Taking Science Where the Diarrhoea Is

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Abstract
With attack rates exceeding two episodes per year in the young, diarrhoea with attendant dehydration is by far the major single killer in the developing world. An invariable accompaniment of the more insidious and chronic protein-energy malnutrition (PEM), diarrhoea is itself an acute form of malnutrition: fluid-electrolyte malnutrition (FEM). Scientific attention to FEM has focused heavily on mechanisms of pathogenesis and disordered physiology, often to the neglect of preventive and effective control measures. A notable exception was the huge step from the short-circuit chamber to the cholera ward which carried the science of coupled transport to the field. Glucose—electrolyte solutions provide effective prevention and treatment of dehydration and, where combined with early proper feeding, an interruption of the FEM-PEM cycle. Wider use of this simple technology awaits greater understanding and interaction with the social systems that determine the ecology of diarrhoeal disease. Advances in laboratory disease models and clinical research should be constantly scrutinized for useful applications: (1) studies of toxin mechanism, transport processes and biochemical binding phenomena are ultimately directed at inhibiting or reversing the underlying transport aberrations in the gut, (2) the immunology of causative agents may not only clarify key epidemiological features of the disease but also provide foundations for effective immune prophylaxis, (3) internal as well as environmental ecology are major factors underlying a complex series of interacting determinants often loosely gathered under the rubrics of nutrition and sanitation, (4) behavioural patterns, beliefs, weaning practices, and other socio-economic factors are prime elements of the FEM problem, and (5) entire communication and health delivery systems both formal and traditional must be better understood and imaginatively utilized if science is ever to find its way to where the diarrhoea is.