OBITUARY: RICHARD CASH
A ProMED-mail post
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International Society for Infectious Diseases
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Date: Sat 2 Nov 2024
Source: New York Times [edited]
https://www.nytimes.com/2024/11/02/science/richard-cash-dead.html
Richard A. Cash, who as a young public-health researcher in South Asia
in the late 1960s showed a simple cocktail of salt, sugar and clean
water could check the ravages of cholera and other diarrhea-inducing
diseases, an innovation having saved an estimated 50 million lives,
died on 22 Oct 2024 at his home in Cambridge, Mass. He was 83.
His wife, Stella Dupuis, said the cause was brain cancer.
In the 1960s, diseases like cholera and dysentery killed some 5
million children worldwide per year, primarily through dehydration
caused by diarrhea and vomiting. Patients could go “from a grape to a
raisin” within hours, Dr. Cash often said.
It was widely understood rehydration could save many of them, but it
was easier said than done: intravenous drips, the standard method,
required equipment, training and clinical settings that were often
hard to come by in the impoverished communities where the diseases
festered.
Dr. Cash, the son of a doctor, arrived in East Pakistan, today
Bangladesh, in 1967 as part of a project through the U.S. Public
Health Service. There he worked with another young American doctor,
David Nalin, to respond to a cholera outbreak outside the capital,
Dhaka.
The 2 had already been researching a simple oral rehydration therapy
and knew of other, previous efforts, all of which had failed. But they
believed the therapy held promise, especially in the face of mounting
deaths.
They realized a main problem was volume: Past efforts had resulted in
too little or too much hydration. Dr. Cash and Dr. Nalin conceived a
trial in which they carefully measured the amount of liquid lost and
replaced it with the same amount, mixed with salt and sugar to
facilitate absorption.
They divided 29 patients into 3 groups, with one group receiving an IV
drip, another an oral treatment through a tube, and the third an oral
treatment by drinking from a cup.
Other doctors and nurses found their experiment bizarre and tried to
stop them. But Dr. Cash and Dr. Nalin persisted, splitting the work
between them in 2 12-hour shifts, to ensure the integrity of the
trial.
The results were definitive: Only 3 of the tubed patients — and only
2 who drank the solution — needed additional IV treatment.
Their approach was put to the test in 1971, when Bangladesh’s war of
independence drove tens of thousands of refugees into camps across the
border in India. Cholera and other diseases soon spread rapidly.
An Indian pediatrician helping with the response, Dilip Mahalanabis,
made oral rehydration a cornerstone of his strategy, with astounding
success — proof for all the world a simple solution could be brought
to bear against one of the world’s greatest killers.
Dr. Cash and Dr. Nalin then worked with a local nonprofit, the
Bangladesh Rehabilitation Assistance Committee (today known as BRAC),
to teach Bangladeshi mothers how to administer the treatment at home.
The organization even devised a song about it, with these lyrics:
Mix with much care,
Good water, a liter,
A pinch of salt with a fistful of gur [molasses],
Remove the menace for good
They ultimately trained some 12 million Bangladeshi parents. Diarrheal
deaths plummeted. What began as a medical trial is, today, common
knowledge in homes across that country, and the world.
“One could say, well, where did the folk wisdom for chicken soup and
colds come from?” Dr. Cash said in a 2018 talk at the Council on
Foreign Relations. “Probably a similar approach was used.”
The World Health Organization estimates oral hydration therapy has
saved more than 50 million lives, a majority of them children. In
1978, the British medical journal The Lancet called their innovation
“potentially the most important medical advance this century.”
Richard Alan Cash was born on 9 Jun 1941, in Milwaukee, Wis., to
Irving and Isabel (Cohen) Cash. His mother taught deaf children while
his father was an internist and gastroenterologist.
Richard graduated from the University of Wisconsin-Madison in 1963 and
received his M.D. from New York University in 1966.
A pacifist, he joined the U.S. Public Health Service as an alternative
to joining the war in Vietnam and soon found himself in South Asia.
In 1977, he joined the faculty at the Harvard School of Public Health
(today the Harvard T.H. Chan School of Public Health) as a lecturer, a
position he held at his death.
Along with his wife, Dr. Cash is survived by 2 stepsons, Alexander and
Krister Weidenhielm; 2 sisters, Kathy and Ellen Cash; and 4
step-grandchildren.
Though his base of operations shifted to Harvard, Dr. Cash continued
to spend as much time as he could in the field, including making
annual trips to Bangladesh.
He continued to emphasize the importance of local, low-tech
public-health efforts; especially in lesser-developed regions, he
said, simple solutions are always better than big, complicated ones.
“We’re enamored by high technology,” he said at the Council on Foreign
Relations. “And we’re not in love with low-tech. Low-tech is always
seen in our eyes as 2nd-class. Why would you do this, when you could
do that? And I would argue just the opposite.”