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Final Days in Bangladesh Pt. II: Chronic Disease Workshop and Modules

April 20, 2012
Global Health, Human Development, Live, Photos, Public Health
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Finally, here we are: The completion of my project at ICDDR, B.

Below you will find a brief article describing the project–its development, aims and goals. The write-up is also to be featured in an upcoming Chronic Disease Newsletter published by the Center for Control of Chronic Diseases in Bangladesh (CCCDB).

Preceding the article is an album containing the powerpoint slides that were used during my final presentation. Click on the image below to view a gallery of the presentation slides, which outline and explain my project, using visuals and text.

CD Community Health Workshop Presentation

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-The Issue-

  More than three in five people will die due to chronic illness this year – a number that is steadily on the rise. According to reports published by the World Health Organization, chronic, non-communicable diseases make up the world’s number-one killer, claiming the majority of lives on the planet annually (7). Of this figure, 80 percent who are affected reside in middle and low-income countries such as Bangladesh, which has proven no exception to these trends. In fact, research has shown that the number of deaths related to chronic diseases in Bangladesh has only grown over the past decades, and will continue to pose a serious threat without proper attention (4, 8, 10).

Chronic diseases are characterized by several key traits, which include (6, 9):

  • Multiple risk factors
  • Require systematic, regulated treatment
  • Lack a cure; in most cases they are life-long diseases

Given their nature, chronic diseases are often quite difficult and expensive to treat, especially at advanced stages. However, due to their prolonged duration and latency period, there are several opportunities for prevention of these illnesses.

This is why it is becoming evermore crucial to address this issue in Bangladesh using preventative measures; especially in rural regions, which experience higher prevalence rates due to a lack of medical resources—doctors, hospitals and medication—and poor levels of health education and awareness (2, 3).

-The Plan- 

  Recent collaboration between ICDDR, B’s Public Health Sciences Department and Chronic Disease Unit has given rise to the creation of the Chronic Disease Community Health Modules as a potential form of intervention for rural communities.

The modules are designed for implementation as a workshop, consisting of a group of villagers (12~15) and one or two appointed facilitators to act as guides. Facilitators provide information and support to the villagers during the workshop, helping them understand the basics of the chronic diseases most prevalent in Bangladesh, namely Diabetes, Hypertension and Cardiovascular Diseases (5).

It has been specified that trial-runs of the project are intended to take place in Chakaria, an Upazila within the Cox’s Bazaar District. The site was chosen based on the location of ICDDR,B’s Chakaria Campus, which maintains close contact with rural villagers in the area via the local Village Health Posts that provide basic health services to the community (4). Additionally, there exist several grassroots Chronic Disease Clubs, where individuals can meet with a village doctor once a month in order to receive minimal assessment services, such as blood pressure monitoring. However, as of yet these clubs do not promote any form of chronic disease education, or further developed prevention-based intervention. This provides for a prime sample population that can be used to assess the potential benefits of the workshop, so that it may one-day be scaled-up and adjusted for use throughout various rural areas in Bangladesh.

-The Modules- 

  The workshop modules focus on the primary modifiable risk factors leading to chronic disease:

  • Unhealthy Diet
  • Physical Inactivity
  • Tobacco Use

The World Health Organization has emphasized that these three items need to be targeted as the first-line means of preventing chronic illness (9). Therefore, by providing information and tactics to navigate these risk factors, the modules may aid in spurring the community to make lifestyle changes necessary for guarding against chronic diseases.

In order to accomplish this goal, the workshop relies on ‘bottom-up’ techniques adapted from Participatory Rural Appraisal (PRA) – a method that facilitates local people to (1):

  • Analyze information,
  • Practice critical self-awareness
  • Share personal knowledge of the community to enact a plan of action

Thus, the majority of the workshop is focused on collaborative problem-solving in the form of group discussion and activities; not only are the participants able to learn about the causes and effects of chronic diseases, but they are also encouraged to examine the underlying systems and barriers in the community that perpetuate risk. Step-by-step instructions, discussion topics, activities, and scientifically verified informational charts and data tables are all provided within the contents of the manual to help guide facilitators to achieve these results.

In total, the manual contains four modules. The first serves as an introduction to chronic disease, and the following three sections are based on each of the primary risk factors. These are outlined in further detail below.

Module 1: Assessing Health and Illness in the Community

This primary objective of the first module is to observe general perceptions of health and illness held by the community. Participants review basic information on chronic diseases, while analyzing how outlying social and physical factors influence health and risk. 

Summary:

• Identify the current physical, social, and health issues faced by the community; examine as a group how these issues overlap

• Discuss the basics of chronic diseases: what are they, who do they affect and how

• Assess risk among participants and within the community

 

Module 2: Diet and Nutrition in Maintaining Chronic Disease

The module assists facilitators to discern general dietary trends in the community, as well as assess the participants’ basic understandings of nutrition. It also provides information and techniques in order to encourage participants to follow a proper balanced diet.

Summary:

• Observe dietary practices and assess dietary knowledge in the community

• Review the basics of nutrition: fruits and vegetables; fats, proteins, and carbohydrates; cholesterol and calcium; salt and sugar

• Assess participants’ learning and reinforce concepts and techniques to maintain a healthy, balanced diet

 

Module 3: Physical Activity and Exercise in Maintaining Chronic Disease

The module reviews the classifications and benefits of physical activity, and its role in guarding against chronic diseases. Not only do participants learn how to better incorporate balanced physical activity into their everyday lives, but they also have the opportunity to participate in a low-impact exercise session as a group for dynamic learning.

Summary:

• Survey seasonal trends that may lead to increased or decreased times of physical activity

• Review the benefits of physical activity and the five keys to incorporating it into everyday life: leisure/sport, house/yard work, occupational activity, self-powered transport, avoiding sedentary activity

• Partake in a group exercise session

Module 4: Tobacco Use and Maintaining Chronic Disease

The final module is designed for in-depth evaluation of the prevalence and effects of tobacco use in the community. An overview of both the health risks of tobacco use and the benefits of quitting give participants the opportunity to discuss ways to mobilize members of the community to quit or reduce smoking and chewing tobacco.

Summary:

• Uncover the root causes and influences leading to tobacco use in the community

• Review the risks, dangers, and health hazards of different types of tobacco use, including: smoking, chewing, and second-hand smoke

• Identify along the “spectrum of quitting” and discuss the personal, economic, and communal benefits to quitting tobacco use

Hopefully, the Chronic Diseases Community Health Modules will prove to be a comprehensive teaching and learning tool, growing in its potency over time. As they are now, the modules serve as a starting point for further development and refinement. As more individuals and specialists access the module—in full or in parts relevant to their work—they may provide their own contributions and feedback, continuing to enhance its effectiveness in addressing chronic disease not only in Chakaria, but eventually, throughout all of Bangladesh.

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WORKS CITED

(1) Bhandari, Bishnu B. “Participatory Rural Appraisal (PRA).” Institute for Global Environmental Strategies (2003). Print.

(2) Center for Control of Chronic Diseases in Bangladesh. “Interaction between Chronic Disease and Poverty in Low- and Middle-income Countries.” Chronic Disease News 2 (Nov. 2010). Print

(3) Center for Control of Chronic Diseases in Bangladesh. “Chronic Disease Prevalence and Risk Factor Situation in ICDDR,B Health and Demographic Surveillance Sites.” Chronic Disease News 2 (May 2010). Print.

(4) ICDDR, B Periodical. “Chakaria Community Health Project Community Mobilization Toward Self-help for Health.” Glimpses 23.3 (September 2001). Print.

(5) International Center for Diarrhoeal Disease Research, Bangladesh. “Diabetes: The Emerging Epidemic in Bangladesh.” ICDDR,B Annual Report (2008): 7-10. Print.

(6) National Public Health Partnership. Preventing Chronic Diseases: A Strategic Framework. Rep. 2001.

(7) World Health Organization. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. 2008

(8) World Health Organization. Impact of Chronic Disease in Bangladesh. Chart. 2002

(9) World Health Organization. Preventing Chronic Diseases: A Vital Assessment. Rep. Geneva, Switzerland: WHO, 2005. Print.

(10) Zunaid Karar et. al 2009 – Epidemiological Transition in Bangladesh 1986-2006, Global Health Action

Final Days in Bangladesh Pt. I: Chakaria

February 3, 2012
Culture, Global Health, Human Development, Live, Photos, Writings
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It certainly has been some time since the last post on Bangladesh. However, after leaving Southeast Asia and returning to United States at the beginning of November, it has taken a couple of months to re-adjust to the modern chaos of New York City. Although I am typing piece in retrospect to my research trip, I believe it to be necessary contribution in order to wrap up and explain the closing of this past trip to Bangladesh—hopefully to be the first of many in the future.

During my time at ICDDR, B, I had been working on a solo project to develop community health modules and a workshop, which would be used to inform rural areas of chronic diseases and how social behavioral modifications could be used in order to prevent the onset of illness.

Within the last 60 days of being in the country it was decided that I was going to be temporarily transferred to one of these rural regions. Once there, I would have the opportunity to meet with local villagers and fieldworkers in order make some ground-level assessments and gain feedback on the project, so that adjustments could be made to help it run more efficiently. Of course, I was more than thrilled at the prospect of meeting with those residing with in the rural outskirts. After all, it was for their sake that the project had even commenced in the first place, and it was important to receive their input and observe the situation locally.

Leaving Dhaka City circa 8:00 in the morning, I boarded a train that would take me on a 7-hour journey southward to the second largest city of Bangladesh, Chittagong. From there, I would immediately continue towards the neighboring district, traveling by car for an additional 4 hours on treacherous unpaved roads, until finally reaching my destination: ICDDR,B’s Chakaria Field Site. By this time, the town was well cloaked by the darkness of night, and my exhaustion from the voyage left me with little interest in anything besides my bed.

 

 

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People vs Profit: Analyzing the Motives Behind Healthcare in Bangladesh

October 6, 2011
Global Health, Learn, Public Health, Uncategorized
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Nolzim Uddin is a man with a dream. Equipped with a radiant white smile and kind eyes, his handsome features are befitting of his job as an actor for Bengali television dramas. But the struggles of a rising actor are not unique to the streets of Hollywood or New York City. If anything, the effects of unsteady offers and competition in the industry are only exacerbated in a country with already limited opportunity. In order to make sure the needs of his wife and one-year-old son are met, Uddin must supplement his income by working at a local restaurant six days a week, only taking small breaks in his schedule when a part comes through.

Although his priorities are first and foremost to ensure the security of his family, Uddin hopes to one day assist his countrymen in their own endeavors of attaining happy and stable lives. His plan of action is to eventually build a hospital in his hometown of Khulna; a hospital where “all people—poor man and rich man—can come when they are sick.”

According to Uddin, healthcare in Bangladesh is currently corrupted by profit-driven motives, both on part of the hospitals and, more importantly, the doctors themselves. Government support to provide access to healthcare has been severely minimal in an already resource-poor country. This has not only perpetuated a cycle of poverty and sickness that threatens the state of the nation, but has also created a market for the privatization of medical centers and services. As a result, the number of hospitals and health care workers in Bangladesh has increased over the last ten years, most notably in the capital, Dhaka. However, with the introduction of private state-of-the-art hospitals, such as Apollo Hospital Dhaka, comes a significant price to pay, as funders tend to have their own agendas at work.

Dr. Dewan Alam of the Chronic Disease Unit at ICDDR, B has noted the progression of public-private partnerships and is disheartened by the outcome. “Health has become a commercial commodity,” he stated, “even a mother and her newborn infant are billed separately on hospital invoices now.” The combination of exceedingly overcrowded public hospitals where it is impossible to get treatment, and private for-profit facilities run by capitalistic mechanics, has made it so that basic health interventions and procedures are not widely available to the people, just under half of which are living below the poverty line.

Rising prices of maternal healthcare services attests to this fact. According to a 2010 report by the Ministry of Family Health and Welfare, expenditures for normal delivery methods in a private facility range up to 3,750 Taka, over triple the amount one incurs at federal hospitals. Moreover, if complications should arise, prompting the need for a C-section delivery, costs can range up to nearly 14,000 TK, which equates to 1-8 times the monthly salary for nearly half the population. These strains are devastating to communities that already struggle for basic necessities.

At the very least, one would hope that the physicians themselves would be moved to revolutionize the system, after witnessing their country’s destitution on the most intimate of levels, but this does not seem to be the dominant case. In fact, as far as Uddin is concerned, “90% of the doctors in Bangladesh are business men…they do not listen, they do not nurse the poor; they just secure money for themselves.” The numbers of patients seen in a day at private clinics far outnumber those that are manageable to provide quality treatment. According to his testimonies, Uddin and his family have never received a health consultation that has lasted longer than 15 minutes, no matter the case. “They just take the maximum number of patients for maximum income.”

It is understandable that in one the most densely populated countries in the world, physicians will be hard-pressed for time during patient consolations, especially if motivated to help as many individuals as possible. However, what is lost in minutes must be made up in attention to detail and effective treatment prognosis, both of which seem to be lacking in Bangladesh.

Due to the conditions previously outlined, many times it is not even possible for people to visit a qualified physician, especially in the rural areas. As a result, nearly 50% of the people in Bangladesh are first diagnosed and treated by Unqualified Allopathic Professionals (UAPs), namely “village doctors”. Although they lack formal medical qualifications, these village doctors still prescribe and practice medical treatment, most of the time with detrimental results. Previously observed issues have included misdiagnosis and harmful or unnecessary prescription guidance, which can easily endanger the lives of patients. But despite these trials, institutions such as ICDDR, B recognize the key role these individuals play in the country’s healthcare system, and have created initiatives to train the village doctors in proper medical treatment, rather than eradicate their practice.

Still, this has proved to be quite a challenge, as unnecessary prescription writing continues to be a reoccurring problem. Village doctors have high incentives to recommend various drug treatments, whether they are needed or not, as pharmaceutical industries offer them a percentage of the money paid towards medication; their income is being directly bolstered by such authorizations.

Furthermore, the same conditions are offered to qualified MBBS and MD practitioners, who also get a percentage of the payments made towards biomedical tests and drug costs. This has led locals, such as Uddin, to grow skeptical towards the healthcare industry, questioning whose interests they truly have at heart.

But of course, not everyone has remained passive to these circumstances. Dr. Sufian Sheikh MBBS has been equally outraged by these systems that continually ostracize those most in need of care. Deeply moved to make change in anyway possible, he has set up a private clinic in Khulna, his own place of birth. In his clinic, Dr. Sheikh charges bare minimums for his services—just enough to keep it running—so as to not deter anyone from seeking the medical treatment they need.

Like Uddin, Dr. Sheikh views the disorderly healthcare structure as fault of the physicians who fail to put people before profit; however, he puts blame on the government, and their failure to address poverty in Bangladesh, for the results of a profit-driven system. “People have five needs: food, clothes, education, health, and shelter—all of which the government is not working to provide,” he states. With these five elements in place, Dr. Sheikh believes the people will not only be able to build up their own success, but in their stability they will also be willing to extend help to others that are struggling to survive.

Research done by Bangladesh Development Research Center would seem to support Dr. Sheikh’s theories. The study refers to Abraham Maslow, an American Psychologist, and his proposed ‘Hierarchy of Needs’ (depicted below), which was used to assess motivational factors in Bangladesh. Outcomes showed that a majority of the respondents, regardless of class, stated that “physiological needs are the prime needs of most Bangladeshis…they will be happy if they are able to get the basic needs.”

Although there was slight mention of needs for safety and security, others beyond these first two tiers of the pyramid were virtually non-existent. Furthermore, respondents went so far as to discount emotional needs, such as love and a sense of belonging, as “worthless”, when most are just simply trying to make ends meet. This may serve as an explanation as to why there is not more active collaboration among communities intra-nationally within Bangladesh.

Yet what is lacking in resources is made up in the sheer number of people living in the country; if the government can start mobilizing communities out of destitution through welfare programs, perhaps it will be possible for a pattern to bloom outwards, as groups work together to reclaim their rights, such as access to healthcare.

Physician-anthropologist Paul Farmer warns that recurrent concepts in public health, such as “cost-effectiveness” and “sustainability”—also relevant to the discussed public-private health ventures—are dangerous because “they are likely to be perverted unless social justice remains central to public health and medicine.” In the case of Bangladesh, concerns of financial stability have overshadowed the primary role of hospitals and healthcare professionals: to serve and treat the afflicted, regardless of socio-economic status.

As it stands now, the healthcare sector leaves much to be desired, and whether or not reforms are made in the near future will have a major impact on status of the nation. However, there remain pockets of hope that carry the promise of one day promoting changes to revolutionize the delivery of medical services. Until that time, it will be up to these few to continue in their efforts of promoting equality—no man left behind.