National Geographic – The Coming Storm
Take a gander at this featured article from National Geographic’s May 2011 issue.
Besides awesomely stunning photos in typical NG style, the authors offer some remarkable, spot-on insights about some present situation in Bangladesh, how the country has fared in tackling problems in the recent past, and the nature and spirit of the people who face trials in the near future – for better or worse.
An excerpt:
Such a catastrophe [rising sea levels causing mass migration leading to disease, religious conflict, chronic shortages of food and fresh water, and heightened tensions between Indiand Pakistan], even imaginary, fits right in with Bangladesh’s crisis-driven story line, which, since the country’s independence in 1971, has included war, famine, disease, killer cyclones, massive floods, military coups, political assassinations, and pitiable rates of poverty and deprivation—a list of woes that inspired some to label it an international basket case. Yet if despair is in order, plenty of people in Bangladesh didn’t read the script. In fact, many here are pitching another ending altogether, one in which the hardships of their past give rise to a powerful hope.
For all its troubles, Bangladesh is a place where adapting to a changing climate actually seems possible, and where every low-tech adaptation imaginable is now being tried. Supported by governments of the industrialized countries—whose greenhouse emissions are largely responsible for the climate change that is causing seas to rise—and implemented by a long list of international nongovernmental organizations (NGOs), these innovations are gaining credence, thanks to the one commodity that Bangladesh has in profusion: human resilience. Before this century is over, the world, rather than pitying Bangladesh, may wind up learning from her example. …
“Let me tell you about Bangladeshis,” says Zakir Kibria, 37, a political scientist who serves as a policy analyst at Uttaran, an NGO devoted to environmental justice and poverty eradication. “We may be poor and appear disorganized, but we are not victims. And when things get tough, people here do what they’ve always done—they find a way to adapt and survive. … “
You can read the entire article and see photos and featurettes on the NG website:
The Coming Storm
The people of Bangladesh have much to teach us about how a crowded planet can best adapt to rising sea levels. For them, that future is now.
Ma O Nobajatak Shishu
By Jon Higgins, Third Year Medical Student
I realize it has now been several months since my last post. I suppose there are many reasons for this. But most probably because the novelty of living and working in Bangladesh has transitioned into a sense of normalcy. And one does not rush to blog about normal things. Of course, a “sense” of normalcy does not mean actual normalcy. Hardly a day goes by where I fail to see, experience, or learn abut something utterly extraordinary, which until I witnessed it only existed in the most creative recesses of my imagination. The very foreignness itself is what actually becomes normal.
But I digress. I would also like to think it’s primarily because I have been hard at work. Evidence:
On the maternity ward at Dhaka Medical College hospital, reviewing hospital documentation, speaking with obstetricians and OB residents, and visiting our field workers. With my Fogarty c0-mentor, Laura Reichenbach (center, seated), Bidhan Sarker, the study PI (left) and Jannatul Ferdous, our study physician (center, standing).
I joined a study here at ICDDR,B which is part of ongoing evaulation of the Bill and Melinda Gates Foundation-funded Manoshi (Ma O Nobajatak Shishu) programme, a comprehensive maternal and child health (MNCH) intervention in the urban slums of Dhaka. The program is led and implemented by BRAC, a non-governmental organization with multi-faceted programs in health, education, economics, and development to “empower people and communities in situations of poverty, illiteracy, disease and social injustice”. My hosting organization, ICDDR,B, partnered with BRAC for monitoring and evaluation of the Manoshi program until the end of 2011, though I imagine their partnership will continue in other ways.
The study was a multi-facility, observational, case-control study of women referred to hospitals from Manoshi program areas (slum areas) within Dhaka. Our field staff surveyed mothers about the supply-and-demand factors in the medical, social, and economic consequences of cesarean section in two phases: first at the hospital, second at least six weeks later. The study collected information on many things: referral indications, indications for C-section, self-reported complications, socioeconomic status, postpartum depression screens, health expenditures and coping mechanisms, household food insecurity, catastrophic health expenditure, and more. I was able to present the findings for BRAC and the Gates Foundation at their Technical Advisory Committee meeting a few weeks back. We are planning, obviously, to do more rigorous analysis and literature comparison to publish for the academic world. You can read the report by clicking the cover, although we have much more to unpack with more rigorous analysis, as we only finished data collection and entry in mid-December.
Why this study?
You might ask, why is an aspiring general surgeon spending time in MNCH (maternal, neonatal, and child health) research? Well, a few reasons:
In my orientation at the NIH, I was impressed with the holistic perspective of the field of MNCH in global health. While many research efforts are mainly vertical in perspective (based on a single disease or topic like HIV/AIDS, tuberculosis, or heart disease), the field of MNCH research has been acknowledging, studying, and effectively addressing health issues from a “lateral” perspective for a long time (focusing on addressing multi-faceted issues not defined by a particular disease or condition). I do not mean to imply that the former is “wrong”; in fact, the vertical approach is responsible for remarkable success, particularly in the fields of HIV, vaccine-preventable diseases, diarrhoeal disease, and more. Yet I find myself drawn to the more lateral aspects of global health: frontline clinical care, care delivery infrastructures, medicine and technology supply, teamwork and communication, training, healthcare workforce issues, and patient healthcare access (or lack thereof). Cesarean section is the most common operation in the world.
The lateral issues which address general surgery go closely hand-in-hand with providing cesarean section; for example, blood banking, provision of anesthesia and pain medicines, adequate operating room space and surgical technology, the role of mid-levels or “clinical officers” for basic providing basic surgery, the need for more operating rooms among the world’s poorest, and the consequences like unanticipated catastrophic health expenditure. (And yes, let us not forget that a C section is a surgery, and it carries risks for both mothers and babies, particularly when done without good medical reason. A fact we often forget.)
I love children. The simplicity with which they see the world, the candor with which they express themselves, the sincerity in their smiles and their tears, and the potential they harbor to become great men and women, make them special to me. I am even strongly considering a future career in pediatric general surgery, but that is a decision to be made at a later time in life. You can thank my pediatric nurse mother for creating a special place for children in my heart.
This is a study among the urban slums. A quick fact: in Bangladesh, nearly one-third of people in the capital city live in slums, and the current 7% annual growth rate means that they will double in size every 10 years. The average income of slumdwellers in our study was $154 per month per household. Thus, when one reads also that the poorest 2 billion people in the world receive a mere 4% of the world’s surgeries, I know that my future work will undoubtedly involve urban sum populations. I speak of it infrequently – perhaps because it is hard for one to speak of things which matter deeply to him – that I am in this pursuit of medicine, of global health research, of long hours in call rooms and hospital wards and foreign places for this very reason. To serve the disadvantaged, the oppressed, the poor. To leverage what I’ve been given for the sake of those less fortunate because I am really not so different. I am incredibly thankful to begin to gain some experience and tools in working with and advocating for the urban poor this year.
Finally, one of my goals in this year and my career is to explore the relationship that academic medicine keeps with charity-based NGO’s, what UNFP calls the “local agents of change”. Such a desire derives from my own observations (and agreement from the World Health Organization) that non-governmental organizations currently play a critical yet highly underexamined role in addressing global health issues in LMICs. For example, in Sub-Saharan Africa, WHO estimates that faith-based organizations – a major subset of all NGO’s – provide an estimated 40% of all health services.
Still to come
As for my next few months, I am working in conceiving and helping design a study trial for a new frontline clinical health worker MNCH intervention. I can give more details on the project once they solidify, but I am learning a great deal about the front-end process of designing and funding clinical research studies, particularly those in the increasingly popular (yet treacherous!) field of implementation science. I am also, pending approvals and willing PIs, taking steps to help analyze and write a manuscript or two with data from the Matlab MNCH program, health facility assessment in Bangladesh, and/or the Manoshi C-section study. I also have plans to visit several of our field sites in Dinajpur and Sylhet, as well as a long-standing hospital down near Chittagong where a foreign surgeon who inspired me many years ago in a video, has invited me to come for a visit.
I could write so much more. About learning to speak Bangla; continuing to join for rounds in the ICU and HIV wards; travels to Rajshahi and New Delhi (India) for research conferences; trekking in Nepal during the Eid holiday; making a home in a foreign city; on Bangladeshi hospitality; on my housemaid’s matriarchal society; on experiencing Bengali art, music, and dance (and sometimes being a part of them); visiting Thailand over Christmas with other Fogarty scholars; getting to know my Bangladeshi coworkers and their families; the ins-and-outs of expat “aid worker” life; and oh so much more!
It is awe-inspiring to think that I am in my Third Year of medical school, with my self and my worldview being stretched in ways unimaginable in the confines of an American lecture room or developed-world hospital ward. I have many more lessons to learn, about this people and place. And about myself, my career, my goals, my dreams, my life as a doctor, leader, follower, and sojourner. I rather look forward to the latter half of my time here.
Jon
1971
My heart breaks today, after reading about the 1971 genocide in Bangladesh. Estimates include 300,000 to 3 million killed (many of them, innocent civilians), hundreds of thousand of women raped. Almost 10 million refugees displaced, and in the time of cholera. Commented one high U.S. official in 1971:
“It is the most incredible, calculated thing since the days of the Nazis in Poland.”
How, in 21 years of education, is this the first time that I can recall hearing about one of the top 5 genocides in the 20th century?
Also, as I continued to read, I was surprised to find numerous accounts and descriptions that the American government – aware of the gravity of the situation – supported West Pakistan with soft power and, some reports claim, weapons. Certainly politics in 1971 were complex, at best, and well-beyond my expertise or experience. However, it is terribly difficult to look back on such an event and not feel moved to ask and wonder whether my government was on the wrong side of history.
(To read further – which I highly recommend – see this 1971 TIME article, Pakistan: The Ravaging of Golden Bengal. Another article wrote another piece on the liberation thereafter: Bangladesh: Out of War, a Nation Is Born. For recently de-classified US gov’t documents and communications, including firsthand accounts and strongly-worded opinions from the American Consulate and Ambassador, George Washington University National Security Archives has them.)
I sat next to a Bengali man on the train the other day who must have been 70 or 80. That means he was a child when India was still a British colony. He was a teenager and young adult when Bangladesh was East Pakistan. He was a middle-aged man when so many of his countrymen were slaughtered in their struggle for freedom, quite possibly some of whom he knew well. I do not presume to understand what he has seen and experienced, yet I am responsible to be cognizant of it as I serve, serve alongside, and learn from his people.
I imagine that his eyes have seen much, his heart felt much anguish. We didn’t talk about such things as these, for certain discussions have their right time and place. Yet he smiled a lot. And in those smiles I remembered that the only trait of Bengalis which matches their vehement kindness is their remarkable resilience.
“My friend came to me,
with sadness in his eyes
He told me that he wanted help
Before his country dies
Although I couldn’t feel the pain,
I knew I had to try
Now I’m asking all of you
To help us save some lives
Bangla Desh, Bangla Desh
Where so many people are dying fast
And it sure looks like a mess
I’ve never seen such distress
Now won’t you lend your hand and understand
Relieve the people of Bangla Desh
Bangla Desh, Bangla Desh … “
- George Harrison, Concert for Bangladesh, 1971
