Tracey Koehlmoos on chronic disease management in Bangladesh

Tracey Koelhmoos Maybe you have never thought about Bangladesh and do not know Dhaka from Dakar, but I do.  I think about Bangladesh every day.  I have lived in South Asia long enough to wrap my own sari and to think that purple and orange go together well at least some of the time.

Before Bangladesh, I lived and worked in Baluchistan (the border province between Pakistan and Afghanistan), and Nepal (among other places), as a trailing spouse. Along the way I managed to produce three sons in rapid succession and acquire a cat, a dog and a PhD.

Now  I work at ICDDR,B which used to stand for the International Centre for Diarrheal Diseases, Bangladesh, but we aren’t just about diarrhea anymore. My small and not-too-glamorous research programme focuses on health and family planning systems.  Some of my time is spent figuring out better ways of getting shots into the arms of babies in the remote hilly areas and swamps, or new ways to deliver health care for the urban homeless. Other times, there is more analytical work like meta-analysis of health systems issues or evaluating maternal financing schemes.

Lately, I have fallen into coordinating a chronic disease research programme—something new, bold and necessary for developing countries like Bangladesh. Now that there has been success with meeting the needs of under-five children, women of reproductive age, and those with a major infectious disease what do can be done for everyone else?

How should a health system be reconfigured or adapted to meet the needs of adults? The public health sector is beginning to gear up to provide the services, but this does not mean that there are not other trained and untrained providers giving advice for diabetes and hypertension.

In the park where my husband and I exercise before dawn every morning there is a man with limited training who has set up an awning with a table and two chairs—one for him, one for his client. For a small price he can check your weight, check blood pressure, give a finger stick or sell you a soda or a bottle of water.

Most of the older men and women also walking seem to have the resources that would take them to a qualified doctor with an office rather than the open air stall. I wonder how this vendor stays in business. It must be the soda and water or perhaps a less affluent clientele circles the lake after the sunrise.

Although male park walkers wear Western clothes, the older women tend to dress head to toe in black burkhas or wrap up like brightly colored burritos in saris so that only their faces show. I admire their willingness to work out in such restrictive garb in the ultra-humid weather with temperatures often as high as 40 degrees even at 5.30am. They do not make very good time in their laps as the sari is designed for slow movement, but at least they are out exercising. The biggest change in the park lately is the daily exercise class for men is now taught by a woman in workout pants and a tee shirt.

I hope that this blog might serve as a forum for communication not just one way but both ways. My goal is to provide you insight into the lives of people serving on the front lines in the war against poverty and disease and the amazing events that take place here. Perhaps the response will be amusement, guidance or, I hope, the generation of a community in which learning can be shared.

Tracey Koehlmoos is programme head, health and family planning systems programme, and adjunct professor, James P Grant School of Public Health, BRAC University.

  • Richard Smith

    I’m delighted that you’ve begun this blog, Tracey. Despite their being many Bangladeshis in Britain I think people are relatively ignorant about the country. I think that I’m right in saying that although Bangladesh is one of the poorest of the South Asian countries it has some of the best health outcomes (although still poor)–behind only Sri Lanka. Can you explain why?

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  • Evelyn Dykes

    Good to read about someone else in Bangladesh. I have been going there intermitttently for the last 3 years – mainly to the hill tracts of Chittagong, and like Tracey have become hooked by the people and the place. And yes, the outcomes in some of the most resource -poor settings are amazing – some lessons for us here in the NHS I think. I have watched some Bangladeshi colleagues institute a Community Health Outreach Programme which in only 1 year made a dramatic impact on maternal mortality and the incidence of hospitalisation for diarrhoeal disease and malaria. It may be easier to have a visible positive impact if the start point is low, but the co-ordination, collaboration, enthusiasm and effectiveness of the few people who deliver this programme is an example to us all. There is no EWTR in Bangladesh!

  • shahriar

    Nice to know all the nice information with regard to Bangladesh. I would like to comment about the basice healthcare indicators(e.g., infant mortality rate or, maternal mortality rate) which are still lagging behind despite enormous efforts from Govt. NGO and private organizations. Right now, i am doing research on ubiquitous health services in developing countries which can come up as a viable soultions for a resource poor country like Bangladesh. I am talking about mHealth services to capitalize the amazing penetration rate(30%) of mobile phones in Bangladesh with tremendous growth rate. I dream of serving the unserved by utilizing this powerful technology………….

  • Anupama Barua

    As a Bangladeshi doctor in UK, I wish to comment about health service in Bangladesh.From outside you can not see the health system as a whole,the essential medical care such as the A&E and ITU are available only in big cities.Well equipped ambulence for emegency is a dream even in the capital.I do think we need to allocate resources in emergency care.Maternal health, infant mortality rate, control of infectious diseases are getting preference for last decades.At this moment,the authority should provide resources to acute medical care.Only enthusiasm and hard working doctors can not provide the services if they do not have access to equipments. I am not thinking of MRI or CT. How many times I have to run along the DHAKA MEDICAL HOSPITAL CORRIDOR to borrow ECG machine,nebuliser machine and oxygen cylinder from medical ward,you will never know. Please do not blame that we are ignorant or do not bother to serve our country……….

  • Carole

    Tracey I found this blog to be very interesting on a number of counts. It’s amazing to think that almost 40 years have passed since George Harrison’s Concert for Bangladesh was produced to show the plight of the Bangladeshi people and now you are showing us that though there has been some change in the right direction there is still so much to be done not only in where you are, but even here in the U.S. My daughter volunteered in Appalacia for 2 weeks a year ago and said the state of medical care in that poverty stricken area was dismal. 3 doctors working between 5 clinics throughout the region. It’s nice to know that there are people like you who are reaching out to do something. I shared this blog with my daughter who has put a medical career on hold because of the chance of socialized medicine to show her there is a lot more to do in the health world than medical school.

  • Nandalal Gunaratne MS FRCS(Eng)

    I appreciate Anupama’s comments on Bangladesh’s health system. However, the important thing is to make the best out of what you have. I have worked for 25 years in my country of birth in Sri Lanka, Our healthcare system is very good and i enjoyed working in my country.

    I also worked in the UK. It is really difficult to gain the confidence we have back at home when we go to work in a developed country and it takes even more to become comfortable. Without initial understanding, support and guidance, we would find it very difficult to survive in the system!

    It is interesting to find out how doctors from developed countries feel when they go to work in a developing country. Not many do that…..

  • Daniela

    Very interesting and inspiring blog! Congratulations for your work, your dedication and commitment to improve health care services! I am from Romania, finishing an MPH now in the Netherlands and I hope I can coordinate a disease management program some day in Romania. (This is also the subject of my master thesis.)
    Great job! Looking forward to hearing more from you.

  • Ken

    Very interesting blog and an insight from someone there with an outsiders view. One of the interesting points coming from the respondents regards the local population opting to work overseas or in their home country. Insight into the challenges of the local population getting involved in the local health care work (village type clinics) would be interesting. What is the desire of a grass roots movement (similar to the female health care worker movement in rural India) or is that still a bridge too far?