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Global Health Centers of Excellence: Travel Report to the Institute
Dr. Susan Shurin - April 28, 2010
Dear NHLBI Colleagues:
I am in Dhaka, Bangladesh, getting ready to leave for Vancouver, and wanted to give you a sense of what Cristina Rabadan-Diehl and I have seen as we have visited some of the NHLBI Centers of Excellence in global health. We are here with two of our UnitedHealthcare (UHC) partners: Richard Smith, who is the director of the Centre program for UHC, and Simon Stevens, who is president of the Global Health Division of UHC. (Note: Visit the NHLBI Global Health Initiatives and Partners for background information.)
Arun Chockalingam, Cristina, and Richard visited our India center in Bangalore, and we all visited the New Delhi Center at the Public Health Foundation of India, which Dr. Srinith Reddy runs.
Our Bangladesh center is a part of the International Center for Diarrheal Diseases, Bangladesh. This is a renowned center that developed oral rehydration solution and other major interventions for impoverished environments. They are branching into chronic non-communicable diseases, now the cause of 40 percent of the premature deaths in Bangladesh as maternal, infant, and child mortality have fallen. The birth rate is now 2.6 per woman, down from 6.7 per woman, but with the decreasing mortality, the population replacement rate is about the same.
Cholera and rotavirus are endemic and epidemic in both rural and urban environments. The International Center for Diarrheal Diseases runs the diarrheal hospital, now seeing 1,000 patients a day—twice their usual rate—with patients staying much longer than usual. Staff set up tents on the hospital grounds. Below is a photograph of the tent and one of the beds.
Surface water is contaminated with Vibrio cholera; well water is contaminated with arsenic. Here's the arsenic treatment plant at the rural site, Matlab; red means contaminated, blue are clean. Sewers run right into the river; you can see effluent pipes right next to swimming children.
Drowning is a leading cause of death for both children and adults.
Almost all the men smoke. Most cooking is done with indoor stoves. In the rural setting these have some ventilation, as you can see in the kitchen hut on the left below; in the urban slums, they do not (right photo above). Four to six people live in rooms about 8-10 ft square. There is electricity (it likely wouldn’t meet U.S. code), and even the rural homes have television. No running water or adequate sewers, but TV reaches all. Asthma is a huge problem in both rural and urban areas. We met with the head of the chest hospital, which has 600 beds. Most patients have COPD, some asthma, some TB, but there is also a TB hospital.
Transportation is a major challenge. Roads and bridges have improved, but much of the rural transport is by water or rickshaw. Urban transport is very congested and impacts residents' quality of life. The city area has about 15 million people, with about 350,000 coming in from rural areas every year. There are a million cars on the roads, plus rickshaws, bicycles, and buses. Most people we met have drivers, which provides employment. The drivers are very skilled. They seem to know exactly the dimensions of their vehicles, and come within centimeters of each other without colliding. They drive on the left, since this is a former British colony. Population density in the urban areas particularly is amazing. The population has more than tripled in the past 40 years and will continue to grow because of improved infant and child mortality rates.
Nutrition is a major problem. Right now, you see this as stunting more often than frank malnutrition. Growth is heavily dependent upon socio-economic status. Obesity is not common in the very poor. We saw a few obese kids in the Kamalapur urban slum, but none at the rural site in Matlab.
People born during the famine of 1974-75 (i.e., in utero during that time), who are now 36 years old, have a 60 percent incidence of diabetes or pre-diabetes. People born before and after the famine are in the mid-20 percentiles. There is a high incidence of myocardial infarction and stroke, often in the mid-30s to 40s, and we saw evidence of that. People eat fruits, but very little in the way of fresh vegetables. An even bigger problem in the cities is that there is too little cold storage to keep fruits for transport. A lot of the foods are fried, and the oils are terribly unhealthy.
Arsenic exposure is also a problem. It causes vascular endothelial dysfunction by inactivating endothelial nitric oxide synthase. Chronic arsenic exposure induces high oxidative stress, increases platelet aggregation, and increases the QT interval. Since it is in the drinking water, it is everywhere, although there are mitigation attempts.
Hypertension is also clearly very common, but there is very little data on prevalence, which is among the projects we are supporting. The water is becoming more salty, which is significantly increasing people's salt intake.
I haven't found any skeptics about climate change here. Decreasing snow coverage in the Himalayas means less fresh water in Bangladesh's rivers. The salinity rises because this country is at sea level. The impact of changes in water level and flow are palpable in both Dhaka and Chandpur, where Matlab is. Increasing salinity is bad for rice crops. Concern about the impact of global warming is prominent in the press and in the conversations we had with people. In many ways—overall nutrition, air quality, arsenic poisoning, salt intake—global warming is detrimental to cardiovascular and pulmonary health.
It was incredibly hot while we were here. It was 45°C (113°F) when we arrived in New Delhi, and the day we left, the temperature was expected to go below 40°C (108°F) for the first time in five days. It was 40-42°C (up to 108°F) most of the time we were in Dhaka. The monsoons start in late June (June 29 is the predicted date this year). The landscape is full of lower-level sections designed for water overflow to control flooding. There are places where people just change from ground transport to boats. The water doesn’t have a chance to soak into the ground, but just goes into the sea, so the water table doesn’t replenish.
Rice fields in Chandpur
Finally, the need to build in-country scientific capacity is absolutely essential. There is an intense need here, and even with international support, change will not happen unless drivers are local. We are helping by providing support for the science and for leadership and technical training.
You can get an idea about the value of education from a personals ad in today’s Dhaka paper:
"HINDU GROOM WANTED
Wanted: a meritorious Hindu groom for a Namasudra girl (21+) Honours Student at Dhaka. Possible opportunity for higher studies (MS/PhD) in USA may be arranged for the candidate with good results in engineering, business or any mathematical subjects. Contact with detailed results and Bio-data […]."
Cristina and Arun will give a report to the Institute when they have settled in. They are in the process of moving into their office on campus.
With very best wishes,
Susan
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