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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

ICDDR, B Fights A Long-Waged Battle Against Cholera

August 24, 2011
Global Health, Learn
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Bangladesh is a country famous for its rich cuisine, its garment industry—one of the major clothing suppliers in the world—and its origin as the ‘birthplace’ of Cholera research.

Cholera is an infectious disease caused by the bacterium V. Cholerae, which causes symptoms of severe diarrhea and vomiting that often lead to deadly levels of dehydration if not properly treated. While the disease has long plagued the sub-tropical regions of Southeast Asia, it was just over fifty years ago that a substantial initiative took place in order to study its nature. It was then that the Southeast Asian Treaty Organization (SEATO) had come into existence, entering into an anti-communist pact between a number of western world powers—Australia, New Zealand, France, the United Kingdom, and the United States—and several developing countries in Southeast Asia—namely Thailand, the Philippines, and Bangladesh, which was then known as East Pakistan.

During that time, the United States was also in the midst of war with Vietnam; many U.S. soldiers occupying the surrounding region, thanks to authorizations consented under SEATO.  In order to ensure their army’s protection, the U.S. agreed to supply the financial backing needed to set up a research facility and study the disease that was running rampant in those parts. East Pakistan was believed to be an epicenter of Cholera, and so it was chosen as the site for the hospital-lab, spurring the creation of Pakistan SEATO Cholera Research Laboratory, which would later come to be known as the International Center for Diarrhoeal Disease, Bangladesh (ICDDR, B).

Since then, ICDDR, B, has consistently remained focused on treating victims of Cholera, however, despite the efforts of its dedicated medical staff, infections continue to recur at steady rates, year after year. Cholera is a water-born disease, making Bangladesh a prime habitat for it to fester. Not only is the country abundant in lakes and rivers, but there is also a plentiful rainy season, which causes various parts of the country to undergo annual flooding.

Chief Physician of the ICDDR, B Dhaka Hospital, Dr. Pradip K. Bardhan MD, sees a countless number of patients every year in the hospital’s busiest ward, the Short Stay Unit. “What’s interesting is that despite being a water-born disease, we don’t see a spike in the number of Cholera patients until the dry season, when the water levels are actually the lowest,” remarked Dr. Bardhan. “Any idea why this might be the case?”

He continued on to explain that humans are not natural hosts for the Cholera germ, which prefer to remain submerged in an aquatic environment. As such, Cholera tends to germinate within plankton, microscopic organisms residing in water. These plankton ‘bloom’ during the dry seasons, multiplying at an exponential rate, and consequently, rapidly increase the number of Cholera germs in the environment. However, this alone is not a sufficient explanation to account for the vast numbers of people that are affected by Cholera every year. In order to be infected with the disease, an adult must ingest over a million germs into their body. “The only way for a person to intake such a large quantity is by consuming either vomit or feces, the two mediums by which the Cholera germs are passed through the body in such high numbers,” Dr, Bradhan declared, “so if you meet a man who has Cholera, you know that he has literally eaten crap!”

While many in the developed world might be disgusted by such a brash suggestion, in Bangladesh, this is not the case—in fact, these conditions occur all too easily. During the dry season, clean drinking water, already in scarcity, is at a bare minimum. This forces many of the locals to take water from contaminated sources they normally would not have been willing to use. With 40% of the country living below the poverty line, few are left with any choice. A serious expression came over Dr. Bradhan’s face as he further commented on the subject, “People are so poor and so desperate for water that they take the risk—some even do so despite knowing the consequences.”

Poor water sanitation and a lack of infrastructure in Dhaka have caused vast amounts of sewage to overrun into the surrounding streams, lakes and rivers. While walking along the water’s edge, one can observe the large trash deposits that pollute the waters and smell the ripe stench of feces that contaminates the air. Even at a glance, it is quite obvious that one of the major inhibitors to the progression of healthcare in Bangladesh is rooted in water quality and sanitation.

In the latest World Water Development Report, the United Nations stated that access to water is not only essential for life and longevity, but also for sustainable development as a whole. Figures estimate that for every $1 invested towards safe drinking water around the globe, there will be a return of $3-$34 dollars, depending on the region and type of investment that is made.  Furthermore, “almost one-tenth of the global disease burden could be prevented by improving water supply, sanitation, hygiene and management of water resources,” which could greatly reduce the numbers of the 1.4 million children dying annually due to preventable diarrhoeal diseases, such as Cholera.

Dr. Bradhan claims that two-thirds of the patients seen in the SSU are child-patients, attesting to the number of children that are being affected by such water-related diseases. This figure translates to a significant amount of cases considering that the number of patients seen at The Centre has risen drastically from the 66 patients a year seen in 1960, to the average of 300 patients treated daily at present. Additionally, with the population of Bangladesh steadily increasing, there are no signs that the high patient count will depreciate.

Taking this into account, the hospital has implemented several strategies in order to more effectively treat the community.All the beds used are simply crafted, yet durable and space-efficient, making them ideally catered for large numbers of people packed into a limited area. Cleaning is also a breeze. Each day of the week has a corresponding bed mat color, which quickly notifies medical personnel if a bed has been freshly made or if it might still be sullied from a previous day or previous patient. Dr. Bradhan comments on the utility of the ‘cholera cots’ in the video clip below:


In the emergency center of the SSU, each bed is readily equipped with four IV bags—two on either side of the bedposts—in an attempt to save as many precious seconds as it is possible when treating the victims of sickness. “We’ve had cases where it has been necessary to insert all four IV’s at once into the patient—one in each limb,” said Dr. Bradhan while recounting instances when patients have been on the verge of death from severe dehydration. “We have to start pumping fluids as quickly as possible; it’s not the Cholera that kills them, it’s the dehydration.” Of course, not all cases are so extreme. For very mild forms of sickness the hospital also offers an area in which individuals can sit while they sip on Oral Rehydration Solutions (ORS) made from rice sugars and water, which have been proven to have greater electrolyte restoration standards compared to traditional glucose solutions. As of now, ORS provide the most effective and least expensive means of treatment, making it a widely accessible and sustainable one.

It is this type of consideration towards the needs of the community, coupled with strong preemptive measures, that has led to the hospital’s wide success in caring for the people of Dhaka, and surrounding areas of Bangladesh. It is also worth noting that the entire hospital runs on a paperless system. Physicians, nurses and staff can be seen making their rounds holding small electronic devices through which they are able to take write up patient charts and take notes. While such technological advancements are not common in other hospitals throughout Bangladesh, it is still an enlightening example of the progression that has been made, and the potential for expansions to come in the future.