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 Prologues of Public Health



by Sally McGrane



The scarcity of IV fluids (above) forced scientists to try a new oral solution against a cholera epidemic raging among 9 million refugees near Calcutta in 1971. (Photo: Thomas Simpson)

On a sultry June evening in 1971, Thomas Simpson, MD, and his wife Doris celebrated their 30th wedding anniversary with a lively dinner in the private garden of their flat in Calcutta, India. Celebrating with them were professional staff, both American and Indian, from the Johns Hopkins International Center for Medical Research and Training (ICMRT) in Calcutta, a joint project of the School of Public Health and the School of Medicine, which Simpson led as resident coordinator. Seated on a porch where the Simpsons were sometimes visited by vagabond snake charmers, keepers of trained monkeys, and multitudes of stray cats, the party dined on lamb shish kabob with rice and red pepper sauce. The summer monsoon season had started, and the mosquitoes were out in force.

Conversations during an anniversary dinner on his Calcutta porch gave Thomas Simpson an idea for solving the cholera crisis. (Photo: Thomas Simpson)

While the occasion for the dinner was a happy one, much of the night’s discussion was not. Early in the year, an independence movement in East Pakistan (now Bangladesh) had been brutally put down by the West Pakistani army. A massacre of the educated middle and upper classes—including doctors, professors, and students—ensued. Terrorized survivors fled the country and poured over the border into India; by June 2, as many as 9 million refugees were amassing near Calcutta.

The discussion at dinner centered on reports from the camps: horribly overcrowded conditions, with almost no sanitation. Refugees had no shelter from the monsoon rains. Some families were constructing houses from sections of sewer pipes. “There was nothing but privation and injuries,” remembers Simpson, now an associate professor emeritus at Hopkins. Worst of all, India’s annual cholera epidemic had begun.

The cholera—an extreme form of diarrhea—already had a fatality rate of 80 percent in the refugee camps (under normal circumstances, it was 30 to 40 percent). The health professionals at ICMRT knew, perhaps better than anyone, how bad the situation was. Research on cholera had been one of the Center’s main projects since its inception in the early 1960s. While effective intravenous (IV) treatments—which could drop fatality rates to under 1 percent—had been successfully developed, the chaotic, destitute, and nearly inaccessible camps precluded treating a massive outbreak among the refugees with IV fluids.

After his dinner guests had left, Simpson went to bed worried. In the night, he woke and remembered another conversation that had taken place at dinner. It involved the results of a test in another cholera research lab in nearby Dhaka, East Pakistan. The team there had successfully completed a clinical test of an oral, rather than intravenous, treatment for cholera using a simple solution of water, glucose, and salt. Because the Dhaka team’s experiment had been conducted under much more favorable, controlled conditions, with plenty of IV fluids available as back-up, no one at dinner had drawn a link between the clinical trial’s results and the refugee crisis.             

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