Richard Cash (1941–2024)

Richard Cash has left an indelible mark in many areas of scientific pursuit. As a public health scientist, his most notable contribution was in the development of oral rehydration therapy. This intervention alone has saved millions of lives across the world and continues to do so. Perhaps his lesser known role is that of a bioethics educator, who focused his energies on capacity building in research ethics particularly in developing nations. While he was not the only US based academic doing so, he was perhaps the only one who could relate to the population he was talking about. That was because of the length of time he spent in the Indo-Pakistan subcontinent after first landing in Dhaka in 1967.

I met Richard for the first time in Karachi, in 2001, when he had come to participate in a research ethics conference. He was directing a training grant of the Fogarty International Centre (FIC), National Institutes of Health (NIH), at that time, focusing on educating fellows from Asia. Encouraged by him to apply for this much sought after fellowship at the Harvard School of Public Health (HSPH), I did, but got held up for over a year because of visa challenges. He was kind enough to defer my application for the next intake and I managed to secure a visa and spend a year in his programme on International Research Ethics as a Fogarty Fellow.

He was particularly proud of the success of his fellows. In response to an article authored by his fellows that I shared with him, he wrote back saying ‘It’s really excellent that the three first authors––Xiaomei, Ruipeng, and Wei were all in the program at HSPH … It is very satisfying to see their contributions––and yours and Mala’s and so on.’

Richard was a master in using cases to teach. During discussions, he would listen to complex descriptions of ethical challenges faced by researchers, and make rapid, entirely illegible notes on any paper he could find. And before the day was over, a crisp case would emerge, stimulating a healthy discussion. I don’t remember him ever giving his own views, or ‘solutions’ but rather generate a discourse where all aspects came out. Richard was one of the editors of the WHO Casebook on ethical issues in international health research, which is used extensively in ethics programmes across the world.

Richard emphasized that ‘cases’ didn’t necessarily need to be written ones. He loved to use films to tease out complex ethical issues. One of the first movies that I remember him using was ‘Good Neighbors’ based in KwaZulu Natal. Like stories, he was always on the lookout for good videos to use in his class. He was particularly pleased when we, in Karachi at the Centre of Biomedical Ethics and Culture (CBEC), Sindh Institute of Urology and Transplantation (SIUT) in 2008, embarked on our first such project to shoot videos on ethics themes, relevant to our context. Since then, we have made 13 and he has always provided expansive feedback on all of them. He has also used our videos in his seminars in Boston and in his teaching sessions across India and Bangladesh.

Always the iterant ethnographer, he was keen on experiencing reality as it unfolded wherever he visited. In an email to me, in response to a writeup I shared with him on Bangladesh, he wrote back saying ‘I first came to Dacca in July 1967 and one of my first impressions was how few women were outside on the streets and most were covered in burqas. Today it is totally different with thousands of women pouring into the streets at dawn going to work in the garment factories. Women are now participating in all walks of like and few wear a burqa. This change in attitude and policy is reflected in many health statistics. The infant mortality rate (IMR) of girls was always higher than boys and the life expectancy (LE) of women was less than men. This has been flipped where now boys have a higher IMR and women have a higher LE than men. And all of this has happened in less than 50 years.’

While coming to teach at our bioethics programme in Karachi at CBEC, given the choice of staying at a hotel or at my residence, much to my family’s delight, he chose our home. At dinner, he preferred to use his fingers to eat his daal (lentil) with rice and chicken curry, the proper way to eat, desi style! Dismissing any concerns that my wife had for a call for a general strike the next day, Richard, using the local term ‘hartaal’ suggested we leave early so that we can reach CBEC in time. He took everything in his stride so calmly, alleviating everyone’s anxiety.

Richard, along with Mala Ramanathan and Amar Jesani made a formidable team that taught our Research and Public Health module to our Postgraduate Diploma and Masters in Bioethics students in Karachi. Richard’s years of experience in the subcontinent as a public health scientist and practitioner served him well in developing his arguments in ethics that resonated with local challenges.

In 2014, Richard was invited to CBEC to conduct a 10-year review of our centre, along with 7 other external reviewers. He encouraged the Centre to continue working on our video productions, something we have done.

Capitalizing on Richard’s knowledge and teaching skills, our entre involved him in our Nairobi based NIH-FIC programme as well, the ‘CBEC-KEMRI Bioethics Training Initiative’.

Unfortunately due to health reasons, he was only able to participate once in Nairobi, but left an indelible mark on the Kenyan participants also.

An endearing quality of Richard was his habit of sprinkling local words and terms in his discussions. ‘Acha’ (OK), ‘haan’ (right), ‘aur’ (and/more), and several such terms would just appear in his sentences, making his arguments even more convincing. He understood his audience, and made sure he was understood by them. This is a quality that is often lacking in western educators when they engage with our local participants. I have attended many seminars with him and I don’t recall a single one in which he didn’t take a nice nap. But if asked a question, he would be able to connect all the dots he ought to have missed while napping!

In many ways, Richard was more of a native ‘South Asian’ than he was American. He had his own distinctive brand of bioethics, and while you may find yourself on the opposite side of his argument, you could not help but admire his articulation.

That is why I used to introduce him as the ‘Sachin Tendulkar of Bioethics in the subcontinent.’ No one has ever disagreed.

Above all, in the words of Dr Farhat Moazam, Chair of CBEC, ‘Richard was a good man’. He will be missed.