Ma O Nobajatak Shishu

19 02 2012

By Jon Higgins, Third Year Medical Student

I realize it has now been several months since my last post, and I am now slightly past the halfway point of my Fogarty year in Bangladesh. There are many reasons for this (certainly not a dearth of stories to tell!), 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 about 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:

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 (MCH) 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.

Manoshi Working Paper No. 18 (2012)
Caesarean Delivery in Urban Slums of Dhaka City: Indications and Consequences

Why this study?

You might ask, why is an aspiring general surgeon spending time in MCH 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 particularly 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 has been responsible for the coordination of some of the most remarkable public health successes of the last few decades, particularly in the fields of HIV, vaccine-preventable diseases, diarrhoeal disease, and more. Yet I find myself personally 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).

The lateral issues involved in providing general surgery go closely hand-in-hand with providing life-saving 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 clear 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 I read 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 30-70% of all health services and an estimated 40% of HIV/AIDS care.

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

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