Each year, roughly 18,000 Bangladeshi children die by plunging into the rivers, ponds and canals scattered throughout their country, often unsupervised and unable to swim.

As hurricane and monsoon season swings into gear, expect similarly startling numbers of deaths due to flooding and extreme weather to make the news. Last summer alone the New York Times reported that more than 1,000 deaths were attributable to unprecedented floods in Nepal, India and Bangladesh. More frequent extreme weather events related to climate change will likely push such numbers upward in the coming seasons.

Of the estimated 360,000 annual drowning deaths worldwide, many victims are children, others from vulnerable populations in harm’s way. Every year since 2013, more than 3,000 migrants crossing the Mediterranean have died in overcrowded and unsuitable vessels. Many perish without lifejackets or the ability to swim.

Drowning touches a primal human terror, hardwired like a fear of fire, epitomizing helplessness in the face of the elements. The mind conjures torrential floodwaters, Leonardo DiCaprio sinking into frozen oblivion, Virginia Woolf stuffing her pockets with rocks and wading into the river. And, too, it seems utterly preventable, simple as putting lifeboats on the Titanic or redoubling efforts to rescue refugees lost at sea.

Ultimately, drowning is asphyxia: it refers to respiratory compromise from immersion in a liquid (regardless of whether death ensues). You can drown and still be alive. Terms like “dry drowning” and “near drowning” are mostly useless and of only historical interest these days, despite persistence in the press.

A person underwater naturally holds his or her breath. But gasping is ultimately unavoidable—a reflex triggered by lack of oxygen and buildup of carbon dioxide and acid in the blood. Gasping happens whether or not a drowning person can manage to reach the water’s surface. When liquid fills the lungs, the sensitive interface where oxygen enters the bloodstream is damaged, causing often irreversible lung injury. After that, the brain lacks oxygen, organs fail, and ultimately, death follows. 

A look at the history of drowning treatment and prevention helps to put today’s approach into perspective and offers insight into the origin of what we now call medical emergencies. As early as the 1700s, public health advocates focused on reducing the number of drowning deaths and devising better resuscitation strategies. In 1774, the “Institute for Affording Immediate Relief to Persons Apparently Dead from Drowning” formed in London, eventually becoming Britain’s Royal Humane Society.

It all started with devices to blow smoke up the rectums of drowning victims on the banks of the Thames. Tobacco smoke enemas offered hope of “reanimation,” based on the theory that tobacco irritated and stimulated the body into restarting spontaneous respiration. Since that awkward beginning, resuscitation spread further afield from hospitals and clinics to the locations of patients.

An increased understanding of physiology and a post-Enlightenment moral and political imperative to further the public good kept drowning in the public eye in the late 18th Century. The subject became a metaphor for the development of a public health culture along with the science of resuscitation.

Besides trauma from war, few medical problems at the time warranted treatment at a moment’s notice—sometimes by untrained bystanders—with the goal of reanimating the apparently dead. The systems and technology put in place for drowning reflect the beginnings of a system of emergent out-of-hospital care, laying the groundwork for today’s EMS and search-and-rescue systems.

In 1776, doctor and inventor John Hunter proposed a double bellows to breathe air in and out of the lungs like a fireplace bellows—and remarkably similar to the positive-pressure ventilation used in modern respirators. Later, in the mid-1800s, physician Henry Robert Silvester described a supine resuscitation method, in which rescuers repeatedly extended patients’ arms above their head, then compressed them to the sides of the chest—a cumbersome flapping to simulate natural respiration.

After developing supine resuscitation, Silvester proposed the absolutely bizarre and grotesquely invasive technique of “self-inflation.” This required making an incision in the mouth literally to inflate someone with air under the skin to achieve enough buoyancy so that individuals could float on their own until rescued. Silvester’s proposal may have been persuasive at the time, as he presented many examples of animals that use air pockets for buoyancy (“many fishes possess hollow sacs filled with air”), almost certainly influenced by Darwin’s work a few decades earlier.

In a precursor to modern CPR, in 1903 physician Edward Schafer described the clearly less invasive and more easily taught “prone pressure method” of resuscitation which was ultimately used worldwide for almost 50 years—basically kneeling on someone’s back and rocking back and forth. Shafer’s method was meant to simulate natural respiration until victims began breathing on their own.

Only in the 1950s was the prone pressure method replaced by rescue breathing, better known as mouth-to-mouth resuscitation. Later, in 1975, Henry Heimlich offered his now-famous proposal for compressing the abdomen to expel foreign bodies from the esophagus, in a paper originally titled “Food Choking and Drowning Deaths Prevented by External Compression.”

So what’s next? Extracorporeal life support, or ECLS, uses a technique similar to that of the external heart-lung machines used to keep blood oxygenated during open-heart surgery—a technology pioneered decades ago but currently experiencing a renaissance. Recent research describes unprecedented successes with ECLS in drowned patients, including reports of good recovery in patients submerged for previously unthinkable amounts of time. One extraordinary report describes a teenager who recovered with no obvious neurological damage following 43 minutes of submersion.

Clearly children and Bangladesh and migrants lost at sea do not benefit from ECLS—public health interventions to prevent drowning deaths have far more impact. One simple solution has already demonstrated a profound effect. The use of “creches” in Bangladesh—essentially day care centers for children when they would be otherwise unattended—has reduced drowning morbidity in some districts to near zero.

Hunter, Silvester and Shaefer walked the first steps of a journey that began with tobacco smoke along the Thames and now extends to ECLS on Paris streets. They engaged communities by teaching resuscitation to the general public. And they formed organizations focused on prevention and rescue. With some attention from the general public and rescuers alike, the model of a dual focus on both high and low-tech will continue to drive resuscitation science forward while helping to curtail a smoldering public health crisis.