This past week has been full of exciting opportunities and it is impossible for me to cover all of these in a single post, so I will try to touch on these throughout the next few blog posts. We traveled to Dhaka on the 10th where we presented our projects at a public health symposium, had conversations about starting a national cancer registry, and had the opportunity to do some sight-seeing at local monuments including the parliament, and Dhaka University. After our exciting time in Dhaka, Shivani and I returned to FCAB’s collaborative partner, Center for Women and Child Health, to make some progress on our Infant and Young Child Feeding practices intervention. While we are excited about how the project is going, it was our time following Dr. Talukder during his daily rounds in the hospital pediatric ward that was the most impactful.
First, there was a newborn infant whose mother had diabetes. The infant lay helpless with jaundice, an infection, and hypoglycemia. Seeing the infant fighting against the intrauterine exposures of diabetes would have been enough to make me respect the ways that diabetes is affecting the Bangladesh population, but a discussion with Dr. Talukder on the most recent Bangladesh autism survey made this even more impactful. Under preliminary analysis of this survey, diabetes was one of the greatest risk factors for autism. While my time at CWCH highlighted the diabetes burden Bangladesh faces, it has also been evident throughout my time with FCAB. I continually define my food as “sugary”, FCAB’s baseline survey noted diabetes as a major community concern, and at one of the recent GRO meetings diabetes remained a central topic of discussion. While FCAB continues to inform people about the risk of diabetes, I wonder the limits of education and communication. Are we called to change a tradition of high rice and sugar consumption? Do we need to improve access to treatment? Is it possible to promote lifestyle changes when a family’s primary focus is survival? These are questions I will continue to consider throughout the coming weeks, as I think about the ways that FCAB and the Bangladesh community can fight the rising burden of diabetes.
The second child seemed to be recovering well from what was, in comparison to the first, a minor illness. A smile broadened across his face as he kicked his chubby legs. This child had looked so happy and healthy that malnutrition had never crossed the minds of the physicians. They were about to check him out with a clean bill of health when Dr. Talukder intervened. We had just finished a conversation on stunting, wasting, and underweight, where an emphasis was placed on determining the child’s respective z-scores; a z-score less than -3 meant that the child was at a 9-11 time higher risk of mortality. When Dr. Talukder took the time to evaluate these measures for the “healthy” child it became evident that the child was underweight, and suffering from malnutrition. A natural assumption of the child’s health, almost made the physicians miss an opportunity to educate and support a mother in Infant and Young Child Feeding practices. This event led me to several questions. First, how often do our perceptions of people’s needs, impact the treatment, education, or service that we do, or do not, give them? Second, how much should we rely on statistics and tests to analyze the needs of the people we are trying to serve? From what I have experienced with FCAB so far, it is clear that our first understanding for the needs of the community must come from conversation. This is evident through FCAB’s Focus Group Discussions, where they invite the community to share their thoughts. Shivani and I are looking forward to interacting with these Focus Groups in the coming weeks, so that we can determine ways to make them more effective. My concern remains that there may be limitations to a purely conversational approach. While conversation can give us great insight into community needs, this scenario showed me that sometimes a communities true needs can’t come out of just conversation or perceptions; they are buried under a lack of education. Statistics, such as calculating the weight-for-age z-score for that little boy, can sometimes provide us with the insight that we need to better understand the nuanced needs that are not revealed through conversation. FCAB has demonstrated a commitment to this by incorporating monitoring systems into their village model. But are these strong enough? My fellow interns and I hope to strengthen FCAB’s integrated monitoring system so that we can combine both qualitative and quantitative information to get an intricate understanding of community needs.
The third patient that we saw was just one of three patients at CWCH that was suffering due to a public health campaign. The day previous, Bangladesh had implemented a nation-wide vitamin A campaign that is supposed to decrease the mortality and morbidity risk from some forms of diarrhea, measles, HIV infection, and malaria.1 What we saw at CWCH told a different story. Children came in with vomiting and swollen fontanelle; signs of vitamin A overdose. As I looked into the literature further it was clear that vitamin A research remained largely inconclusive; some studies had shown improvements in health while others had found that it increased the risk of acute respiratory infections.2 Again, this made me ask many questions. Should public health interventions that aim to improve health for all, be given to an entire population, if it is going to hurt some? Are we called to look at public health from purely a population perspective, or should we intervene at an individual level? I think in public health we often look at doing “good” from purely a population perspective; we are limited for resources and therefore try to do the most good with what we have. The result of this is the sick, vomiting kids, bed ridden from vitamin A overdose. Reflecting on Paul Farmer’s mantra that is revealed in the book Mountains beyond Mountains, I do not think we should settle for “doing the best we can”, but instead we should actually do what is best for all people. What does this look like in terms of vitamin A? This means giving vitamin A only to those who need it. Again, this is a scenario where we, as public health practitioners, are disregarding the true needs of the community. Giving someone something that they don’t need, is just as bad as failing to give them something that they do need. It may take extra work to make this differentiation, but these are simple fixes that we cannot skip over. In the next couple of weeks Shivani and I also want to go beyond the confines of the FCAB focus group discussions. We want to reach those who don’t come to FCAB’s events and discussions, and we want to see if FCAB is underserving or over-serving their community. Not only will this help FCAB tailor its interventions, but it will give us a better understanding for what public health service should look like.
I am thankful for amazing roommates – Michelle and Shivani – who consistently ask the hard questions and help me reflect on all of these experiences. This internship has already been a great growing experience, and I am looking forward to updating you more as I continue to learn.
- Villamor, E., & Fawzi, W. W. (2005). Effects of Vitamin A Supplementation on Immune Responses and Correlation with Clinical Outcomes. Clinical Microbiology Reviews, 18(3), 446–464. http://doi.org/10.1128/CMR.18.3.446-464.2005
- Eduardo Villamor, Wafaie W. Fawzi; Vitamin A Supplementation: Implications for Morbidity and Mortality in Children, The Journal of Infectious Diseases, Volume 182, Issue Supplement_1, 1 September 2000, Pages S122–S133, https://doi.org/10.1086/315921