Joshua Schulman-Marcus reports on the anthropological and psychological impact of chronic diseases in developing countries.

A Personal Reflection

Over the past year, I have written several articles for the Lancet Student on the growing prevalence of chronic noncommunicable diseases (CNDs) in developing countries. Major studies have indicated that diseases and risk factors such as hypertension, diabetes, tobacco use, and asthma are increasing in low- and middle-income countries in all regions of the world (1,2). Recognizing these trends, the World Health Organization (WHO) has recently begun to address this new global health priority (3,4). Researchers and advocates have pointed out that more investment in prevention, screening, and treatment will be needed to avert the resulting unnecessary disability and mortality (5,6). These reports indicate that CNDs will be a major item on the global health agenda for the duration of our careers.

Most of the research, including the recent series published by The Lancet (7), has been predicated on epidemiology, economic impact, health systems, and potential interventions. Less has been said about the non-technical implications of a transition to chronic disease in the developing world. This is unfortunate as “health” extends far beyond the biomedical realm; it is intertwined with sociological structures and culture. A shift from acute infections and traumas to chronic, often asymptomatic ailments, thus presents a paradigm shift in the notion of what it means to be a healthy person. This is a serious adjustment that deserves careful consideration. For how can we expect people to take medicines or alter lifestyles if they don’t believe that they are ill?

I personally saw the anthropological and cultural challenges of the epidemiologic transition when I worked with the Ethiopian Israeli community in 2005. Arriving in urban Israel from rural Ethiopia in the 1980s, the immigrants had a conception of health that largely revolved around the acute infections and malnutrition endemic to poor countries. Within ten years, though, the prevalence of Type 2 diabetes rose from 0.5% to 17% in some cities. Similarly, asthma, blood cholesterol levels, blood pressure, and red meat consumption soared.

The Ethiopian immigrants had no word in their common language for diabetes. I spoke with a man with longstanding diabetes who had never heard of the pancreas. He didn’t believe he was sick. As the deleterious elevation of blood glucose is often asymptomatic early in the disease course, it was exceedingly difficult to convince patients to adhere to therapy. Even worse, the language used to explain diabetes can be very confusing, as the notion of “high sugar” led some patients to believe that sugary foods were the cause of the condition. Miscommunication between the Israeli primary care providers and the Ethiopian patients, compounded by poverty and power disparities, led to distrust and very poor quality of care. And this was in a country with a well-financed health system designed to address chronic noncommunicable diseases.

Indeed, the entire notion of chronic disease resulted in confusion and frustration for some Ethiopian immigrants. “Why can’t the doctor cure me? Why doesn’t he give me a shot?” asked one. “He must just be a bad doctor, or maybe he doesn’t treat me because I am Ethiopian.” I heard similar confusion about the concept of lifelong drug therapy. One mother, for example, refused to give her son an asthma inhaler, lest he become “addicted” to it like tobacco. Another, however, wanted constant steroids to treat his mild asthma, because “they make me feel good.”

My discussions with the Ethiopian immigrants and Israeli health workers also hinted at the complexity of advocating lifestyle changes to prevent chronic disease. Lifestyle is the product of thousands of choices, many of which are heavily influenced by economics, sociocultural norms, and status. People in developing countries may aspire to eat Western foods high in saturated fats and may choose to smoke American cigarettes to indicate their wealth. Being overweight or obese, even having some diabetes, may be lauded as a sign of success. These attitudes can be deeply ingrained, and modifying them will require interventions informed by a nuanced understanding of local culture and health beliefs. If chronic diseases are not presented in terms that make them believable, most people will be hesitant to significantly alter their lifestyles in order to “prevent” an abstraction.

Over the past few years, attention has been increasingly paid to the coming epidemic of chronic noncommunicable diseases in the developing world. These diseases can lead to devastating consequences, both physically and economically. It has thus been recognized that many disciplines will need to be rallied in order to adapt health systems for chronic care, re-train workers, ensure access to medicines, and design cities amenable to physical activity (2-7). Yet the barriers to the effective prevention and care of these diseases cannot be lowered through the technical expertise of biomedicine or policy alone. Rather, my experiences have taught me that it will require a more holistic understanding of how individuals adapt to a revolution in the conception of health, illness, and healing. To do so, I think we first will need to learn how to be better and more patient listeners.

Joshua Schulman-Marcus
4th year medical student
Mount Sinai School of Medicine
New York, USA

jschumar@gmail.com

(1) Lopez AD, Mathers CD, Ezzati M et al. Global and regional burden of risk factors, 2001: systematic analysis of population health data. Lancet 2006; 367:1747-57

(2) Jamison D, Breman J, Measham A, Alleyne G, Claeson M, Evans DB et al. Disease control priorities in developing countries. 2nd ed. New York: Oxford University Press and the World Bank, 2006.

(3) Innovative care for chronic conditions: building blocks for action. Geneva: WHO, 2002

(4) Preventing chronic diseases: a vital investment. Geneva: WHO, 2005

(5) Leeder S, Raymond S, Greenberg H, Liu H, and Esson K. A Race against Time: The Challenge of Cardiovascular Disease in Developing Countries. New York: Trustees of Columbia University, 2004.

(6) Yach D, Hawkes C, Gould CL, Hofman K. The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA 2004; 291:2616-2622.

(7) Horton R. Chronic disease: the case for urgent global action. Lancet 2007; 370:1881-82.

Amanda J. Redig, a student at the Feinberg School of Medicine in Chicago, has written an article on the challenges in biomedical research and the increased need - and opportunity - for translational knowledge sharing between physicians and scientists.

An Indian fable tells the tale of several blind men asked to describe an elephant.  The man who reaches the tail declares the unknown animal to be like a rope; the man who brushes past the leg asserts that what is in front of him must be like a tree; while the final man bumps into the tusk and concludes that the unseen creature resembles a spear.  In the end, those of us who can see the elephant know that each individual assessment is both right and wrong: what is missing is the vision required to put all of the pieces together into a comprehensive whole.  What I want to know, as an MD/PhD trainee during arguably the most exciting time to be a student in the history of both medicine and biology, is whether the biomedical community is now confronting a similar challenge.  Recent advances offer a tantalizing glimpse of what our future could be, but has the quest to integrate an ever-widening information pool and spectrum of disciplines become an exercise in describing the elephant?

Without doubt the 20th century’s remarkable achievements in clinical therapies and scientific discovery provide a solid foundation for the enthusiasm with which we can move forward into the 21st.  Yet for every shining success story-the 85% survival rate for pediatric leukemias or the technical achievements behind transplant surgery-we must still confront the published survival curves for a disease like lung cancer.  And here, as with far too many other diseases, despite decades of effort and millions of dollars, not much has changed.  The complexity of understanding human health and disease means that we must continue what is often a painstaking process of piecing together insights that move from structural biology and model organisms to targeted therapies that do have efficacy in the clinic.  From Watson and Crick to chromosomal translocations and the development of imatinib, the connection between scientific advancement and new medical therapies is undeniable.  However, what I can’t help but wonder as I move through the process of dual training as a physician-scientist is if the current trajectory of our research efforts-the overlap between basic science and clinical medicine-is one that in the end will achieve the greatest results.  The progression from lab to clinic might be self-evident, but unless our framework for biomedical progress moves to truly integrate not only the expertise of multiple clinical specialties but also a full spectrum of scientific investigators, 21st century advancement in medicine cannot live up to its potential. 

The foundation of this challenge is clear: much of the time, physicians and scientists simply do not understand one another.  Both parties ask questions, but the good physician arrives at the same diagnosis as any other good physician while the good scientist sees what no one else has and arrives at a new conclusion.  Unfortunately, the stark differences in training and perspective that make laboratory investigators or clinicians successful within their respective fields can and do inhibit the success of potential collaborations that are not exclusively one discipline or the other.  Speaking to this challenge, much has been made in the literature of late about the directions of academic medicine, biomedical research, and the future of so-called translational research.  Editorials and analyses discuss the role of the physician-scientist or clinical investigator as a go-between (1,2) as well as concern about funding mechanisms and the increasing age at which investigators secure independent grants (3-5).  However, even as initiatives such as the National Institutes of Health roadmap or the recommendations of the Cooksey review are exploring ways to bridge science and medicine (6,7), there is also controversy over whether this is even a good idea let alone a feasible goal (8-10).  In the end, much of the discussion falls back to the fundamental differences between how basic scientists and clinicians ask questions-investigator-driven mechanistic grants on the one hand and large-scale correlative studies on the other.  Yet in order to build on the promise of the last century, our challenge is not merely to discuss the possibility of a new paradigm for biomedical research but rather to implement it.

First, we face the task of integrating physicians and scientists when the barriers between them are constructed with each year of the extensive training process.  In most cases, physicians must complete medical school, residency, and often some fellowship training before they have the time to become involved in meaningful laboratory research.  During this same training period, their early-career scientific colleagues have been just as immersed in the no-less rigorous and time-consuming program of focused graduate school and post-doctoral research.  By the time their paths overlap, the boundaries are set: physicians are physicians and bench scientists are bench scientists.  From the perspective of a post-doc who has spent the last ten years dissecting the most intricate of molecular details, the physician who waltzes into the lab not knowing how to pipet but expecting multiple first author publications in less than two years will never be a scientist.  On the other hand, for the senior resident who has thirty seconds to respond to a coding patient in the throes of cardiac arrest, the scientist planning to spend a career elaborating a pathway in fruit flies is out of touch with the real world.  Is it any wonder that each field can view the other with more than a healthy dose of skepticism and sometimes even outright resentment?

Unfortunately, the separation between these fields continues past the early stages of training. By the time a junior scientist is ready to start his own lab or a junior attending moves into her own niche as a professional, the responsibilities of career development at this crucial juncture take priority over exploring the complex challenges that will likely require input and ideas from both physicians and scientists to solve.  Molecular science is emphasized in the very beginning of medical school, but after that, the details take a back seat to the pathophysiology that is the territory of the physician.  This works for training clinicians, but what about clinician-investigators? In turn, Drs. Kaushansky and Shattil encourage aspiring physician-scientists everywhere as they editorialize about supporting the development of biomedical investigators in hematology-oncology, but this very same op-ed also highlights a hole in the cross-disciplinary mentoring of junior scientists (11).  If physicians who move into the scientific arena need support and mentoring to tackle multidisciplinary problems, then the same is true of their scientific peers seeking to apply scientific training to clinical problems.  Yet there seem to be few, if any, organized opportunities for scientists to be introduced to the clinical problems that their technical skills and hypothesis-driven training could help solve.  Even more problematic, although biomedical research buildings are often adjacent to academic hospitals in an attempt to promote translational research, it is much less common to see such collaboration with scientists several steps further away from medicine; engineering, applied math, and computer science have yet to become as closely integrated with biomedical research as molecular biology and genetics.  It is true that the more conventional partnership has led to some success stories-understanding the role of a single gene or pathway in disease has allowed the development of new therapeutic options.  However, as the aftermath of the Human Genome Project has made clear, the majority of chronic diseases-like cancer-that continue to cause great suffering around the world are too complex for the approach of inhibiting a single pathway or kinase to work.  Indeed, the molecular biology-based success of a targeted drug like imatinib remains to be replicated in the mathematically more complex signaling milieu of solid tumors.

While it is easy to take sides in the pull between medicine and science, morbidity and mortality statistics make it clear that we cannot afford to maintain the status quo: we need to fix the culture gap.  In order to translate our leaps and bounds of information acquisition into leaps and bounds that make a tangible difference in patients’ lives, we must broaden not only the scale of our vision but also the connections we are willing to forge to get there.  If communication-or lack thereof-amongst early-career trainees is a barrier to future success, then an added dimension to the training process might produce physicians and scientists with enough common vocabulary to minimize the height of the walls.  For example, Duke University’s medical training program-and now a joint medical school started in collaboration with the government of Singapore-includes a mandatory year of independent scholarship (12).  While the range of chosen research projects is broad, each graduating MD does so not only with firsthand experience of biomedical investigation but also with a new set of skills and language that can be a bridge to future collaborations outside of strictly clinical medicine.  Many academic institutions have recognized the need to better integrate medicine and the life sciences; key to these efforts will be not only involving medical appointees but also providing opportunities for scientists of all stripes to learn more about the clinical challenges-metastasis, antibiotic resistance, microimaging-that practitioners of medicine cannot solve on their own (13-15).  While excellence in a specific discipline should be the goal of graduate training, the gradual acquisition of blinders that prevent recognition of excellence in an outside specialty is not. 

What we are missing, it seems, is a greater focus on not only what our own skill set- whatever that might be-can bring to the table, but also what we stand to gain from the contributions of the others around us.  Although the initial steps of beginning an initiative that focuses on a problem, not a five-year grant project, can be daunting, the results of innovative collaboration are no less remarkable.  When the problem is that of infertility in young women who are cancer survivors, a reproductive biologist at Northwestern University chose to establish a partnership with an engineer to address the structural and biological challenge of ex vivo oocyte maturation.  The combined expertise of two divergent branches of science led to further expansion and a move towards the clinic.  Today, the Center for Families After Cancer encompasses the work of oncologists, surgeons, scientists, engineers, ethicists, and social scientists to move forward a new field that has been dubbed ‘oncofertility’ (16).  On their own, each member of this team held only part of the puzzle, but together their skills and uniquely valuable perspectives have combined to produce a vision that is both more extensive, more accurate, and ultimately more productive than anything they could have done on their own.  Within the time-span of a career, the members of this team will see a profound change-a giant step forward-in a clinical dilemma that until now had no solution.

And if this and similar advancements are slowly developing in some areas of medicine, then why not in one area after another?  As an aspiring oncologist, the challenges are clear-from lung cancer to pancreatic cancer, the list of malignancies for which there are very few options is still far too long.  Yet with the combined expertise of talented scientists and clinicians the world over, are we closer than we think to moving past the pieces of the elephant?  The mainstay of lung cancer therapy is some combination of surgical resection, radiation, and chemotherapy, which in the end most often delay, not prevent, the inexorable progression of the tumor.  But what if that picture changed?  Imagine a world that still started with thoracic surgery and the metastasis of lung cancer but then moved to a physical chemist and nanoscale visualization techniques implemented by an engineer and then data-mined by a mathematician using a program designed by a computer scientist who then together present a kinetic model of invasion to a molecular biologist who uses an animal model to uncover a mechanism and then collaborates with a pharmacologist to design an inhibitor cocktail which is prescribed by a medical oncologist working in tandem with a thoracic surgeon.  And in the end, the patient goes home to live, not to die. 

These changes have already begun and I know they will continue-but as baby steps or giant strides? The extent to which we can revolutionize both scientific inquiry and medical treatment is directly proportional to our ability to see beyond the walls that can-but only if we let them-separate us from our colleagues.  We owe it to ourselves, to each other, and most of all to the patients who are our family and friends and sometimes even ourselves, to work towards a future that is worthy of what we have already gained and what we stand to lose if we let our moment at this historic juncture slip away.  The men in the elephant fable are blindfolded, but we don’t have to be. 

Acknowledgements: I am grateful for the thought-provoking discussion and insightful commentary provided by Alan Hauser, MD, PhD and HG Munshi, MD during the preparation of this manuscript.

(1)  Varki A, Rosenberg LE. Emerging opportunities and career paths for the young physician-scientist. Nat Med 2002;8:437-9.

(2)  Dickson D. UK plans to encourage physician scientists. Nat Med 2000;6:490.

(3)  Weinberg RA. A lost generation. Cell 2006;126:9-10.

(4)  Vastag B. Increasing R01 competition concerns researchers. J Natl Cancer Inst 2006;98:1436-8.

(5)  McNally N, Kerrison S, Pollock AM. Reforming clinical research and development in England. BMJ 2003;327:550-3.

(6)  Zerhouni EA. Clinical research at a crossroads: the NIH roadmap. J Investig Med 2006;54:171-3.

(7)  Black N. The Cooksey review of UK health research funding. BMJ 2006;333:1231-2.

(8)  Marks AR. Rescuing the NIH before it is too late. J Clin Invest 2006;116:844.

(9)  Marks AR. Rescuing the NIH: the response. J Clin Invest 2006;116:1460-1.

(10)  Crowley W, Courtney J, Jameson L et al. The Clinical Research Forum and the Association of American Physicians disagree with criticism of the NIH Roadmap. J Clin Invest 2006;116:2058-9.

(11)  Kaushansky K, Shattil SJ. Bloodlines: the importance of mentoring for the future of hematology. Blood 2007;109:1353-4.

(12)  O’Connor Grochowski C, Halperin EC, Buckley EG. A curricular model for the training of physician scientists: the evolution of the Duke University School of Medicine curriculum. Acad Med. 2007;82:375-82.

(13)  Humphrey JD, Coté GL, Walton JR, Meininger GA, Laine GA. A new paradigm for graduate research and training in the biomedical sciences and engineering. Adv Physiol Educ. 2005;29:98-102.

(14)  Tadmor B, Tidor B. Interdisciplinary research and education at the biology-engineering-computer science interface: a perspective. Drug Discov Today. 2005;10:1183-9.

Dianna Louie and Shafik Dharamsi discuss the role of health workers as health advocates and use Dianna’s experiences in Uganda to illustrate their points

“We are the first generation in history that can end extreme poverty.
That’s our good fortune, our challenge and our responsibility.” Jeffrey Sachs

Many students spend the summer between first and second year conducting medical research in order to improve their resume for entry into postgraduate medical training. Others shadow different specialists in an attempt to figure out what type of medicine they want to practice at the end of their four year program.

I decided to do something different. (more…)

In the second installment of his experiences, Paul Park tells us more about the situation in the Ugandan refugee camps

The clinic tent

An elementary school in the bordertown of Busia, Uganda housed the 2,000 refugees with each packed classroom inevitably creating a ripe environment for disease. In addition, the threat of violence was still present due to the proximity to the border and the similar tribal demographics in comparison to that of western Kenya. The Red Cross refugee site was located just 1.5 km from the local public clinic. Thus, without any medical infrastructure, Red Cross personnel were sending all refugees with health needs to the clinic. As you could imagine, the Red Cross staff was pleased to learn of my medical background and immediately gave me all clinical and public health responsibilities. I gave health education presentations (sanitation, personal and community hygiene, etc.) and continued to make referrals, in which I would write a brief history and physical to assist the overwhelmed clinic. Additionally, I initiated a patient record system. As a medical student, it is easier to feel competent when the safety net of your attending is always in place, and this scenario was no different. However, that was all about to change. (more…)

Medical student, Paul Park, was in Kenya when the violence started. In the first installment of his experiences, he explores some of the ethical considerations of his evacuationTension ripped across an entire nation on the 29^th of December, 2007, just two days after the Kenyan presidential election, when the election results were surprisingly announced to be “too close to call.” In Eldoret, Kenya, the majority, being of Kalenjin ethnicity, were ready for a new beginning with the expected victory of their presidential candidate, the challenger Raila Odinga of the Orange Democratic Movement (ODM) party. News of riots breaking out in other cities of western Kenya began trickling in as Eldoret citizens anxiously continued to wait. As the day progressed, accusations against Mwai Kibaki, incumbent candidate for the Party of National Unity (PNU), of election fraud gained credibility as his popular vote deficit of 900,000 was reduced to 100,000 out of 8 million votes, while Odinga’s numbers remained virtually unchanged. That afternoon, I received a text message from the manager of my housing compound: DO NOT GO INTO TOWN, RIOTS. (more…)

 Mukhtar Ahmed shares an uncomfortable experience

My elective and adventure in Africa began in London. I remember the feeling of excitement and nervousness tying my stomach into a knot; all the new sights, sounds and smells that I was going to experience! For me this was what made medicine so appealing to me. It would be my key to the world. With it I was going to experience life. (more…)

Misty Richards, Marc Freiman, Stephanie Van Dyke, and Neil Gray discuss the ethos behind the setting up of the Engeye Health Clinic in Ddegeya Village, Uganda

Religion, wealth, and power are among the principal causes of human conflict.  Religious, nationalistic, and ethnic ideologies are frequently exploited to facilitate the dehumanization of another people, allowing violence to become an acceptable option.  Frequently, migration is both a contributor to, and a result of, such conflicts.  The influx of a new people into a region often leads to conflict over land, resources, and political power, particularly when accompanied by significant cultural, religious, and/or ethnic differences.  Conversely, prolonged or significant conflict frequently creates a strong impetus for migration, as people abandon their homes in search of a security.  Hence, conflict and migration are linked in a vicious cycle. (more…)

According to Guus Bol, this situation  is a problem induced by a failing mental health system

A homeless man on the beach in San Francisco

Just arrived in San Francisco and I already ripped my sneakers. Still a bit drowsy from my jetlag I wander out of the hostel to find a shoe store so that I can replace my beloved but tormented shoes. I’m walking down Mission Street when a homeless person asks me if I can spare a buck, I give him a dollar and walk on. A little further a guy in the same outfit asks me the same question, and as I am a guest in this city I should be friendly, I give him a dollar as well. Next, one peculiar guy requests nuclear weapons instead of money. This scene is repeated until I reach the shoe shop where I find some nice sneakers to replace the old ones, although I now have no money left to buy them. (more…)

 Love it or loathe it, it looks like facebook is here to say. Elizabeth Leyland discusses how this latest social network phenomenon could affect medical practice

Raging across the globe with alarming speed, the spread of Facebook shows no signs of stopping. It has been doubling its users every six months and now has more than 55 million worldwide. (1) Perhaps worryingly, even medical students are susceptible to its highly contagious charms. Having signed up as a half-hearted sceptic eighteen months ago, I now find myself craving a daily Facebook fix. Should there be a role for Facebook in the life of a medical student? Don’t we poke innocent victims quite enough when practising examinations, without subjecting people to unlimited Facebook poking? I launched an investigation to determine whether social networking is predominantly positive or destructive. I began my research by checking my Facebook page. (more…)

Kayvan Bozorgmehr gives an account of his experiences following Cyclone Sidr in Southern Bangladesh where he was working with the Bangladeshi NGO, Gonoshasthaya Kendra

The devestation in Kakchira village, Patharghata District

On 10^th November the International People’s Health University of the People’s Health Movement took place in Savar, Dhaka in the North of Banagladesh. On the campus of the local NGO Gonoshasthaya Kendra (GK- Gonoshasthaya Kendra- People’s Health Centre is a Bangladeshi NGO founded in 1971, which provides people-oriented health management, primary education and women’s empowerment programmes), more than 40 health professionals, activists and scientists from 15 different nations came together to discuss and exchange their experience on the social, political and economical determinants of health.

Five days later Cyclone Sidr threw a shadow over the country. In Dhaka, telecommunication, internet services and electricity supply broke down. Government officials were unable to provide the number of casualties in the worst affected areas, but with every passing day, news about the vast impact of the cyclone emerged. While international donors made the first financial comittments to the Government of Bangladesh, the stunts of US helicopters at the Bay of Bengal dominated the media - we were observers of a CNN-effect just being launched.

Another scene from Kakchira Village

I joined Dr. Rezaul Haque, the Rural Health Coordinator of GK on his assessment mission to the South in order to get an impression of the impact of the disaster on public health, the needs of the people and the coordination of the humanitarian relief. While the public health consequences associated with tropical cyclones include many factors like storm-related mortality, injury, infectious diseases, psychosocial effects, displacement and homelessness, damage to the health-care infrastructure, disruption of public health services, transformation of ecosystems, social dislocation, loss of jobs and livelihood, and economic crisis (1), it is known that these outcomes disproportionately befall developing nations, with human factors strongly influencing the observed disparities. (2)

It was too early to assess the economical losses, but I had the feeling that this disaster combined with its counterpart of extreme poverty, international debts and corruption was going to increase the sufferings of millions of affected people for a long time - especially as Sidr affected areas are surplus areas for production of rice to feed Bangladesh. (3) Despite some success in cushioning exreme poverty to a limited extent in rural Bangladesh, the process of poverty reduction in such Bangladesh is always fragile and the livelihoods of rural areas are fraught with vulnerability that stems from a variety of factors, ranging from natural to social arenas and macro to micro levels - like floods, economic shocks, death and illness in the household, insecurity of life and property - all these and other factors can offset the gains in the poverty frontier. (4)

On day 8 after the cyclone, we headed for the south with a public bus from the Saidabad bus terminal in Dhaka - with generic antibiotics and other essential drugs on the roof of our bus. At that moment GK had 10 doctors and approximately 40 paramedics in the Southern regions, who were already providing health care services.

After two hours we reached the river Padma. The stream, which springs from the Himalaya and the Ganges, carried us on a ferry towards the Bay of Bengal passing a beautiful landscape. Two more hours passed until we left the ferry and continued our ride on the bus. We crossed the river Payra with a second ferry and reached a stoney, torn road, on which we continued our trip. We followed the track of devastation, passed thousands of broken trees and power poles bent like blades of grass. Finally we reached our destination after 10 shaking hours - the subdistrict Patharghata in the district Barguna.

Mr. Selam Khan, the UP Officer of Patharghata and the authority in charge for the subdistrict, was responsible for the coordination of the support in the seven unions of the subdistrict and for the communication with the 20 NGOs, which worked in these areas. He explained the comprehensive Cyclone Preparedness Programme (CPP) provided by the Ministry of Disaster Management and Relief and the Bangladesh Red Crescent Society, while Dr. Haque informed him about the intentions of GK in the nearer future.

According to Mr Khan, “As one of the worst affected areas, Pathargatha has been hit by the eye of the cyclone with a speed of 220 miles per hour for a duration of 3 to 5 hours, accompagnied by a tidal wave with the height of 15-17 feet (approx. 5meters). 95 % of the houses, a total number of 35.700, are lost. 283 people died, 205 are still missing. 36.000 livestock have been killed. 190 educational buildings, 626 kilometers of road and 39 bridges are destroyed. There has been a warning 48 hours before the disaster, so we succeeded to evacuate 24.000 people - but many refused to be evacuated.”

The death toll of Sidr was relatively low compared to the 1991 Bangladesh Cyclone, one of the deadliest tropical storms on record that killed nearly 140.000 people. (5) Sidr was not less severe than the 1991 Bangladesh Cyclone, but due to preventive actions of the government and local NGOs, the building of cyclone shelters and embankments, and the appropriate action of evaquating 1.5 million people of an estimated 5 million people in the costal areas, the death toll could be reduced this time.

Apparently lessons learned from previous cyclones, namely that the risk of dying was related to the type of shelter (6) and that easy access to shelters was a significant factor in reducing the risk of dying (7) had led to an emphasise on preventive actions. But we noted, that there is still a lack of shelters, especially of multifunctional ones. In the whole subdistrict of Patharghata, an area of 387 km², there were only two official cyclone shelters - for many people too far to reach. Mr. Khan agreed with us that additional shelters for animals could increase the willingness of people to be evacuated as that would decrease the loss of livestock - a loss which can impoverish a whole family.

Among the 20 NGOs, only one was dealing with mental health problems. The lack of awareness of mental health problems after disasters may lead to delays in the psychosocial rehabilitation (8) or even to Post Traumatic Stress Disorder among the survivors. The impact of Sidr on the psychological status of the people revealed itself, when we strolled through destroyed villages in Kakchira, Bodma, Horinghata and Djintola and talked to desperate people, each with individual stories of beloved, but lost family members.

We also saw the effects of well-intentioned but poorly implemented aid: for example youngsters from Dhaka throwing clothings randomely from the roof of a building towards a crowd, creating scenes of fighting women and screaming children. There was also a camp organised by a leading NGO, with the capacity to supply 200 children with food for one day over a period of one month. But how can you pick 200 children out of the many in need for help? The information about the camp had been announced in the few schools which had outlasted the cyclone. Lots of children had walked many kilometers to reach the place. I remembered a scene from Bodma, a fishing village in 11 kilometers distance: a 4 year aged child with a spoon in his small hands scratching out a green coconut and feeding the last bits of the precious coconut-flesh to his crying brother with ascites, who was younger than himself. I wondered if those children, who could walk such a distance were those in most urgent need of help. And what about newborns and infants? Among 200 hundred children there were only 8 newborns, all carried by their brothers or sisters - parents or mothers were not allowed to stay in the camp. There were no sanitation facilities for the 200 children.

The medical support and food distribution in the areas we visited was disproportionate. While the international NGOs mainly concentrated on central areas, they were underrepresented in remote areas and duplication of aid occured more than once - despite the CPP and the general effort of the NGOs to coordinate and to cooperate with the governement. In general, the governmental primary health care stations were very poor equiped - a few antibiotics, some paracetamol, some waterpurification tablets. The GK teams and other NGOs were fairly better equiped. But still there was a lack of many things, e.g. gloves for the staff, simple surgical instruments, local anaesthetics and tetanus vaccines in some NGO camps.

I met Zaman, a young doctor of GK. He had reached the affected areas as one of the first teams and had been working in remote areas for the last 8 days. He described the situations he had faced shortly after arriving, the dead bodies, the seperated hands and limbs lying around in the villages, unpassable roads and severe fractures. He said that the main problems now were diarrhoea, pneumonias, colds and fever, and major water and sanitation problems.”  In fact all the 451 ponds in the subdistrict used for drinking water were damaged.

Dr. Amal Chandra Roy, the Union Health and Family Planning Officer, was in charge for the coordination of health and medical supply for all the seven unions in the subdistrict Patharghata. By the light of a lantern, we sat in his office, a small room of the only hospital in an area of 387 km² with a total sum of 31 beds. 18 doctors of the government were working in this area since the disaster happened - 18 doctors for an estimated population of 162.000 people. “That is almost one for 10.000 people”, he told us. “Before the disaster there were only two doctors in the whole area, this is a 9-fold increase”. He would appreciate a better cooperation with NGOs, especially with international ones, to avoid duplication.

Experiences from 1991 show, that in the post-cyclone period, the affected areas actually received a much higher level of health-services than they had ever before. Nevertheless, 6 months after the cyclone 1991, there was a significant rise in the prevalence of severe malnutrition in the affected areas for children aged 1-5. This suggests that there were deficiencies in the post-cyclone medium to long term health response. (9) This is the time when the international and national media coverage of the rehabilitation process usually fades - and with them the CNN-effect of pulsative aid, leaving behind the need of sustainable aid to turn relief into self-relience. There is a urgent need to solve not only disaster related problems, but also longterm, global problems - the manmade parts of natural disasters.

I left Dr. Roy’s office and stepped into the room next door, the emergency room of that hospital, where a paramedic sewed an injury close to a man’s eye by the pale light of a candle while a doctor, one of the eighteen, examined a crying child. “We are used to this darkness”, he said.

Kayvan Bozorgmehr
Globalisation and Health Initiative (GandHI)
German Medical Students’Association
bozorgme@stud.uni-frankfurt.de

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(5) http://en.wikipedia.org/wiki/1991_Bangladesh_cyclone

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(7) Siddique AK, Eusof A. Cyclone deaths in Bangladesh, May 1985: who was at risk. Trop Geogr Med. 1987 Jan;39(1):3-8.

(8) Choudhury WA, Quraishi FA, Haque Z. Mental health and psychosocial aspects of disaster preparedness in Bangladesh. Int Rev Psychiatry. 2006 Dec;18(6):529-35.

(9) Rahman  MO, Bennish M. Health related response to natural disasters: The case of the Bangladesh Cyclone of 1991. Soc Sci Med. 1993 Apr;36(7):903-14