The Myths Around Dr Dilip Mahalanabis, the “Father” of ORS
How science and scientists’ work are distorted in the social media jungle
(This was written for The Wire Science in Nov 2022 after the death of Mahalanabis. Today I am putting it out again after coming across a popular Twitter account publishing some incorrect claims regarding Mahalanabis and ORS)
Dr. Dilip Mahalanabis, best known as one of the world’s foremost experts in oral rehydration therapy (ORT), passed away last month. The news took me back to many years ago when I was an aspiring public health student with dreams of joining the World Health Organization. I had come across a 2009 interview of Mahalanabis (and another stalwart, Dhiman Barua) in the WHO’s Bulletin. There he recounted his pioneering work in Bangaon, Bengal in 1971, when he and his associates treated hundreds of cholera and diarrhea patients with the then new and experimental oral glucose-electrolyte solution. As a young physician with a strong interest in public health, the work and experiences of Mahalanabis and Barua made a deep impression on me then — and Mahalanbis’s death last month transported me to that fond academic memory.
However, I was uncomfortably lurched back to the present upon reading some of the supposed tributes that people were paying to Mahalanabis. Alongside several thoughtful commentaries, a lot of what was written or shared about him contained toxic nationalism and incorrect, often blatantly wrong, information. I was also struck by how almost all the major media publications simply rehashed the same few details of his life and work in their obituaries, and offered little, if any, glimpses of Mahalanabis as a person. In fact in many commentaries, it was difficult to gauge whether it was Mahalanabis the person or ORS the solution that was being remembered and celebrated.
The tributes, obituaries, and commentaries on Mahalanabis got me wondering about how we approach science and history, how we commemorate the dead, and how society and politics intersect with science. This essay is a product of those reflections.
First and foremost, I was surprised by the unfortunate and needless erasure of the long history of the development and advocacy of ORT, including the involvement of many researchers and institutions both Indian and international. Firstpost gushed about how Mahalanabis “never patented his ORS solution”, and a popular account on Twitter spread the blatantly false information that he “invented the ORS sachet” (this tweet was shared thousands of times and the “invented ORS” idea was propagated by many others).
Even an otherwise fine obituary in the Times of India said in the headline that he was “father of ORS”. Most mainstream platforms used the ambiguous term “pioneered” instead of “invented”, but then failed to accurately portray and contextualize his work, with readers perhaps getting the impression that Mahalanabis was the sole, or at least the most deserving, “scientist who developed” oral rehydration therapy, as well as the scientist who single-handedly devised the ORS formula.
Mahalanabis was a genius. And like every genius he stood on the shoulders of and rubbed shoulders with other geniuses. As my own memory of coming across Barua and Mahalanabis together indicated to me, ORT was a massive innovation behind which were the mammoth efforts of many (Barua passed away in 2020, and the very few obituaries one can find describe him too as a “pioneer” of ORS). The original 1973 paper in which Mahalanabis laid out the details of the spectacular ORT work in Bangaon, was written jointly with four other experts.
In the very first paragraphs of this article, Mahalanabis and his co-authors made multiple citations of earlier research on which their work was based and which preceded the steps taken in Bangaon. For example, they wrote that the “effectiveness of oral glucose-electrolyte solutions” had already been demonstrated in hospitalized patients, and that the ingredients and proportions in the solution they used were derived from previous research. Clearly, ORS (or for that matter the “ORS sachet”) was not “invented” by Mahalanabis, and neither was ORS “his” (or of any single researcher’s) to patent.
In fact, far from being the product of the stereotypical lone genius scientist working alone away from the messiness of the world, ORT was the product of multiple researchers and organizations toiling deeply in the world’s diarrheal trenches. In recent decades, historians and other scholars have worked to dispel the myth of the typical “lone genius” portrayal of great scientists: Nature for instance published an article titled “Einstein Was No Lone Genius” in 2015. Some of these efforts are also part of larger initiatives towards “decolonizing” modern science and its narratives, with scholars showing how it is incorrect to assume that only white European and American male researchers were responsible for the major scientific advancements in the modern era, and how we need to be aware of the erasure and invisibilization of indigenous and Global South communities in conventional histories of modern science.
Considering these recent progressive directions in thinking about science, it was jarring to witness the extreme Indian/Hindu nationalistic content of some popular tributes paid to Dilip Mahalabanis [after his death in 2022]. The ignorance and erasure of the collective efforts of researchers and scientists across the globe was striking. While many elite Indians have always mimicked the attitudes of their erstwhile European colonizers and made preposterous claims that ancient Hindus (like ancient Greeks) made singular, single-handed contributions to global knowledge, the Mahalanabis commentaries show how the Indian/Hindu exceptionalism bulldozer might not even spare recent science history.
One consequence of the misleading and confusing information about Mahalanabis in these tributes and obituaries, was that people were left with really little idea of what it is that makes his work so important. The history of ORT written three decades ago by Joshua Ruxin provides useful contextualization of Mahalanabis’s work. By 1970, it had already been demonstrated that ORT worked well in stable, hospital settings under expert supervision, but these studies were inadequate to convince the mainstream medical and public health communities of the feasibility and effectiveness of large-scale or field ORT treatment. Mahalanabis et al’s daring and innovative work in the dire, emergency circumstances of 1971 Bangaon (“in order to treat these people with IV saline, you literally had to kneel down in their faeces and their vomit”) was what helped ORT “really hit the map … [since] it probably took that kind of a demonstration in a crisis to really document what could be done”. Soon after, “ORT began demonstrating success after success as physicians experimented with it in different cases of diarrhoea and among patients of all ages”.
In their own words, what Mahalanabis et al accomplished was to provide “confirmation of the effectiveness” of ORS in a “field trial… [where] extremely adverse logistic and administrative conditions prevailed”. Once again, let it be remembered that Mahalanabis even himself (with his co-authors) laid no claim on having “invented” ORT/ORS — their claim to fame was on having demonstrated the effectiveness of locally-produced ORS in a field setting.
Another historical aspect that needs revisiting is the oft-repeated claim (which appeared even in the 2009 WHO Bulletin mentioned above) that ORS was termed by a 1978 Lancet editorial as the (or among the) “most important medical advance” of the twentieth century. However, the Lancet said nothing of the sort. What a 1978 editorial (titled “Water with Sugar and Salt”) did say was: “The discovery that sodium transport and glucose transport are coupled in the small intestine, so that glucose accelerates absorption of solute and water, was potentially the most important medical advance this century.”
In other words, as Ruxin wrote, the Lancet was enamored less by the practical, public health aspects of ORT, and more by the theoretical, laboratory-based aspects of intestinal absorption which are the physiologic basis of ORT. This of course does not mean that ORT is insignificant, — it absolutely is among the most revolutionary therapeutic innovations ever — but clearly the Lancet was saying something slightly different than terming ORT as the “most important medical advance” of the twentieth century.
Finally, despite the abundance of articles and tweets on Mahalanabis, there was not much one learned about him either as a person, or even as a physician and scholar beyond his 1970s ORT work. A few reporters were indeed thoughtful and reached out to people who knew Mahalanabis personally (as seen in the ToI and Financial Times obituaries). One learned that Mahalanabis was a great mentor and “delighted in developing the next generation in his field”.
I myself briefly spoke with Richard Cash, among the three ORT researchers who shared the 2006 Prince Mahidol Award with Mahalanabis. He emphasized that Mahalanabis’s deep and lasting commitment to child health in India was tremendously admirable (it is worth noting that Mahalanabis and his wife made a large donation to Kolkata’s Institute of Child Health in 2017).
It is true that as a general rule, trend-setters in fields like public health receive far less public and media acclaim than those in other areas and topics in science and medicine: one saw, for example, surgeons rather than public health experts being overwhelmingly invited to TV studios for discussions on COVID prevention and policy. This common bias against supposedly “unglamorous” fields could be one of the main reasons why many of us stumbled upon Mahalanabis and his work only after his death.
But nevertheless, if we are genuinely interested in learning about and celebrating such stalwarts and their achievements, then propagating misinformation and false histories under the agenda of nationalism and even decolonization, is certainly the worst way to do that. It is high time we abandoned exaggerations and sensationalism, and started being sensitive and sensible in both our celebrations of our stellar compatriots, and in the stories about us that we tell ourselves and to the world.
