Firoz Mahmood Iqbal
BANGLADESH-ITS YOUNGEST GENERATION & CHILD HEALTH CARE SERVICES
I am Dr. Firoz Mahmood Iqbal from Bangladesh. It is definitely one of the greatest moments in my life. I am truly honored for getting this splendid opportunity to write something about my most beloved motherland Bangladesh concentrating significantly on her wonderful youngest generation. With my little experience I will modestly try to highlight the special health problems of our children and their management in the comprehensive perspective of our health care system.
Bangladesh is a unitary and sovereign republic known as the people's republic of Bangladesh. Bangladesh emerged as an independent country of March 26, 1971. The war of liberation ended on 16th December 1971 in victory of Bangladesh forces and surrender of the occupying army. The area was under Muslim rule for five and a half centuries and passed into British hands in 1757 AD. During the British rule it was a part of British Indian province of Bengal and Assam. In August 1947 it gained independence along with the rest of India and formed a part of Pakistan and was known as east Pakistan.
The state language of Bangladesh is Bangla. The National anthem of Bangladesh is the first 10 lines of "Aamar sonar Bangla" written by a noble laureate poet Rabindranath Tagore. The national flag of the republic consists of a circle cloured red throughout it's area resting on a green background. The emblem of the republic is the flower shapla (nympoea nouchali) resting on water having on each side an ear of paddy and surmounted by three connected leaves of jute with two stars on each side of leaves. The capital of the republic is Dhaka 1353 sq km in area (statistical metropolitan area population in 1991 was estimated to be 6,844,131. Now what about some data & statistics about Bangladesh? If you allow me, I would like to present you some facts & selected statistical figures of my motherland.
Geographical location Between 20¡34' & 26¡38 north latitude
Between 88¡01' & 92¡41' east longitude
Neighboring countries North India
West India
South Bay of Bengal
East India & Burma (Myanmar)
Area 55,598 Sq. miles or 143,998 sq km
Territorial water 12 Nautical miles
Standard time GMT+6 hours
Population 114.400 million of 11th March 1991
(Census)
57.3 million male
54.1 million female
Sex ratio 106 males per 100 females
Annual growth rate(1981-1991)
1.82%
Density 755 per sq km.
Literacy rate all ages (1991) Both sexes 32.4%
Main seasons Winter (Nov.-Feb.) max. 29¡C min. 11¡C
Summer (Mar-Jun.)max. 34¡C min. 21¡C
Monsoon (Jul.-Oct.) average rainfall
1194-3454mm
Principal Crops Rice, wheat, jute, tea, tobacco, sugarcane,pulses, oilseeds, spices, potato, vegetables, mango, banana, coconut & jackfruit
Principal Export Raw jute, jute manufactures, tea, hides & skins, newsprint, fish & ready-made
National Income & GDP GDP in 1989-90 at (1984-1985) constant factor-cost 469.3 billion taka & current factor cost 695.7 billion taka.
per capita GDP at (1984-1985) factor cost TK. 4202 In 1989-90 & at current factor cost TK. 6229.
Education(1990) Universities 7 (4 general 2 technical & 1 Islamic)
College-893.
Engineering college-4
Polytechnic Institute-18
Primary schools - 45,783
Primary school enrollment 12.3 million
Secondary school 9,822 (10-14 years)
Secondary school enrollment 3.4 million
University enrollment 47,888
HEALTH
Hospital 903 Govt.611
Non Govt. 292
The rural health complex 384
Hospital beds- 35280 govt. 27637
Non govt. - 7643
Person per hospital bed - 3208
Registered physician - 22400
Person per physician - 5054
Registered nurse - 9455
Registered midwives - 10104
Govt. dispensaries - 397
Maternity & child welfare centres - 96
Health personnel - 77209
Life expectancy at birth (1993) both sexes 57
male - 57
female - 56
CDR BY RESIDENCE
Year National Urban Rural
1991 11.2 7.8 11.4
1993 9.2 7.2 9.8
CBR BY RESIDENCE
Year National Urban Rural
1991 31.6 23.9 32.9
1993 28.4 22.1 30.0
INFANT MORTALITY RATE (IMR), PER THOUSAND LIVE BIRTH
BY SEX
1991 1993
Both 92 84
Male 94 87
Female 90 81
BY RESIDENCE
1991 1993
National 92 84
Urban 69 61
Rural 94 88
NATURAL GROWTH RATE (CBR-CDR) BY RESIDENCE
1991 1993
National 2.06 1.82
Urban 1.60 1.50
Rural 2.18 2.02
TOTAL GOVT. EXPENDITURE ON HEALTH INCLUDING FAMILY PLANNING.
1991 1993
Crore Taka 698 1128
PER CAPITA GOVT. EXPENDITURE ALL HEALTH & FAMILY PLANNING
1991 1993
Taka 62 107
ESTIMATED NUMBER OF INDOOR & OUTDOOR PATIENTS IN DIFFERENT HOSPITALS & CLINICS.
No. No. bed indoor outdoor
IPGMR 1 1750 40767 3,65,271
Govt. Medical college
Hospital 8 5400 1,85,985 1,33,0181
District Hospital 59 4000 381990 3633591
THC/RHC 384 11652 64151 13759286
TB Hospital 4 406 2470 Not available
TB Clinic 44 - - 19647
(INCLUDING OTHER DIFFERENT SPECIALIZED & GENERAL GOVT. & NON GOVT HOSPITAL TARGET DURING 4TH 5-YEAR PLAN(1990-95)
1989-90 Bench mark Plan target 1994-1995
Hospital beds 34488 364888
Doctors 20590 25600
Nurses(basic) 9100 11350
Population control
Contraceptive prevalence rate
CPR% 35.5 50.0
CONSUMPTION & NUTRITION INDICATOR
AVERAGE PER CAPITA PER DAY CALORIE INTAKE (KCAL)
Bangladesh Rural Urban
1988-89 2215 2217 2183
1991-92(P) 2264 2267 2183
Average per capita per day protein intake gm
Bangladesh Rural Urban
1988-89 64 63 68
1991-92(P) 63 62 68
Crude birth & death rates
per thousand
birthrate death rate
1990 32.8 11.3
1993 28.4 9.2
I believe you have got some superficial impression about the people & some of it's major statistics. Since Bangladesh is a member of the least developed countries it's the common phenomenon that our people is really poor and naturally dependent on their luck. Bangladesh is ranked 9th in the world population series. Our people is naturally tied down by so many socio-economic problems. The geographical location of my country is such that she has got to be very often vulnerable to natural calamities of vast diversity. Repeated devastating flood & cyclones aggravate the misery of our economy further. Over population and poverty inherent to an under developed country has obviously been putting immense stress to our national life.
Against this backdrop of all odds our government & people are morally determined to ensure the availability of fundamental health care facilities within their limited resources to each and every citizen. We are ensuring the smooth health care delivery system through intimate & coordinated approach at different levels. Practically Thana Health Complex is the nucleus of our rural health care system. Since ours is a country dominated overwhelmingly by rural population, Thana Health Complex has been receiving highest importance. Let us have a look at the staffing pattern in the THC & UHFWC. If you kindly care to look at the chart you will find how systematically we are dealing with it.
STAFFING PATTERN OF THANA HEALTH COMPLEX
Serial No Type of personnel No
1. Thana Health and Family Planning Officer 1
2. Surgical Specialist 1
3. Gynaecologist 1
4. Medical Specialist 1
5. Dental Surgeon 1
6. Resident Medical Officer 1
7. Medical Officer 2
8. Medical Assistant 2
9. Pharmacist 2
10. Staff Nurse 2
11. Laboratory Technician 2
12. Radiographer 1
13. EPI Technician 1
14. Dental Technician 1
15. Driver 1
16. Junior Mechanic 1
17. Typist 2
18. Sweeper 5
19. Support Staff 10
Domiciliary Service
1. Health Inspector 1
2. Assistant Health Inspector 3
3. Family Welfare Worker 15
4. Family Planning Assistant 3
5. Family Welfare Assistant 10
UNION HEALTH AND FAMILY WELFARE CENTRE
Serial No Type of Personnel No
1. Medical Officer 1
2. Medical Assistant 1
3. Pharmacist 1
4. MLSS 1
TARGET DURING 4TH 5-YEAR PLAN 1992-95
TARGET DURING 4TH 5-YEAR PLAN (1990-95)
1989-90 bench mark Plan target 1994-1995
Hospital beds 34488 364888
Doctors 20590 25600
Nurses (basic) 9100 11350
Population control
contraceptive prevalence rate
CPR% 35.5 50.0
Only 10% our entire population lives in urban areas. They are definitely receiving better health care services in comparison to their fellow countrymen, in cities we have got both govt & private hospitals & clinics. They are equipped with comparatively newer facilities. but in rural areas services of only govt health centers and non government organizations working voluntarily are available. Their jurisdiction is wide but their penetration is yet far less than expected. However 90% of our people has got to rely on them. If we consider paediatric age limit up to 15 years of age, the proportion of this age group is around 40% in our country. Virtually contributing the single biggest proportion to the total population. Poverty, parental illiteracy, superstition negligence make them most vulnerable segment of our society. Children of our country need to visit the health care centres with complaints attributable to diseases peculiar to the tropics. Everyday in our clinical practice we usually find them down with the following disease.
If I am asked to provide you a list of commonly occurring paediatric problems, in my opinion gastro intestinal problems should come first the commonest g.i. tract disease is diarrhoea. When they usually come up to a physician they are already in an advanced stage of malnutrition. Children very often suffer from tonsillitis though here it falls within the jurisdiction of an ent specialist, parents are usually bringing their child to a paediatric output. department. One thing merits special mention here that in our country incidence of rheumatic fever & its subsequent complication are alarming. Thousand of children suffering from eventual morbidity just for gross parental ignorance & negligence. Each year more than 80 million children are born in the developing world & each year about five million die from common contagious childhood diseases because less than 19% are protected through immunization. In our county we have already made significant coverage
EPI BANGLADESH
COVERAGE EVALUATION SURVEY 1992
Total dosage in percentage Doses administered by one year age
12-23 months (cards+history) under one in percentage (carde+history)
divisionBCGDPT1/OP1DPT3/OPV3MeaslesGCGDPT1/OPV1DPT3/OPV3Measles1Chittagong83.284.662.658.678.779.148.234.42Dhaka83.783.762.754.581.376.750.644.13Khulna95.894.987.085.693.087.673.674.14Rajshahi88.888.973.767.786.282.560.453.4National88.888.973.767.786.282.560.453.4Urban
areas91.991.4184.279.987.081.566.352.4
Still children with whooping cough & measles & their natural complications in untreated cases are found occasionally. Children with respiratory, gastrointestinal, renal, nutritional deficiency diseases are generally encountered in the indoor department. Amongst the respiratory tract problems, Acute respiratory infections (ARI), Acute bronchiolitis of infancy, Bronchial asthma, Tuberculosis are common.
IDCH DHAKA- The hospital presently I work with is an institute of diseases of the chest & hospital. It is situated at Mohakhali in our capital city Dhaka. This hospital has 500 beds & two main departments Viz-surgery & medicine. Patients suffering form chest problems including casualty casee from all over Bangladesh is referred to our hospital for ultimate management. Here at reference clinic which can be other wise called "out door" we get patients of all ages including children. Those children who visit here mostly suffer from tuberculosis & its complications, chest trauma & foreign body impaction cases are also not very infrequent. In my daily hospital activities I usually deal with the children. There are as many as 20-30 cases remain admitted in any time. Both of our departments are well equipped with sophisticated apparatus we have one nice intensive care unit where many state of the art instruments are available. We have as many as 25 doctors 10 consultants, 07 professors along with a good number of nursing staff in our hospital. Our hospital is the only specialized hospital for chest disease in Bangladesh.
Prior to my joining here I used to work in Bangladesh institute of child health which was previously called Bangladesh Shishu (children's) Hospital. My interest in tuberculosis in children developed while I was working there. Institute of child health is the only specialized hospital for children in Bangladesh. It is situated in Dhaka city. It has 400 beds. There are two main departments here-surgery and medicine. Medicine departments again have 3 major units-general, renal & neonatal. In children's hospital we have both indoor & outdoor departments along with emergency cell. In medicine patients suffering from g.i. tract diseases, ARI, Fibrile Convulsion, Pem, Agn, Nephrotic syndrome, Meningitis parasitic diseases are generally encountered. In surgery along with casualty cases & general surgical cases, genetic abnormality cases are also common.
While working in the institute of child health, the children suffering from tuberculous meningitis (TBM) specially draw my attention. TBM affects primarily children below five years of age & in a major cause of morbidity & mortality. It has insidious onset with lathergy, anorexia, headache & vomiting. There is history of lack of interest in play. Low grade fever, drowsiness or frank convulsions. As the disease progressed manfestations of raised intracraial pressure & meningeal irritation appear. Finally child becomes deeply comatosed with severe head retraction, opisthotonus or decerebrate rigidity, paralytic squint and unequal or fixed pupils.
Most important complications are hydrocephalus, blindness, deafness & mental deficiency. Cerebrospinal fluid is routinely examined for diagnosis. Isolation of acid fast bailli is diagnostic but rarely possible. Mantoux test may be positive but negative Mantoux test does not exclude tuberculous meningitis. In a statistics of children hospital patient suffering from tuberculous meningitis (TBM) shows the following picture-
year Total No. of TB patient Total No. of TBM Percgentace
1990 156 6 3.8%
1991 214 11 5.1%
1992 213 12 5.6%
1993 173 17 9.8%
1994 116 04 3.4%
Total 872 50 5.6%
In a recent study done in children hospital of TBM cases regarding the functional out-come of 29 children with TBM aged 41.8+_ 34.4 months. Treated between 1988-89. The TBM cases were graded as per British medical research council definition. Eleven children were fully conscious with no focal neurological sign-stage one, 10 children had disturbed consciousness with or without focal neurological sign stage II, eight children were critically ill and comatose-stage III. Twenty cases (69%) made complete recovery. Among them 100$ of stage I, 70% of stage II and 25% of stage III had made complete recovery. Overall mortality rate was 7% and all in stage III. Tuberculous meningitis is a dreadful and fatal form of tuberculosis in children resulting in permanent brain damage and disabilities. But early diagnosis and adequate management can lead to complete recovery and minimize the functional disabilities. Twenty-nine cases were selected who were admitted at tuberculosis unit of Dhaka Shishu Hospital in the year 1988. Their general characteristics were noted. The diagnosis of TBM was made mainly on clinical basis and laboratory investigations including CSF examination, tuberculin test, radiological examination of chest and demonstration of acid fast bacilli. The nutritional status, ABCG score and contact history were carefully recorded. The TBM cases were categorized into three stages as per original British medical research council definition of 1948. All the patients were treated with streptomycin (20 mg/kg/day for one month), isoniazid (15-20 mg/kg/day) and refampicin 10 mg/kg/day daily in empty stomach for one year. Patients were regularly followed monthly at tuberculosis follow up clinic of the unit for two years since start of therapy. Regular physiotherapy was done while in the ward and the mothers were trained and asked to continue physiotherapy at home.
The outcome of treatment in tuberculous meningitis is influenced by many factors, such as the severity and neurological status of the patient, the effectiveness of antituberculous drug, the management of neurological complications and appropriate general supportive measures. It has been demonstrated by various studies that early diagnosis and immediate & adequate treatment can lead to almost 100% recovery without any sequelae. The outcome of treatment in tuberculous meningitis in the advanced stage is still unfavorable, even with optimal medical care and effective antituberculosis medication. The main reasons are arteritis of the cerebral arteries-causing cerebral infarction and severe increased intracranial pressure. but by proper and adequate antitubersulous drug and by comprehensive management of CNS infection, the incidence of functional disability can be reduced to a significant number. In a country like ours with high prevalence of sputum positive adult cases, the mortality and morbidity from tuberculosis can be reduced by BCG vaccination, early case detection and appropriate chemotheraputic regime and good compliance.
The present health status of our children is gradually improving. This is greatly attributable to the mass awareness of our parents availability of health facilities in the doorstep even in the outreach rural areas and above all the concern of our government to the eradication of six most common communicable diseases of childhood with world health organization's active participation. If the present commendable score of success is maintained in near future we hope we will find a healthy younger generation. I feel very proud to be a member of a team of pediatricians who is engaged in a great cause like caring of childrens health in my country.
