The world's leading 'cholera hospital' looks to the future

DHAKA, Bangladesh — On a humid afternoon outside the world’s largest diarrheal disease hospital in Bangladesh’s capital, a constant stream of patients is seeking urgent medical care. Some of the new arrivals rely on friends and family to carry them through the doors, while the most feeble are wheeled inside on stretchers by medical staff.

It is understandable that many locals simply refer to the building as the “cholera hospital” instead of using its official name, icddr,b, or the International Centre for Diarrhoeal Disease Research, Bangladesh.

The organization’s three hospitals across Bangladesh treat up to 40,000 patients with cholera each year, according to professor John Clemens, executive director at icddr,b. At certain points during the year when the rains surge and temperatures increase, up to 1,000 patients are admitted each day in Dhaka.

“It’s fair to say there’s no place in the world that’s treating more cholera patients than what we do,” Clemens said.

As one of the world’s leading international public health research institutions, icddr,b has more than 4,000 employees. Since its foundation, the institution’s history has been closely intertwined with the history of cholera research.

Globally, there are between 1.3-4 million cholera cases each year, and up to 143,000 deaths. Cholera is endemic in Bangladesh and each year there are at least 100,000 cases and approximately 4,500 deaths across the country.

The center was initially founded in the ‘60s as the South-East Asia Treaty Organization cholera research laboratory in Dhaka. It quickly came to the forefront of treating cholera after its researchers, along with their colleagues at the Johns Hopkins Center for Medical Research and Training in Kolkata, India, developed an oral rehydration solution to treat cholera.

The solution, a mixture of sugar, salt, and water, went on to be adopted by the World Health Organization as the primary tool to fight the disease. The simple treatment has saved an estimated 50 million lives globally.

In its early years, icddr,b was also deeply invested in testing injectable cholera vaccines. It later hosted one of the first trials for an oral cholera vaccine in the ‘80s. More recently, it developed the first oral cholera vaccine, which WHO stockpiles to prevent and treat cholera outbreaks across the world.

Countless health workers in the field also rely on icddr,b’s expertise, particularly in challenging public health situations.

The institute regularly dispatches experts to countries experiencing cholera outbreaks, where local health care providers have limited experience in dealing with the disease. To this end, icddr,b has trained hundreds of local health care workers in various humanitarian crisis zones such as Yemen, Syria, Iraq, and Somalia.

Although cholera is the disease that led to icddr,b’s international recognition, the center continues to expand its research areas.

Innovation is key

The center’s current key research themes include maternal and neonatal mortality, maternal and childhood malnutrition, enteric and respiratory infections, emerging and re-emerging infections, and universal health coverage.

“Our interventions are cheap, feasible, and acceptable. These three principles have pretty much guided us in what we do in developing innovation,” Clemens said.

One example is icddr,b’s activity in the field of ready-to-use therapeutic food, made of locally available ingredients. Ready-to-use food is an effective way of treating children with severe acute malnutrition, but because of its high price, it is out of reach of many countries with a high burden of malnutrition. Using cheap and widely available local staple items, icddr,b has developed an alternative formula that could bring production costs down to a quarter of the current price.

Another low-cost health intervention is in the field of maternal health.

Icddr,b designed the Q-mat, a low-cost, biodegradable birthing mat that helps to identify cases of postpartum hemorrhage that occur at home. The mat can be used by untrained health care providers, and follows a simple concept: If the mat can’t absorb all the blood a woman loses during childbirth, the mother has excessive bleeding and needs to be immediately transferred to a health clinic.

The birthing mat is currently distributed by several NGOs throughout Bangladesh as part of safe delivery kits, and costs $0.80 to manufacture. It is hoped the simple innovation will be scaled up and made available in other countries experiencing high rates of postpartum hemorrhage.

Dr. Shams el Arifeen, senior director at icddr,b’s maternal and child health division, said the Q-mat showed that interventions don’t need to be expensive — often the most simple solution is best. But in child health — a field which has historically focused primarily on preventing deaths — he expects future challenges to be far more complex.

Enabling children to not only survive but thrive in their environment is hugely challenging, but Arifeen stressed that it’s even harder to rally for the cause politically. Bangladesh has made drastic improvements in reducing child mortality in recent decades, but that, in turn, has made it difficult to convince donors and government agencies to continue putting money toward the cause.

Engaging with private health care providers is another issue — in Bangladesh, only a third of women who give birth at a health facility do so at a government institution, he said.

Arifeen also sees real challenges elsewhere: “Maternal health, child health, infectious diseases are much more straightforward than climate change.”

New challenges

Bangladesh is one of the world’s most vulnerable countries to climate change, and its capital, Dhaka, is the most densely populated city in the world.

Health services are overstretched and struggle to address basic primary health care needs. About one-third of the capital’s population lives in slums below the poverty line, facing continuous public health threats such as public air pollution, malnutrition, and tuberculosis.

Dr. Quamrun Nahar, senior director at the health systems and population studies division at icddr,b, said that urbanization and climate change have an impact on almost every aspect of life in the city: “We know less than 1 percent in terms of what we need to know about research on climate change and health. If we don't invest in this, at some point we won't be ready to deal with these problems.”

The only way to gain a better understanding of health and climate change is through international and multisectoral collaboration with other research institutes, she said.

Climate change aside, Bangladesh is also transitioning from a low-income country to middle-income country. As a result, its disease profile is simultaneously changing from communicable diseases to that of noncommunicable diseases. As part of this epidemiological transition, cancer, diabetes, and mental health illnesses are on the rise and expected to increase. Subsequently, Nahar believes that icddr,b needs to change as well.

“We're still focusing on the things we focused on 10 years back. We are changing our focus, but not that much. This will be a challenge for icddr,b,” Nahar told Devex.

In order to address new health challenges, icddr,b is running two research initiatives in addition to its five core research priorities. One is examining the health consequences of climate change, and the other is focused on the prevention and treatment of NCDs.

Clemens said that such challenges will not change icddr,b’s determination to turn its scientific findings into real-world applications: “It’s one thing to describe and predict, but it’s another thing to do something about it.”

“You can have all the innovations in the world but unless you figure out how to integrate the innovations in a cost-effective, real-life manner into a health care system, you won’t have much impact on human health.”