David Nalin
(April 22, 1942 - )
Born in the United States
Year of Discovery: 1968
Oral Rehydration Therapy - A Unique Medical Breakthrough

UNICEF released a special report in 1987 that said, "No other single medical breakthrough of the 20th century has had the potential to prevent so many deaths over such a short period of time and at so little cost."  What is this miraculous breakthrough and who is the hero behind it?  The answer is Oral Rehydration Therapy, or ORT, and the scientist is Dr. David Nalin. 

Every year millions of people die from the dehydration brought on by diarrhea. Children are especially vulnerable. A patient with severe diarrhea can lose up to 20 liters of water per day (10-20% of their body weight), which can lead to severe dehydration, shock, coma and death within hours--often before medical care can be accessed. Cholera is a killer because its major symptom is just such a devastating diarrhea.

In the fall of 1968, Dr. David Nalin, at a young 26 years of age and having completed only his first year of medical residency, was working in Dacca, Bangladesh, at the Pakistan-SEATO Cholera Research Lab when a cholera epidemic broke out near Chittagong, along the eastern Burmese border. Working in a tent housing patient overflow, at a small missionary hospital carved out of the jungle, Nalin was confronted with a failed protocol that was attempting to use a drinking solution to put liquid back into cholera patients as a means of weaning them off of intravenous solutions, which was the only known treatment. Nalin realized that the treatment would work if it was changed. Further, he realized that such a treatment could completely replace IV treatment and could work for most diarrhea, not only that caused by cholera.  His breakthrough was his realization that patients needed to be rehydrated at the same rate as their fluid loss.

He and his colleague, Richard Cash, through resourcefulness and persistence in an adverse research climate, fought to perform scientific trials that would prove Oral Rehydration Therapy would work. Until the discovery of ORT, the only efficient means of rehydrating a patient suffering from serious dehydration was to provide fluids intravenously. For the vast majority of people in the developing world cholera, or any severe diarrheal illness, was too often a death sentence, since people infected usually had no recourse due to the cost and inaccessibility of IV therapy.

The effectiveness of ORT can be summed up in a single word: remarkable. The solution, which has saved millions of lives since its inception 40 years ago, can be made with household water, salt and sugar. Moreover, applying the solution can be done at home instead of in a hospital. But, it took David Nalin’s keen intellect and persistence to put all the pieces of the puzzle together and solve the problem.  Encouraging worldwide use, in 1978 the prestigious English medical journal, The Lancet, called ORT "potentially the most important medical advance of this century." Since the adoption of this inexpensive and easily applied intervention, the worldwide mortality rate for children with acute infectious diarrhea has plummeted from 5 million to about 1.3 million deaths per year.  

The hospital was now crowded from the cholera outbreak and many patients had family members staying with them. Having only a few dozen beds, the staff erected a large tent next to the hospital to handle the overflow, moving patients there to convalesce. Day after day Nalin administered IV's. Something of a polyglot, he was learning Bengali so that he could communicate with the local staff and the patients. Particularly poignant were the emaciated children. Sometimes they had to be strapped down to keep them from pulling out their IV tubes. 


Order the Book on Amazon
Amazon

Key Experiment
Nalin quickly asked his colleague, Richard Cash, to help and they went to work on revising the existing methodology of previous oral rehydration research and devising a new protocol.  This new practice would measure fluid output levels from vomiting and diarrhea every hour, over a four or six hour period and then give a volume of oral solution to the patient that equaled the previous hours' output.

The experiment began in April, 1968, and included 29 of the sickest cholera patients that had been brought to the Cholera Research Laboratory in Dacca.  The condition of these patients was so dire that many were admitted having no pulse and very low or non-detectable blood pressure.  All of the patients were administered IV treatment until their blood pressure returned to normal, and then they were divided into three groups.  The first would remain on IV treatment, acting as a control group.  The second was administered the oral solution by a tube, threaded down their throat.  The third group was given the oral solution to drink.

The staff at the hospital made use of a Watten Cholera cot to measure the output of patients' fluid through vomit and diarrhea. This special bed was a wood frame cot with a hole cut in the middle, which was attached to a plastic sleeve, which would empty the patient's diarrhea output into a bucket in order to measure fluid output.  Vomit was collected in a basin and measured separately.

Originally, Drs. Nalin and Cash planned on rotating shifts with other staff. Unexpectedly, their doctor colleagues working the other eight hours of the night shift refused to adhere to the protocol, and instructed the staff to restart IV treatment for some of the patients selected to receive oral therapy only. They didn't believe the new protocol would work. Nalin and Cash had to alternate 12 hour shifts to monitor their patients around the clock and ensure the protocol was accurately followed.  Of course, they had backup tests that would indicate if their protocol was failing, so the patients were never in danger.

The results of the trial exceeded expectation.  Only three of the patients receiving oral solution through the tube required extra IV therapy and only two of the group drinking solution required IV.  All 29 patients recovered completely! Success!

These results of the original trial were published, only four months later, in The Lancet.  Oral Maintenance Therapy for Cholera in Adults. 1968 Aug 17;2(7564):370-3.

The paper concluded: "The ingredients of the oral solution are cheap and widely available in virtually all areas affected by cholera. The solution need not be sterile and it can be made up with any suitable drinking-water. Ingredients could be pre-weighed and stockpiled for use in cholera epidemics. The drastic reduction in the need for intravenous fluids which results from the use of an oral therapeutic solution should make it possible for cholera treatment centers with limited supplies of intravenous fluids to reduce the mortality from cholera to a level previously not possible in the absence of abundant intravenous fluids. Mild cases of cholera (without shock) may be treated with oral solution alone."

Further Research
In a follow-up to their landmark study, Nalin and Cash showed that ORT can treat even the most severe cases of cholera. Then they proved that it works on children. In fact, later studies demonstrated that infants as young as one month old can be given ORT. They also demonstrated that the addition of glycine substantially reduced both the duration and volume of diarrhea in cholera patients, which set the stage for numerous other studies refining and improving the solution. Nalin and Cash also demonstrated that cholera patients could be fed food along with the oral solution, not long after shock was corrected, overturning the wrongly held tradition of starving patients for several days. In fact, nourishment can help a patient fight off the cause of the diarrhea.

Self Monitoring
A big surprise was discovered by Norbert Hirschhorn when, in a study of Apache children in Arizona, he revealed that people instinctively know how much solution to drink to properly rehydrate their bodies.  It is in a doctor's nature to want to prescribe specific doses of treatments.  But it turns out that without a doctor's prescription, even children usually drink as much as they need, then stop (although there are certain conditions that may inhibit this ability). In hindsight, this makes a lot of sense - people live their whole healthy lives regulating the amount of water in their bodies, and being sick doesn't impair their ability to do so.

Other Diarrheas
Most significantly, and surprisingly to many doctors, Nalin and Cash demonstrated that ORT is "as effective in the non-cholera diarrhea patients as in cholera patients." The importance of this finding was monumental. While cholera raises our awareness of diarrheal dehydration, because it comes in attention-grabbing epidemics, it accounts for at most 10 percent of the cases of diarrhea sickness in the world.

Landmark Academic Journal Articles
Oral maintenance therapy for cholera in adults. 1968. Nalin DR, Cash RA, Islam R, Molla M, Phillips RA. Lancet, Aug 17;2(7564):370-3.

A Clinical Trail of Oral Therapy in a Rural Cholera-treatment Center. Cash, R.A. Nalin, D.R.., Rochat, R.L., Reller, B., Haque, Z.A., Rahman, A.S.M.M. 1970. American Journal of Tropical Medicine, 19:4 653-656.

The Science Behind the Discovery
Diarrhea is not a disease itself, although it can be deadly.  It is a symptom usually caused by bacteria or viral infection. The accompanying dehydration can quickly destroy the body's ability to function.  It is particularly dangerous for children who, on average, exchange more than half of their extracellular fluid in their intestines each day, compared to one seventh in adults.  Before sanitary sewer systems and chlorination of water, diarrhea was the fourth-leading killer in the United States.  Currently, the Centers for Disease Control and Prevention (CDC) estimates there are 1.5 billion episodes of diarrhea every year around the world.

While cholera raises our awareness of diarrheal dehydration because it comes in attention-grabbing epidemics, it accounts for only a small portion of diarrhea sickness in the world. Other common causes of diarrhea include dysentery caused by bacteria or amoebas, traveler's diarrhea, usually caused by E. coli strains, and norovirus that contaminates food and water. In 2002, there were norovirus outbreaks on 25 cruise ships, sickening 2,648 passengers.

The most prevalent cause of diarrhea is the rotavirus. It affects all income groups, because poor sanitation is not its vector. Spread by direct human-to-human contact, the CDC estimates that rotavirus causes 39 percent of all childhood hospitalizations for diarrhea worldwide and up to 50 percent of all deaths. There is now a vaccine for rotavirus.

ORT has proven to be the main line of defense against dehydration for diarrhea, no matter the cause. In fact, in 1972 Dr. Norbert Hirschhorn, a key player in the discovery of ORT, concluded that IV use in the treatment of diarrhea was "old fashioned" and said that ORT was clearly the superior treatment.

Why drinking water doesn't work to combat dehydration
For centuries, every scientist knew that cholera victims could not rehydrate their bodies by drinking water. When O'Shaughnessy suggested using a saline solution for IV treatment, scientists tried to add salt to water for an oral solution. This didn't work either, even though scientists learned that salt played a crucial role in the body's ability to move water around by way of osmosis. The key to the mystery of how the body absorbs water in the gut proved to be sugar. Sugar was slow to be recognized as crucial because it plays no role in osmosis. Although scientists don't completely understand all the details even today, they began in the 1960s to unravel the intricacies of how water is absorbed in the gut. Specialized proteins in cell membranes bind to and transport sodium and glucose (sugar) across cell membranes simultaneously-one glucose molecule for every two sodium ions-and neither can be transported without the other. Hundreds of water molecules are bound to each of these glucose molecules, and this is how water is absorbed. A number of other sugars and amino acids can act in the same way. A driving force behind this transport mechanism is the concentration gradient-or difference-of sodium ions between the intestine and the insides of the intestinal wall cells. Scientists first learned that water absorption requires salt; scientists then learned that water absorption requires sugar; therefore for water to be absorbed in the gut, all three-water, salt, and sugar-are absolutely required.

Cholera
Cholera: The breakthrough in treating diarrhea came from cholera research. Cholera is caused by bacteria attacking the small intestine.  It has the unfortunate distinction of being one of the fastest killers, potentially killing a patient within hours of the first symptom.  Cholera outbreaks usually begin with zooplankton blooms, which contain the bacteria, found in costal estuary areas.  Animals will eat the zooplankton and become contaminated and humans will eat the animals or drink contaminated water.  Human feces carry the bacteria into the sewer system and, if the sewer becomes intermingled with the water system, cholera can spread very quickly.

Essentially, cholera was and is an Asian disease, but in modern times it has escaped to cause seven pandemics. In 1817, cholera broke out onto the trade routes into China and southern Russia. A second pandemic erupted in 1829, which spread to Western Europe, across the Atlantic to America and Canada, striking in New York, Philadelphia and the southern states, and eventually made its way to Central America. A third pandemic caused more than a million fatalities in Russia and, in 1853, more than 10,000 died in London alone. Later pandemics erupted from Indonesia in the 1960s, spreading through the Middle East and across Africa by the 1970s, reaching Peru in 1991. From there, it expanded to every country in the Western Hemisphere. Another outbreak was reported in India in 1991. On Feb. 14, 1992, an Aerolineas Argentinas 747 landed in Los Angeles with 336 passengers and crew. Seventy-five of them had cholera, acquired from a seafood salad loaded onto the plane in Peru. Ten were hospitalized and one person died, but the disease did not spread. Another pandemic erupted from Indonesia in 2000.

Cholera's affect on the human body begins with understanding how our bodies absorb water. An ion is an atom or molecule that has lost or gained one or more electrons, making it electrically charged. Electrolytes are simply ions dissolved in water. In our bodies, electrolytes come mainly from dissolved salts such as sodium chloride (table salt), which contains equal amounts of positive sodium ions and negative chloride ions. These electrolytes play vital roles in many cellular processes, and our bodies regulate very carefully the concentrations of different ions inside and outside of our cells, using highly specialized ion channels located in our cell membranes. For instance, virtually all our cells have hundreds of thousands, or even millions, of sodium-potassium pumps that are constantly at work exchanging three sodium ions inside the cell for two potassium ions outside the cell. As cells in the intestinal wall pump out sodium ions into the bloodstream, more sodium ions enter the cells from the intestine. Nature has a tendency to create equilibrium-in other words, to balance the concentration of electrolytes/ions/salt on either side of a semi-permeable barrier such as a cell membrane.

Cells also have chloride ion channels, and these are what the cholera toxin attacks. When negative chloride ions flood the intestine, sodium can no longer easily move into the intestinal wall cells, because of another simple natural tendency-to avoid concentrations of electrical charge. This phenomenon is no different from what happens when you build up charge by scuffing your feet across the floor in winter and then touch a doorknob or other metal object. Nature wants to get rid of the concentration of negatively charged electrons on your body, so they jump from your finger to the metal object and get absorbed by the ground-and you get a shock. Likewise, positive sodium ions are needed in the intestine to balance all the negative chloride ions, and this in turn causes a massive volume of water to travel across the intestinal lining due to a principle called osmosis, by which water moves to balance the concentrations of both types of ions. The chemical imbalance literally sucks water out of the body, the excess liquid cascading into the colon, which can only reabsorb a maximum of about 4.5 liters per day. The only place the rest of the water can go is out.

Diarrhea - watery, profuse, and often painless-begins abruptly, twelve to twenty-four hours after infection. Vomiting may also occur early on.  As this vomiting and defecation draws water out of the body, the patient's skin becomes cold and withered, the face becomes drawn, blood pressure falls, and the pulse becomes faint. Death comes from dehydration, after the patient has plunged into shock and coma.

ORT Goes Global
To get ORT to the masses, researchers faced huge obstacles: A medical culture that clung to IV therapy as superior to what they perceived as a primitive oral form; a very high prevalence of illiteracy, and no way to distribute ORS packets to remote, roadless areas. 

Dilip Mahalanabis, a pediatrician working with the Calcutta Cholera team, organized and applied exclusive Oral Rehydration Therapy to adults and children in refugee camps during the Bangladesh War of Independence. This was one of the first uses of ORT in emergency situations that required the administration of resuscitation fluids by family members, rather than medically trained personnel. This demonstration encouraged widespread use of the technique.

Nalin himself worked in the worldwide public health campaign promoting ORT in Costa Rica, Jamaica, Jordan, and Pakistan. "We realized for this to have optimal effects, we really had to get it out of the hands of doctors and nurses and into the hands of experienced mothers," Nalin said. "One tool that proved very successful was to teach doctors and nurses that they had to communicate three or four rules to a mother when the mother is concerned her child is sick. Are the child's eyes sunken? A mother knows better than a doctor when a child is ill. ...At the first signs of diarrhea, take out a packet, mix with a liter of water and start giving it to the child, every half hour or so until the child looks normal and starts to pee. We told her to watch the child's eyes; give fluids until the eyes return to normal. We taught her to keep pinching the skin on the back of the hand - it will ‘tent' if the child is still dehydrated and needs more oral solution. Mothers were sent back to villages with the packets. That sometimes met resistance from the local medical community, which had been making money giving IVs or charging several dollars for packets that cost pennies. But one mother back in the village would spread the word."

BRAC
Bangladesh had a war of Independence in 1971 and broke away from West Pakistan. Abed Fazle Hasan, who had been an accountant working for Shell Oil in Chittagong, fled the war. When he returned, he chose to help rebuild his country by forming a private foundation, the Bangladesh Rural Advancement Committee (BRAC).

BRAC went on a 10-year campaign to turn a scientific discovery into a home remedy. Beginning in 1980, BRAC sent an army of 10,000 female health workers into the Bengali countryside, where they taught ORT to 13 million illiterate mothers. Children, too, learned the ORT recipe through one-room schools set up by BRAC, that today number 37,000. In time, this simple solution became part of the national lore. A poem about ORT became so common that the government eventually put it on a stamp (gur is a molasses made from sorghum).

Mix with much care,
Good water, a liter,
A pinch of salt with a fistful of gur (molasses),
Remove the menace for good

At least 75 percent of Bangladesh families use ORT to treat diarrhea, according to government surveys. The acceptance and use of ORT for treating diarrhea, regardless of patient age or cause of diarrhea, have been important to the development of the WHO Global Diarrheal Diseases Control Program. As a result of these successful ORT programs, diarrhea case-fatality rates have declined dramatically. 

ORT in the West
Surprisingly, despite these results, many clinicians in industrialized countries have been reluctant to use ORT. Many physicians continue to recommend a variety of "clear liquids" to treat patients with diarrhea, instead of an appropriately composed ORT.  These "clear fluids" can cause osmotic diarrhea and electrolyte imbalance. 

Without the encouragement of doctors, most American parents don't even know that drugstores sell ORT in packets or solution over the counter.

ORT is an example of a less technological solution being superior to a more complex solution, making some parents who believe that the best treatment for their child is what costs the most money reluctant to use it. More cynical critics suggest that the medical industry is simply greedy. The cost of ORT is a few dollars a treatment. The cost of putting a child or elderly person on an IV, and often keeping him or her overnight in a hospital for observation, can run into the thousands of dollars. Estimates suggest that ORT use could save billions of dollars annually in the U.S.

Gatorade - An Oral Rehydration Derived Solution
It's especially odd that ORT hasn't caught on as a treatment for diarrhea in the U.S., considering that most Americans have used an oral rehydration solution. In the South, in the 1960s, football players were falling from heat exhaustion like flies on DDT. University of Florida assistant coach Dewayne Douglas, himself a past player who had experienced heavy sweating and no urine output during games, asked physicians at the college to develop a drink for the football team. They found the water-salt-sugar coupling research and formulated a solution for the players to drink. The rest is history. That year the moribund Florida Gators began using Gatorade and finished 7-4, winning many games in the second half. It was their first winning season in more than a decade. The next season they went 9-2. Soon every team was using Gatorade, an out-and-out, scientifically formulated oral rehydration therapy.

While it works based on the same physiological mechanisms as ORT, Gatorade is not a substitute for ORT in diarrhea cases because it is formulated for healthy athletes, chiefly to replace sweat loss, not for sick children or adults who have diarrhea, which is significantly different in composition, so requires a different solution. In order to make it easier for busy Americans to take, Abbot Laboratories created a ready mixed ORT drink for diarrhea, available in a bottle, called Pedialyte. And, only in America does taking medicine have to be fun. To encourage its use, Abbot began producing Pedialyte Freezer Pops in numerous flavors. So maybe ORT will yet catch on in the United States.

Personal Information
David Nalin was born in New York on April 22, 1941.  His father had wanted to become a physician himself but, when his own father, David's grandfather, died of pneumonia and his mother had to support the family, it was not possible.  He later became a pharmacist and pharmaceutical manufacturer. As David and his brother grew up it was suggested that, now that the family economy had improved, it might be a good thing to become a doctor.  

As a child, David began collecting many different things.  Some collections were as simple as baseball cards, some as exotic as turtles and salamanders.  Not a common sight in most Manhattan bathtubs!  He credits his parents' high level of tolerance for nurturing his curiosities and collections.  A young Nalin also liked to visit local museums and auctions in search of interesting beads or antiquities.

David Nalin soared academically.  He skipped several grades and, after graduating from Bronx School of Science, was accepted to Cornell, studying zoology by age 16.  He was then accepted to Albany Medical College at age 20, making him one of the youngest medical students in their history.  Nalin applied for a cross cultural clerkship in his third year and went to Guyana in South America, where he would visit three times, saying that this is where his life changed. He was confronted with the developing world, fascinating art, and became interested in research.  After completing only his first year of residency he signed on to the Pakistan-SEATO Cholera Research Lab in Dacca, Bangladesh. 

Dr. Nalin worked for the National Institutes of Health (NIH) from 1967 to 1970.  He later accepted a series of academic appointments at Harvard, Johns Hopkins, and the University of Maryland which took him and his research skills all over the world.  As a WHO consultant, he helped establish a number of highly successful national programs on the Oral Rehydration Therapy for diarrhea diseases in Costa Rica, Jamaica, Jordan, and Pakistan.  Dr. Nalin became the Director of Clinical Research for Infectious Diseases at the pharmaceutical company, Merck, in 1983 and remained at that position until his retirement in 2002.

Likely beginning in his early years, rooted in his affinity for collections, Nalin developed a passion for ancient Indian art, which he collected as he traveled the world.  His collection grew to be so extensive that Harvard University produced three catalogues of it.  He donated much of his substantial collection to a University of Vermont Fleming Museum exhibit in 2006.

The scientist's other research
Dr. Nalin has over 120 peer reviewed publications, spanning 40 years of work.  In addition to ORT related discoveries, these publications chronicle his remarkable contributions to:

David Nalin's Life: A Timeline
1941 - David Nalin was born in New York City.
1965 - Graduated from Albany Medical College.
1967 - Arrived in Dhaka (the capital of East Pakistan, as Bangladesh was known before gaining independence)  to do cholera research at the Pakistan-SEATO Cholera Research Laboratory (CRL), as a research associate at the U.S. National Institutes of Health (NIH).
1973 - Established and served at the Johns Hopkins Center for Medical Research in Dacca, Bangladesh.
1975 - The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) agreed to promote a single, orally administered solution of oral rehydration salts to prevent dehydration caused by diarrhea.
1979 - Nalin arrived in Lahore, Pakistan to take charge of the malaria research centre where he was later expelled by Pakistani authorities, early in 1982, due to unfounded Soviet allegations that the research being conducted there was for the CIA.
1983 to 2002 - Director of Vaccine Scientific Affairs at Merck's Vaccine Division.
2002 - Received the first ever Pollin Prize in Pediatric Research.
2007 - Received the Mahidol Medal from His Royal Highness the King of Thailand, presented at a ceremony at the Chakri Throne Hall in Bangkok.

Books by David Nalin
Displaying Many Faces: Art and Gandharan Identity Selections form the David R. Nalin Collection by Chandreyi Basu, David Robert Nalin January 2004.

Links to Science and Related Information on the Subject
David Nalin's Wikipedia Page
https://en.wikipedia.org/wiki/David_Nalin
Against the Odds - Making a difference in global health - A Simple Solution
http://apps.nlm.nih.gov/againsttheodds/exhibit/community_health/simple_solution.cfm
Magic Bullet: The History of Oral Rehydration Therapy, by Joshuan N. Ruxin
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1036912/pdf/medhist00037-0005.pdf

Awards
 2002 - Nalin received the first ever Pollin Prize in Pediatric Research.  This honor was shared with Dr. Norbert Hirschhorn, Dr. Dilip Mahalanabis, and Dr. Nathaniel Pierce.
2007 - The Mahidol Medal from His Royal Highness the King of Thailand was presented at a ceremony at the Chakri Throne Hall in Bangkok, in recognition of the discovery and implementation of Oral Rehydration Therapy

 Sources/References
Cash, R.A. Nalin, D.R.., Rochat, R.L., Reller, B., Haque, Z.A., Rahman, A.S.M.M. 1970. A Clinical Trail of Oral Therapy in a Rural Cholera-treatment Center. American Journal of Tropical Medicine, 19:4 653-656.
Elliot, J. 2007. A Life Changing Experience. Albany Medical College Alumni Bulletin.
Farthing, M.J.G. (1988) History of ORT. Drugs. 36 supplement 4:80-90.
Foex, B.A. 2003. How the cholera epidemic of 1832 resulted in a new technique for fluid resuscitation. Emergency Medical Journal, 20, 316-318.
Fontaine, O., Garner, P., Bhan, M.K. 2007. Oral rehydration therapy: the simple solution for saving lives. British Journal of Medicine 334(suppl 1):s14.
Guerrant, R.L., Carneiro-Fiho, B.A. & Dillingham, R. 2003. Cholera, Diarrhea, and Oral Rehydration Therapy: Triumph and Indictment. Clinical Infectious Disease, 37, 398-405/
Harrison, H., Darrow, D., Yannet, H., 1935. The total electrolyte content of animals and its probable relation to the distribution of body water. The Journal of Biological Chemistry. http://www.jbc.org/cgi/reprint/113/2/515 (accessed November 20, 2008). 
Hirschhorn, N. 1990. Speech at the Charles A. Dana Awards For Pioneering Achievements in Health and Education.
Horn R., Perry, A., Robinson, S. 2006. Diarrhoea: why is a simple and inexpensive treatment not more widely used?  IRC International Water and Sanitation Center. http://www.irc.nl/page/31514. accessed October 2, 2007).
Mendler, J. 2007. Take the Science to the Problem! Oral Rehydration Salt Solution solves one of humanity's most dire problems. The Concord Consortium. Concord.org. (accessed October 1, 2007).
Nalin D.R., Cash, R.A., Islam, R., Molla, J., Phillips, R.A. 1968. Oral Maintenance Therapy for Cholera in Adults. The Lancet, 292, 370-375.
Nalin, D.R., Cash, R.A. 1970. Oral or nasogastric maintenance therapy for diarrhoea of unknown etiology resembling cholera. Trans. R. Soc. Trop. Med. HI-g., 64 (5): 769.
Phillips, R.A. 1964. Water and Electrolyte Losses In Cholera, Federation Proceedings, 23: 705-712
Quotah, E. 2006. A Not-So-Simple Solution. Harvard Public Health Review.
Ruxin, J.N. 1994. Magic Bullet: The History of Oral Rehydration Therapy. Medical History, 38, 363-397.
Victora, C.G., Bryce, J., Fontaine, O., Monasch, R. 2000. Reducing deaths from diarrhoea through oral rehydration therapy. Bulletin of the World Health Organization. 78(10).
Woodward, B. 2008.   Scientists Greater Than Einstein:  The Biggest Live Savers of the Twentieth Century.
1992. The Management of Acute Diarrhea in Children: Oral Rehydration, Maintenance and Nutritional Therapy. MMWR
2001. The Oral Rehydration Therapy. Rainbow Pediatrics Knowledgebase. http://www.rainbowpediatrics.net/faq/12.3.html. (accessed September 27, 2007)
2003. The History of Gatorade. Gatorade. http://www.gatorade.com/history/ accessed September 38, 2007.