Cross worker wrote a diary from Zimbabwe for the BBC [1]. Despite technological advances it revealed the desperate circumstances under which people are providing and receiving health care in parts of the world, even when the evidence for cause and cure is beyond doubt. Cholera was originally restricted to the Indian subcontinent and spread along trade and migration routes to the rest of the world in the early 19th century. Between 1816 and 1923 there were six cholera pandemics which killed millions worldwide. The seventh cholera pandemic in the 1960s rampaged across Indonesia, Bangladesh and India, and since then outbreaks have only occurred in impoverished, politically unstable countries in Africa. John Snow, a British physician considered by many to be the founding father of epidemiology, published his essay, 'On the Mode of Communication of Cholera', in 1849 [3]. During a cholera outbreak in Soho, London in 1854, Snow was able to trace the outbreak to the infected water pump in Broad (now Broadwick) Street, proving that cholera was a waterborne disease, and triggering the sanitary revolution in the industrialised world. 3000 years ago the Indian physician, Sushruta, advocated the use of rice water and carrot soup for the treatment of cholera [4]. In the 1830s, dehydration was recognized as the cause of death in cholera and intravenous salt solution was tested as a therapy with good results. In the 1950s, physiological research showed that salt and glucose are transported together, underpinning the formulation of oral rehydration therapy (ORT). In the first clinical trial of ORT, published in 1968, an oral solution containing glucose and salts was given to patients with acute cholera in rural Bangladesh. In comparison with control patients who received only intravenous fluid replacement, the patients who received the oral solution required 80% less intravenous fluids for cure [5]. Over the next 20 years ORT became the mainstay of treatment of cholera and diarrhoea worldwide and the sachet-form became compulsory in the first-aid kits of Western travelers. The story of cholera is an exquisite example of how simple therapies can be rolled out to all parts of the world, but illustrates how painfully long it can take for evidence to be translated from “the bench to the bedside”. Translational research is an extension of evidence-based medicine, but even after translation, the political, economic and social situation in an area can prevent implementation of good health care, as in Zimbabwe, and thousands of lives are lost to a disease which we have known how to cure for over 40 years.
  1. Zimbabwe aid diary: Fighting cholera. http://news.bbc.co.uk/1/hi/world/africa/7871949.stm
  2. Kapp C. World Report: Zimbabwe's humanitarian crisis worsens. Lancet 373: 447.
  3. Snow J. On the Mode of Communication of Cholera. 1849 http://www.ph.ucla.edu/epi/snow/snowbook.html
  4. Cunha Ferreira RM, Cash RA. History of the development of oral rehydration therapy. Clinical Therapeutics 1990. 12(Supplement A):2–11.
  5. Nalin DR, Cash RA, Islam R, Molla M, Phillips RA. Oral maintenance therapy for cholera in adults. Lancet. 1968. 2:370-3.

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