Remembering Dr. Richard Cash: How a 'simple' intervention helped save millions of lives

Dr. Richard Cash, who played a key role in the testing and implementation of an inexpensive and easy treatment for cholera and other diarrheal diseases that has saved tens of millions of lives, died at home in Cambridge, Mass., from brain cancer this week, his wife by his side. He was 83.

His greatest achievement — oral rehydration therapy for diarrhea — is something so simple that people can be trained to do it at home. Even so, an editorial in The Lancet in 1978 called ORT “potentially the most significant medical advance of the century.”

Cash's role in developing ORT came after he had graduated from the New York University School of Medicine and completed an internship in New York City. In the late 1960s, he headed to Dhaka — in what was then East Pakistan and is now Bangladesh — to address the tragic toll taken by cholera.

Cholera patients suffer diarrhea, which causes them to lose both salts and water. The disease could turn you "from a grape to a raisin" in a matter of hours, he observed.

At the time, it was well known that simply drinking water didn’t help. Cash and his colleagues had people drink water with carefully chosen salts and sugar, and found that the formula allowed for successful rehydration. So long as people were conscious and could drink oral rehydration salts, they would survive.

Working with others at the Cholera Research Laboratory, Cash conducted field studies proving that oral rehydration therapy is effective; a study conducted years later showed an estimated effectiveness rate of 93%.

Earlier this year, Harvard Magazine ran a story about his work. Cash told the reporter that ORT was an example of where the simplest solution to a problem is the best one. Fancy technology isn't always required for difficult problems. "Simple doesn't mean second class," he said. 

Lessons in humility

In 1977, Cash began teaching at the Harvard School of Public Health and remained a senior lecturer there till the end of his life, making frequent visits back to Bangladesh as well as other Asian and African nations to teach and work on public health projects.

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On one such visit to Bangladesh in 1979, Cash went on a field trip with Mushtaque Chowdhury, who worked for BRAC, a large development organization aimed at helping poor people by promoting physical and economic health and education. They were checking out a child survival program. It turned out to be a learning experience for Chowdhury, who eventually became vice-chairman of BRAC.

“The first thing I learned was how to be humble,” Chowdhury told NPR in a phone interview. Cash always approached the villagers with great respect, he recalled: “People coming from the Western world are not always respectful of the local culture and people. I found him to be exactly opposite of that.”

Working on a project to teach people how to make their own rehydration solution, Chowdhury and Cash visited a home where the people were so poor that there were no chairs. The homeowners scurried about, trying to find something their eminent visitor could sit on. Cash immediately plopped down on the floor with everyone else.

The ethics of global health policies became a passion. He taught and wrote about the need to focus on acceptable and affordable solutions to difficult global health problems such as COVID. In a paper in The Lancet a few months into the pandemic, he bemoaned the focus on rich country approaches such as lockdowns and sophisticated hospital treatment that wouldn’t be feasible in poor countries.

Cash was one of the forces behind the school of public health founded by BRAC in 2004 and was a lifelong faculty member.

Teaching was another passion — and his students were impressed by his commitment. About eight years ago Dr. Junaid Nabi, a senior fellow at the Aspen Institute, took a course from Cash at Harvard on global health innovations. Nabi knew about Cash’s landmark work on oral rehydration therapy. What struck him most was that someone so eminent was always available.

“He would instantly find time,” Nabi said. “Whether it was a student who was trying to work on a paper, whether it was someone who was trying to create a new intervention for a different global health problem, whether it was a group of students who were trying to create an advocacy group, he was always happy to help. He saw potential in every effort. With him, it seemed like everything was possible.”

“What he was trying to teach us was that you can have an impact in the real world,” said Nabi. “You can drive an innovation in a way that is helping people in real time, rather than publishing papers about it when there really isn’t anything happening on the ground”

Cash remained single until the age of 60, when he married writer, businesswoman and yoga instructor Stella Dupuis, whom he met at an ayurvedic spa in Kerala, India. They traveled extensively to places like the Skeleton Coast in Namibia, the Mongolian steppes and the Silk Route in China, stopping along the way to make friends and, as noted in an obituary written by his friends, to take pictures of toilets at ancient sites, sparked by his interest in water, sanitation and cultural beliefs — much to the amusement of his wife.

In 2006 Cash shared the prestigious Prince Mahidol Award given by the Thai royal family for outstanding achievements in public health and medicine with David Nalin and Dilip Mahalanabis for their work in establishing the use of oral rehydration for people with diarrhea. Others who worked alongside Cash include Bangladeshi researchers Rafiqul Islam and Majid Molla.

Ron Waldman, an emeritus professor of global health at George Washington University, became good friends with Cash when both were living and working in Delhi. He wrote in an email to NPR that Cash was remarkably open and caring: “kind, generous, smart, modest (or, at least, unassuming), opinionated (but usually right), anti-establishment (unless the establishment was heading in the right direction).”

The obituary written by Cash's friends says that he lived his final months as he lived his 83 years: “with grace, gentleness and humor; making those who came to visit and say farewell feel special and loved.”

 Joanne Silberner is a freelance journalist and former health policy correspondent for NPR. More than 30 years ago, she was a student in a global health course co-taught by Dr. Cash.

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