By the numbers

It is the eve on my last full day here in Bangladesh. While initially I felt somewhat lost in this (for me) strange land, in retrospect time seems to have flown by: I cannot believe all the things we saw/did/experienced over the brief expanse of 30 days…

102 women surveyed: 32% of whom are or will be in need of family planning

2 trips to Dhaka, 1 to Sylhet and 2 random villages in between… for a total of 24 hours + in a car (obviously not at one time, though it often felt like it)

30+ CNG rides with ~7 rickshaw rides (it takes more skill than you think)

Consumption of 7.5 lbs of rice (minimum) and no less than 900 roti… as well as countless bags potato crackers (i.e. spicy potato chips) and innumerable packages of “energy” biscuits

77 stairs up to our Dhaka hotel room (my only exercise all month)

10 hospital/clinic tours (with dozens of interesting cases)

~20 – the number of Bangla words I know (PITIFUL)

1 very LARGE bat living near our Narsingdi home (which I could have done without seeing)

1 stomach that remains “confused”
AND

0 roadsides used as a toilet (my personal success story)

Now for the 19 hours+ separating me from JFK .

Tea?? Biiiiiscuit??

It’s a good thing I really like tea. And that I am a fat kid who can never turn down food, especially if it happens to be in carbohydrate form… because during our tour of the many medical institutions in Sylhet, we were offered tea and biscuits (sometimes more) at every single turn. Basically, if we went to 4 different institutions, there were a minimum of 4 tea breaks… which is fine, but given my usual overheated state and aforementioned paranoia of urinating anywhere outside the comforts of my lodgings it was, occasionally, just TOO MUCH. (Two “quick” digressions. 1. It still boggles my mind that there were so many medical facilities in the city of Sylhet, when there is clearly an dire need for such institutions across the rest of the country, and reportedly even across the district of Sylhet, itself. If only they could disperse. AND 2. While many aspects of this culture have been difficult to adapt to (like the fairly constant spitting… men, women, kids… doesn’t matter, big lugey coming your way), the overall hospitality offered to me, to anyone really, is amazing. People are often overly concerned that the big white bideshi will hurt herself, but they are always well-intentioned. OK. Digression complete).

Of course, on one such tea-laden day we ALSO stopped at the tea garden (on the ~border of India). Tea everywhere! But it was actually quite pretty and serene. The company doctor gave us a tour of the gardens, themselves, as well as the processing plant (which given the lack of safety anything could only conjure images of missing limbs for me). We had… TEA… but outside, at the exclusive guest cottage (formerly used for vacationing/relaxation by the wealthy during the British colonial era; one's stay apparently required royal approval... it has weathered some). Despite my overload, I must say that the tea here is fairly good, and when enjoyed in normal people quantities, I quite like it.

We left Sylhet on Friday, safely carried by “local” transport, though the air conditioned version which most Bangladeshis cannot afford. Our ~4.5 hour journey was interrupted by 2 stops: one for afternoon prayer and the second for lunch. At the second stop I ventured to the bathroom: it had been scouted out by Rupa prior to my leaving the bus. She gave due warning of my bideshi arrival. No less than 4 people enthusiastically directed me to the washroom, which was really only about 3 feet away. And the attendant inside knew to guide my bideshi behind to a western toilet. I have managed to avoid the side of the road thus far. Fingers crossed.

Arrested Development

I forgot to mention the other interesting thing I learned during the course of my travels. At the start of surveying, we ventured to the char in a fairly massive group: myself, Rupa and up to four interviewers/logistics people. However, as part of our work here, we hoped to train the interviewers to go alone to administer the survey (sounds silly, but actually the concept of surveys is foreign, thus troubleshooting is often required). That way this survey (and then others) would not require our presence. We planned to send our female interviewer with one of the other NGO workers (who happened to be male) early last week, but quickly discovered that this was not possible: a female CANNOT travel with any male who is not family. Basically, you can get arrested for such “activities.” Oh, ok. Under the umbrella of the NGO, this may become possible later but because vigilance is heightened during Eid we decided to hold off at present.

In other news: am currently in Sylhet (northeast Bangladesh, ~4.5 hours outside of Dhaka) visiting a variety of medical institutions here. On Monday, I visited a private medical college. While this was certainly interesting (it is always intriguing to see a different medical institution, particularly one that is international), the highlight for me was yesterday’s visit to the leprosy hospital. Leprosy is certainly not as prevalent as it was previously, but still enough of an issue here to warrant ~3 government hospitals. Given that we NEVER see it in the US, this was the first time I was able to see patient’s afflicted with the disease. Most of the patient’s were doing well, though many had suffered debilitating injuries secondary to its natural course. [http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002323/]. Later in the afternoon, I witnessed another personal first – a patient afflicted with tetanus (remember how much your tetanus vaccine hurt? It is worth it). He also was doing fairly well (actually ready for discharge), had initially presented with difficulty swallowing due to lockjaw. He had inadvertantly injected himself with the bacterium when he tried to drain a foot abscess with a piece of metal. [http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001640/].

Infectious Disease Hospital

In general, the government hospitals are much worse off than private institutions (similar to home, really). The infectious disease and leprosy hospitals we visited were government-run, so more dilapidated but not entirely horrible. However, these are relatively low-flow facilities (the leprosy hospital had ~48 beds). Today, we visited the Sylhet Osmani Medical College, a 500 bed facility typically at 3 times (!!!!) capacity. Where do the extra 1000 patients go? On the floor and every other available space in between. It was fascinating to see (we participated in morning rounds) but (not surprisingly) depressing as hell. The doctors are knowledgeable and doing a phenomenal job in a very difficult, resource constrained setting. But I could easily identify a handful of patient s that I knew would never leave. (There was a young girl who suffering from acute kidney failure who would have been an ICU admission at home, quietly suffering in a corner bed… dialysis was planned, but I am not sure there was a permanent solution. I did, however see a curable and SUPER INTERESTING case of cholecystitis (gallbladder inflammation)… the usual cause is an obstructing stone, but here it was… wait for it… a roundworm, ascaris (http://en.wikipedia.org/wiki/Ascaris). You could SEE it on the ultrasound!

Sylhet Osmani Medical College

Old Maid

Among the many questions hurled at me during the course of our interviews on the char (and there are MANY), the one I most frequently recognize is that regarding amar shaami and bacha (my husband and kids…. or lack thereof). Of course, there is still not much in terms of Bangla that I recognize, but this comes up often enough that I can quickly respond bacha na to the laughs of many (the mute speaks)! I guess for the village women this answer is amusing for 2 reasons: 1) I am very much an old maid (to be discussed below) and 2) they probably want to know why this random outsider is coming in asking about family planning, having no family of her own.

In reading about family planning here in Bangladesh, I’ve learned that the country has in fact made great strides in terms of implementing contraception use. Since the 1970s, the average number of children per woman has gone from ~6 to ~2 (concurrent with an increase in contraception use from 8% to 61%). Yay!

Buuuuuuut… there is still plenty of room for improvement (hence our potential family planning project). Though the legal marriage age here is 18, national data indicates that most women get married at the age of 16. In the char (and other rural areas) this number is closer to 15 (though we have had numerous survey participants who married at 12-13, with one as young as 9). Marriage marks the point at which childbearing then becomes acceptable; thus the younger you marry, the more time you have to bear children, the more children you are likely to have. And, all of these things directly impact both maternal and child health (and ultimately, maternal and child mortality).

So, at my current age of 28+, I should have been married for ~15 years, already with a child as old as ten. Considering how plants fare under my care, this thought is terrifying.

A tale of two kidneys

So our aforementioned field trip involved some ~7 hours in the car with a brief stay in a remote village as well as a quick trip to the char. Even though the weather has become much cooler as compared to the temperature on my arrival, it is still HOT. Our short walk to the house of our patient left me mildly sweaty. Then we were ushered into a relatively small room accompanied by no less than 5 family members. There was no “current” (electricity), thus no fan for circulation, and all surrounding windows were quickly blocked by curious villagers. Initially, we wore masks (to protect ourselves from the possibility of measles or chickenpox), which we removed after determining that the patient’s rash was most likely viral in nature. These masks are also HOT, suffocating even, given the right circumstances (such as NO circulation and a crowd of 900). What I really wanted was some pani (water) BUT I had to balance this desire with my EXTREME fear of having to pee. My terror is based on the fact that there is NO WHERE to go, other than the surrounding landscape. Even in the villages, latrines are not an absolute guarantee. Given that this white bideshi draws a crowd just standing there, I did not want to see what would happen in the event I needed to squat on the side of the road with my behind exposed. Not to mention that there is not much of a road “side,” and quite a bit of “fresh” water, just a slippery slope away. I, thus, decided that I would ignore my thirst and not drink ANYTHING all day. And hold any urine I happened to make for 14+ hours. Moral of this story: my kidneys HATED me! HATED.

A brief commentary on the bathroom in my lodgings . Unlike our “wet and dry” system back home, the bathrooms here (and in India, per Rupa) are a one-stop shop. It is as if the toilet bowl were literally in the shower. Basically if I shower and later decide to the use the facilities, the floor/shower floor is all wet/sudsy. It’s also quite difficult to dress post-shower as everything is wet.

(note my suds in the corner post "shower"... basically I dart in and out under the cold water... in the mornings it is so cold, it usually takes my breath away)

And lastly, the highlight of my day: Diet Coke!!
(tastes a little different , but still a nice change from water)

Field Trip

Yesterday was a fairly interesting day in that we took a pseudo-field trip to a remote village some 3 hours away (by car) from Narsingdi. Our purpose was to offer medical advice to a family friend, who was initially described to us as lethargic and weak with both fever and a rash. He had been this way for at least five days, and since getting to a hospital or clinic was nearly impossible due to a combination of distance and expense, we were deemed the next best thing. At the very least, we could determine if a trip to the hospital was absolutely necessary.

Driving here is… special. To the bideshi (“foreigner,” like myself) there seems to be no organization. However, one quickly realizes there must be some order to the chaos, or no one would ever get anywhere (and certainly not in one piece). This particular car ride was slightly better than our trip to Dhaka. Rather than a 2 lane road for the entire journey, there was actually a 4 lane highway, and subsequently much less traffic. That being said, it was still a free-for-all between rickshaws, CNGs, scattered cars, massive trucks and of course 9 gazillion pedestrians. (And cows apparently. Per Jasim, the “Eid holiday” (I believe Eid al-Adha) is in ~2 weeks; beshi (many) cows are being imported from India (ironic, given that they are deemed sacred there) to be sacrificed here as part of the holiday; http://en.wikipedia.org/wiki/Eid_al-Adha. The markets have been bustling in preparation).

Once near the village, we were forced to make a slight detour due to the current rain (and heavy rains the day before) which had washed out the road. We proceeded into the village on a mud path; the surrounding area was lovely - scenic, quiet (the perfect spa retreat). I wound up having plenty of time to take it all in: a little less than half a mile from our destination our car got stuck in the mud/cement. It takes a village… to get a car out, apparently. With lots of help we were able to free our transportation, thereby resolving to walk the rest of the way. It would have been a very picturesque trek, but I remained strictly focused on maintaining my footing. The mud really was like cement. There were times when I advanced, but my flipflops did not.

Our patient looked ill, but not critically so (yay)! We suspected he had a virus (affecting the respiratory tract and epiglottis). What he needed most was fluids, which we subsequently obtained at the not-so-nearby pharmacy. Pharmacists here do not receive any formal training, yet are front-line providers for many patients. Based on symptoms, they “prescribe” any number of medications (antibiotics, steroids, breathing treatments, you name it). The pharmacist helping us would actually also be the one returning to our patient’s home to place an IV and start the fluids. The entire concept seems crazy to me (given the recurrent possibility of medication misuse), though the lack of human resources/healthcare often makes it the best (and only) option for individuals who are sick.

"Google?"

Can you remember the last time you googled something? (Not to frighten anyone, but us, doctors, google stuff... a lot). What about the first time? Ever? I certainly can't remember. For what seems like forever, the internet and search engines have enabled me to find information, and since my move to NYC, not get lost (at least as much as I would otherwise). Most of us could not fathom a world without computers; it is an integral part of out everyday lives. And yet, despite this, it is not something I can readily teach... at least not based on my experiences here.

Farzana is one of our interviewers/basic translators. She is an absolutely lovely, somewhat reserved 18 year old currently taking a year off of school. Given that she is related to the family I am staying with, she was enlisted to help with the development of the NGO and for now, the family planning project. She has completed (I think) ~11 years of schooling and has NEVER used a computer. One of my first tasks was to teach her Excel, so that she could help us enter our data (and better understand exactly what it is we are doing). She picked it up quickly given that she had never seen Excel/basic computer programming before... nor had she ever used a mouse (a laptop mouse, no less). While we were in Dhaka (with Wifi), I took the liberty of introducing her to Google-- an instrumental component of my life. Have you ever tried to explain Google to someone who hasn't seen it before? Now add in a fairly significant language barrier. We muddled through, though I don't think she was as excited about its existence as I was. However, she did make her way to YouTube which got slightly better reviews.

(Aside: once Jasim's (my Bangladeshi host's) NGO, Ongkur, is really up and running,there is a plan to introduce computer training in the schools, potentially allowing students to get more competitive jobs in Dhaka).

Lastly, my pic of the day, courtesy of the government run TB hospital in Dhaka.

If spewing blood doesn't scare you enough into taking your TB meds, not sure what will. This was the featured mural in one of the waiting rooms.