In pursuit of “humanitarian science”BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7427.1308 (Published 04 December 2003) Cite this as: BMJ 2003;327:1308
In the late 1960s a research institute in Bangladesh pioneered a treatment that has saved 40 million lives worldwide. What happened next? David Sack explains
“We ought to pass a UN resolution that no country should be allowed to make a nuclear weapon until its infant mortality rate has dropped below 30 [per thousand].” Dry humour from Professor David Sack, as he points out how different countries—Pakistan and Bangladesh, in this case—have different priorities. Pakistan possesses the bomb, but Bangladesh, though poorer, and without nuclear weapons, has fewer deaths in infancy.
As director of the International Centre for Diarrhoeal Disease Research in Dhaka, Sack rejoices in the positive things he can say about Bangladesh, a country often dismissed as one of the world's basket cases. Sack views it in a more sympathetic light. “I often say it's one of the most successful nations. Nowhere else is there a piece of land that supports so many people with such little adverse impact on its ecology.”
The centre itself is descended from the Cholera Research Laboratory set up in 1960 by the South East Asian Treaty Organisation. It runs hospitals and clinics in Dhaka and elsewhere, does research, and was the first—and remains the only—international health research organisation based in a developing country.
It adopted its current name exactly 25 years ago. This is an anniversary that has offered a focus for Sack's recent fundraising visit to Britain. In fact there's far more substance to the centre's success than mere survival. Among its best known achievements is the development of oral rehydration with a solution of salt and sugar, a method reckoned to have saved more than 40 million lives around the world.
“Intravenous therapy for cholera was perfected in the mid-sixties,” says Sack. “So then we had a good treatment, and I suppose things could have been left there.” It was people working in the field who appreciated the need to find something simpler. So the research continued.
“We had some anniversary celebrations at the centre recently,” he adds. “I asked one of the nurses who's been there for years how many lives she's saved. ‘Oh, I don't know,’ she said, ‘a few thousand I suppose.' Every day she comes to work she probably saves five or six people who would have died if she couldn't offer the appropriate treatment.” The centre has estimated that the average cost of each child's life saved at the centre is £100 ($172; €;143), somewhat less than the cost of each life saved at London's Great Ormond Street Hospital for Children.
Oral rehydration is an outcome of one of the centre's key objectives: the promotion of “humanitarian science.” This does not exclude high tech research: witness the centre's work on DNA sequencing. Rather it's about what Sack describes as doing things with a purpose. “We try to prioritise our research efforts according to what we see in the field. We may be doing a good job taking care of children—for example, identifying new vaccines and so on. But then we realise that 70% of infant deaths occur during the first 28 days, and most in the first three. All the vaccines in the world aren't going to help children dying then.”
Thinking of this kind explains why the centre originally broadened its activities beyond cholera. With the rise of respiratory infections as a common cause of death, it made little sense to view diarrhoeal disease in isolation from all other conditions. The centre now likes to style itself “International Centre for Diarrhoeal Disease Research in Dhaka: Centre for Health and Population Research.” A mouthful, but one that makes the point. It does retain an interest in diarrhoea, most recently showing how zinc can shorten current episodes of illness and protect against future ones.
The realignment of priorities continues. HIV, for example, has risen up the agenda. “Many of the policy makers,” says Sack, “have felt that an Islamic country is immune to it [HIV] because of the behaviour of good Muslims. And if we were all good Muslims or good Christians that might be the case. But people are people. Bangladesh has had a low prevalence up to this point. Now we're seeing an epidemic in the injecting drug population.” He fears that Bangladesh may soon catch up with other countries.
David Sack is on loan from Johns Hopkins University Medical School, where he'll eventually return. His very first job, in 1969, was also at director level: running the Indian Health Center in Lame Deer, Montana. Why that job? “It was a good time not to be in the military,” he explains. An alternative, in other words, to Vietnam.
Looking after the health of 3000 people on a reservation in Montana is hardly the same as working in a developing country, but there are parallels. So did the experience trigger Sack's interest in the infectious diseases of faraway places? “I hadn't thought about that. But it probably did.”
Montana was followed by three months as a volunteer physician in Zaire. “I've often said that we went to Africa to get the travel bug out of our systems. It didn't work.” Back in the United States he joined Johns Hopkins and went on to do two separate three year stints in Dhaka before returning again in 1999 as director of the centre, where he's now into his second term of office.
“It's a country with a lot of frustrations. You keep thinking if they just did this or that better then they'd move ahead more quickly. On the other hand there are tremendous opportunities. And they do innovate. The infant mortality has come down from 130 to 70 nationally [since 1977], and in our area it's about 45. Either because of or in spite of the system, things do happen.”
As for Sack's own motives, they're partly intellectual and partly the thrill of a challenge. But there's also that idea of science being guided by humanitarian principles. “Finding new knowledge is nice, but if you do it with a purpose it's even nicer. And I do have religious feelings about why we're here on Earth. Bangladesh is an exciting place to be.”