An Ounce of Clean Water

You wouldn’t know it now, but the bacterium that causes cholera is a surprisingly flimsy organism. This scourge that kills thousands every year and has terrified many millions is actually quite easy to kill. A low dose of chlorine will do the trick. Even a little citrus juice to bring down the pH a bit will work. In fact, the acidity of the stomach will kill the vast majority of V. cholerae that a person ingests. It is far easier to kill than enteric viruses, parasites, and most bacteria.

But if you don’t kill it, cholera will not be interested in doing you the same favor. Thank god for Oral Rehydration Therapy (ORT). This simple and cheap cholera therapy composed of water, glucose, and salts has completely changed the outlook towards cholera treatment. What used to be an expensive and grueling intravenous rehydration process has been simplified so that the cost of the therapy itself is almost not an issue. If an infected person can get to a site with oral rehydration salts, that person has a very good chance of surviving.

I have been amazed recently to learn about the mechanism for ORT. I had always assumed that it was a simple replenishment of lost fluids and nutrients due to severe diarrhea. This is pretty far off. I won’t get into the details, but suffice it to say that ORT replenishes lost fluids and electrolytes through a complex mechanism that requires a significant understanding of human physiology.

Yet the beauty of ORT lies not in its hidden complexity, but in its outward simplicity. There are plenty of medications with equally intricate pathways. ORT is distinguished from these other therapies by the ease with which it can be implemented, even in the most resource poor settings. How many medical treatments can boast to have saved so many lives using such simple ingredients as water, sugar, and salts?

Unfortunately, as we all can see on the news, even something so basic as ORT can be out of reach in a place like Haiti. If we could dedicate the same brilliant scientific effort that led to the development of ORT to the development of simpler, cheaper, and more efficient water treatment strategies, we would be far better off. Rather than grapple with V. cholerae when it has already taken a hold in someone’s body, we can attack it while it is weak and susceptible to the simplest treatment methods.

I am not saying anything new. But I am frustrated to see how good medicine is at addressing an illness when it has already begun and how much more we should be doing to prevent this illness from occurring in the first place. I know first-hand that it is difficult to effectively implement a safe drinking water intervention, but I am sure we could have done more to provide clean water to Haitians months or years ago, possibly preventing the current epidemic or at least diminishing its impact.

The challenge will not be in finding ways to produce clean water—we already know how to do that very well—but in finding new ways to provide that water cheaply and in an appealing way. I hope people will take the ORT approach to address this challenge: Combining sound science with an awareness of the need for simple and cheap interventions for low-income settings.

Idealism in the Real World

For my first blog entry ever, I’ve decided I would write something a little controversial and maybe even combative towards another blogger, you know, just to make sure things get off on the right foot.

No better target than Lakshmi Krishnan.  The other day, in the break between a lecture on multiple sclerosis and another on brain tumors, I happened to stumble into a conversation Lakshmi was having with a fellow classmate, Michael, who was arguing that the “human right” to healthcare is not innate, but bestowed upon a people by its government. Lakshmi conceded that in reality, governments have the most control over what healthcare their people have, but there are still certain rights to which everyone is entitled. Before I go on, I should clarify that most of our conversations deal more with topics like the latest episode of Jersey Shore or how much cream cheese we like on bagels than high-brow philosophy, but that morning was an exception. I of course jumped in.

“What does it even mean to have a right to healthcare?”

If I were a more eloquent person, I might have said that, while it would be great if everyone in the world has perfect health, that is clearly not possible. So what do we define as access to good healthcare? Does it mean that everyone in the world must have a free pass to the Mayo Clinic, or does it mean that everyone receives their basic childhood vaccines and maybe has access to a clinic staffed by a community health worker 10 miles away? Because in two different parts of the world and two different social classes, both of these conditions might meet the qualifications for good healthcare.

I think this is a nice argument, and in part true. But it fails to get at the root of what made me uncomfortable with the discussion Michael and Lakshmi were having. Because my real problem wasn’t that I thought Lakshmi or Michael was wrong, but that the argument seemed irrelevant.

This apparent irrelevance was underlined for me the next day. I received a call from Ecuador. It was Heriberto Napa, the director of Agua Muisne’s (www.WaterEcuador.org) work in Ecuador. He called to update me on a situation that had been developing over the past couple weeks. The Health Commissioner for the Province of Esmeraldas had been threatening to close Agua Muisne’s water treatment plant in Mompiche. He claimed to have ordered tests of water from this plant that had come back with coliform bacteria. He refused to provide any documentation of these tests, but he maintained that the water system would have to be closed down. It did not matter that the tests Agua Muisne’s workers had taken themselves had come back free of bacteria, or that our purification process used reverse osmosis and chlorination, two highly reliable sterilization methods.  The Health Commissioner also did not appear concerned that the Agua Muisne water plant was the only affordable source of treated water for Mompiche.

It took awhile for Heriberto to get around to the crux of the issue, but eventually he said that the Health Commissioner had said he would have to pay a fine to avoid being shut down. Given the circumstances of this request, it did not take a large leap to conclude that the Commissioner’s “fine” was really a demand for a bribe. Heriberto knew it, but had refused to pay anything pending a meeting this coming week in the provincial capital.

I don’t know what the outcome of this particular incident will be.  But the countless repetitions of corrupt acts like this have already had a crippling impact on attempts to improve the health of the developing world. Corruption, at the local, national, and international levels, is the single greatest impediment to implementing public health programs in poor countries. And in my own limited experience in public health circles in the United States, it appears to be largely disregarded or ignored.

Over the time I have been working in Ecuador, I have experienced corruption in many forms. I’ve seen it from foreign NGOs, police, municipal administrators, customs officials, and even clergy. At times it has been a minor annoyance, but it has also caused severe impediments that almost ruined some of our projects. It’s easy to be jaded when efforts born of idealism are blocked by greed.

So is there any point in arguing about the existence of a “human right to health” when the biggest challenges to improving the health of people around the world are so much more banal?

Well, yes, I think there is. Although we must keep in mind the practical challenges to improving the world’s health, it is still important to hold onto ideals about how the world should be. These ideals are what must drive us to overcome the frustrations and failures that inevitably accompany public health efforts in the real world. The human right to good healthcare is worth the fight. And as always, Lakshmi was right in the end.