Last Ramblings

It has been a little less than a year and half since I returned from my adventures in Bangladesh. I was compelled to write this post, mostly because memories from that green country flooded my mind in vivid detail as I sat in graduation chairs in December, reviewing the experiences that made my undergraduate years so rich.

Experiences like first rickshaw ride of my life on my 20th birthday. Little did I know I would have hundreds more. Places like Bismillah Fried Chicken, Kamal Ataturk Avenue (this was a sign!) that brought comfort, laughter and adventures and others like the upper floor of BRAC and Dhaka slums that brought me a harsh dose of reality. The serenity of the chars and my very humbling realization that I’d never really experienced real darkness, in a world I saw from the dock of the EFH – no electricity, little connection with the outside world. I remember and miss the effervescent streets – the honks and bickering of the rickshawallas.

The walk to and from work every day and stopping by the mango stand at the corner to pick up breakfast. It only took me a couple of days to realize that I wanted to walk to work, despite parental concerns. It was a very explicit decision not to experience or see Bangladesh from car windows. Worth it 100%, no matter how many stares I got. The monsoon rains and the consequent reaction of the Earth, as if everything had taken a collective sigh of relief. Debates with European businessmen during my few excursions to the foreign clubs of Dhaka – little, protected worlds where many fall numb to the inequities that surround them – about development in Bangladesh. Rocking back and forth for hours on end in boats in transit to chars, or in the buses that introduced me to rural Bangladesh. My patience is one thousand times stronger as a result of these journeys.

A dear Bhai from work telling me stories about the Dhaka of his childhood. A dear grandmother of a colleague who took my hands and kissed them after I kissed her in traditional custom for Ramadan, and the way my eyes welled up in tears because my grandfather used to kiss my hands, too. We are all more alike than we think. Hearing the drums pound during Eid from a rooftop in Dhaka, with the sun setting after a heavy rain. The way everyone, everyone, seemed to smile with their eyes.

When I was in Bangladesh, people asked me all the time why I came. I was never quite sure how to answer. The realities of the health infrastructure in Bangladesh and the obvious societal inequities taught me more about the importance of developing social responses to health issues than I could have ever imagined. It is certain that this realization has now permanently shaped the rest of my career.

Bangladesh was a time for me to truly exercise my love for humans, discovery, and ethnography; it was a time of constant motion, seeing, and doing. It was, and still is, substance and meaning for me as I envision and chart a course for myself in public health.

In his early experiences in Haiti, Paul Farmer was confronted with the ethical question of leaving a place behind, after having seen its problems and met its people. Such awareness inspired him to dedicate his life as well as his passion for public health and anthropology to addressing the roots of the problems he experienced. On a related note, a dear friend, one of my favorite writers, also pondered this question of observation versus “full” participation in a travel blog years ago, asking: “what does one do with a passion, a powerful and motivating interest, in another society? To do nothing but observe it feels futile. Where is the middle way?”

After all, this is the question of the traveler, one who is lucky and unlucky all at once to have had nomadic experiences that have awakened him or her to the implications that there is a world beyond ours – one which, no matter how hard we try, we cannot fully know. And yet, this same world is just as easily impacted, affected and often infected by our actions, even from thousands of miles away.

For me, the opposite is also true – my memories from Bangladesh, fleeting in nature, still very much influence me. And though my personal philosophy around travel binds me to the humble realization that I still have so much to learn and perhaps more importantly, that I will never fully know, my experiences in Bangladesh are anchored deeply into my personal history. These anchors have since created a new depth in my life and career, one that I hope will enlighten and inform my passions and interests moving forward, no matter where I am.

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Women and BRAC

Last week, a friend and I braved the Eid traffic to visit a colleague’s wife who works in the Gender Specialty unit in BRAC. We got lost, of course, which made getting to the final destination that much better.

It was interesting to hear what BRAC is doing on the issue of women’s rights and equality in Bangladesh. This visit is also uniquely timed; news of women committing suicide over harassment has been dominating the news over the last several weeks. It was only earlier this month that Bangladesh adopted the National Women Development Policy with a provision for equal share to property, employment and business for women.

Bangladesh has made some strides in women’s equality, but there is still so much more to be done.

Another anecdote about BRAC is that from its top floors, you can see Dhaka spread out before you. Covering an entire side of the landscape visible from the high windows is Korail Slum (one of ~7 big slums in Dhaka). If you can’t tell from the picture, the houses are actually built on water, held up by stakes, with tin roofs and walls.

The views from the top floor of BRAC, the largest NGO in the world, overlooking Korail Slum

My friend and I were so taken aback by the sheer size of it. How could we have missed something so big? The affluent districts and water almost circle it completely. In fact, the divide couldn’t have been clearer.

Korail Slum and the beginnings of affluent Benani across the water

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Visiting Family Health International

It’s amazing how much public health has helped me make connections in Bangladesh. Two days ago, I decided last-minute that I wanted to try to visit Family Health International (FHI) in Gulshan-1. I left work right around 4 PM, with the full expectation than when I arrived at their office, they would be closed. I was right. The office was empty. I went up to the counter where a man was sitting and introduced myself as a public health student from UNC- Chapel Hill, right down the road from the international headquarters for FHI. The man, with a kind smile told me everybody had already left work early because of Eid. Understandable. I asked if I could just take a look around, and the man nodded.

Like the obvious nerd that I am, I took out a pen and paper and started to take notes on some of the published material they had on their shelves. What can I say? Their work especially in HIV/AIDS monitoring and evaluation mesmerized me. I have always been a huge fan of FHI, but it was just entirely different seeing the models at work (well, kind of) that I had heard so many of my guest speakers talk about. After fifteen to twenty minutes of this, the man at the counter then called someone and talked to them on the phone. A few moments later, another gentleman came downstairs and introduced himself as the Director of FHI. He had stayed behind to work a little longer, and they’d phoned him upstairs to tell him about a student that was just really interested.

He took me upstairs to his office. As we walked, I noticed that beautiful facial portraits of some FHI beneficiaries covered the walls, labeled with their “name,” age, occupation (many sex worker or IDU), and one or two lines of their story. What a way to arouse inspiration in the workplace.

The director and I ended up talking for almost 2 hours about their current services and programs regarding STI, STD, and HIV in specific populations. It was absolutely phenomenal! I love their program structures, which are very multifaceted in nature. As I was leaving, I mentioned Friendship’s own findings of increasing incidences of STI and syphilis on the chars, and if there was any chance of information exchange or collaboration between Friendship and FHI. He gave me his card, smiling, telling me that they “would love to help with capacity-building.” YES.

Check out this success story of Pahari, a hijra or transgender sex worker who greatly benefited from FHI’s Shustha Jibon (Healthy Life) Program.

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Why Boats?

“She has challenged the legal system and won, she’s confronted environmental crimes, relocated the population of a South Pacific Island contaminated by radiation, provided disaster relief to victims of the 2004 Tsunami in South East Asia, and sailed against whaling, war, global warming, and other environmental crimes on every ocean of the world.”- Greenpeace International

Last week, Friendship grew. Rainbow Warrior II, Greenpeace International’s vessel retired, officially transitioning to her new life as Friendship’s third floating hospital, Rongdhonu. Read more about it here.

You might be asking this question: instead of sustaining hospital boats, which are  more expensive than land hospitals, why doesn’t Friendship just build a hospital in the chars?

Don’t worry. I asked it, too.

Boats are such a pivotal part of char life; many char-dwellers rely on boats for market access, disseminating agricultural goods, fishing and migrating from char to char. If there’s anything you can take away from this blog, it’s that chars aren’t dependable. One char which is there one year might have disappeared the next.  The extensive investment of money and human resources needed to build hospitals, on land or water, shouldn’t be risked in any circumstances. So, why not build a hospital on the mainland then, near the shore, instead of the chars? There is technically at least one hospital in every one of the >500 “upazilas” or counties of Bangladesh. There are mainland hospitals already near the shores, but the reason Friendship intervened in the chars a decade ago still rings true. Many people cannot access the mainland hospitals because they don’t have the money needed to afford transportation.

One could argue that small boats could be disseminated widely to char-dweller families to give them access to mainland opportunities, but having a hospital boat – one that travels to the char-dwellers and addresses their specific needs is a source of pride for many of these char communities. This way, the healthcare comes to them. Think of it this way – most men in the chars can probably, some way or another, find their way to the mainland hospital to seek care in the case of illness. But this journey is obstacle-ridden and almost impossible for women to undertake on their own. With Friendship, this isn’t the case.

Friendship’s floating hospitals travel among the chars, docking in a central, more stable char for 3-4 months at a time to provide healthcare. It’s true, char-dwellers still need some money to travel to the char where the boat is docked, but this is a considerably smaller cost. Additionally, the boat is strategically docked on an island where char-dwellers access markets for food and supplies anyway, so the char network ends up working in their favor.

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On brain drain and innovation

Several weeks ago, a colleague and I were sharing a rickshaw ride home. We conversed on the complexities of development in Bangladesh, of Friendship and of what we had seen and experienced since our arrival. Following the flow of the conversation, I asked: “Well, what is next for Bangladesh? What are their choices, what should they do?”

We started talking about how the Bangladeshi government might plan to shape policy around benefiting and preparing for out-migration. We agreed that this idea is realistic only to a certain degree, but also reflected on how out-migration is almost always associated with brain drain (assuming that those who are higher on the socioeconomic spectrum are usually the ones who have the opportunities to move and live abroad). This association is often one of the first points raised in migration debates, and one that is not really backed by any micro-evidence of what it is these migrants might actually be doing. As in, to what extent does “brain circulation” actually happen, if at all? At what levels do remittances occur? Are migrants actively engaged in knowledge transfer about study and work opportunities abroad?

Perhaps the most interesting part of this is that those countries which keep their best and brightest inside their borders do not necessarily show impressive rates of growth and innovation (North Korea, for example).

Which brings me to my next point – my colleague said that she believes the reason that Bangladesh is and will remain resource-poor is because “there is no innovation here.” My initial visceral reaction to this was pretty intense, to say the least, but I wanted to write just so I could organize my thoughts on why I disagree with this statement.

i) We need to stop defining innovation from our Western point of view. Bangladesh is its own country (and one that is just 40 years old) and will undoubtedly create and shape its own story. We cannot expect our own European and American models for growth to apply to all other countries.

ii) Bangladesh is often referred to as the Silicon Valley of Social Innovation. Think about it – revolutionary organizations like BRAC and Grameen Bank came into the world from this country. The loudest critiques of Grameen’s micro-finance techniques, and thus strongest alternatives, also come from this country. Again leads me to beg the question, by whose terms are we defining innovation? From a public health standpoint, Bangladesh has achieved in just 20 years with its population growth rate what the US and Europe barely achieved in 200 years. This is a result of health marketing campaigns, BCC, IEC, which all requires a certain amount of innovation.

iii) If anything, Bangladesh just doesn’t have the infrastructure necessary to support the mass scale-up of innovations we might envision happening elsewhere. There’s a certain amount of time and energy lost in cultivating the innovation that’s already there, because the fundamentals of statistics, monitoring and reporting are missing. This doesn’t mean say anything about the Bangladeshi people’s ability to innovate, just that the country is in the middle of the taxing and continuous process of building a system to make innovations operational.

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NCDs

Came across this interesting article on non-communicable disease in the Daily Star a couple days ago. Check it out here in the Daily Star.

Quite an interesting take on things – and it’s true. A closer look at DALYs (disability adjusted life years, which are a public health indicator of total disease burden) in Bangladesh reveals that NCDs now impose the largest health burden in the country. As the article states, NCDs (inclusive of injuries) accounts for ~61% of disease burden while ~39% is from communicable disease, maternal and child health and nutrition combined.

Policy reflects this as well. Bangladesh’s five-year plan for health identifies cancer, CVD (cardiovascular disease), and diabetes as severe public health problems. But does the policy translate to action? Efforts towards NCD prevention and treatment have been a low national priority for funding and programming in light of the current focus on the MDGs.

We establish global criteria for improving health, which end up defining national public health agendas. It’s unfortunate when the global benchmarks do not reflect the true need of the nation in question; nations are tied down by outside influences that define funding and thus what initiatives can do and what they must focus on.

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Last Char Visit

*August 16, 2011

The boat carried us through the smooth water, to our last char, Kharjani Char. The char is relatively new, only about two and a half years old. Because of this, a permanent FCM hasn’t been assigned to this char of approximately 85 houses and over 700 people above the age of 18.

However, we picked up an FCM from a nearby char to join our crew of health manager, paramedic, translator, and Sareeta Apa on the boat. The FCM would aid the paramedic and conduct the uthan boitak (health meeting) today.

The clinic, a small shack with a side of reed, was only half-full when we arrived. There was a baby on the ground in the front, playing with a piece of trash. A small boy ran past me, brushing past my legs. On his chest, there was a burn mark extending the length of his bottom rib, to match the red color of his shorts.

Later, as I sat with my checklist at the uthan boitak, watching the FCM show women family planning posters, I noticed an old woman about five feet in front of me. She had a kind face, but worn with years, unhappiness deeply planted in her eyes. Protruding from her orange sari, below her chin, was a lump, bigger than the size of my fist.

I leaned over to Sareeta Apa, and asked her if she was here to get it checked out. After the meeting, as patients waited in line to be seen, Sareeta Apa asked. The patient was at the satellite clinic to seek care for headaches, not for the tumor, as she had already been living with the condition for more than three years. Can you imagine? Three years without medical support.

I asked her, through my translator, if she had any pain or trouble swallowing. She had none.  But if it had grown to this size in 3 years, there was no telling when it would reach the point of obstructing her esophagus or larynx. The health manager intervened, telling the patient that we had a hospital where a simple surgery could fix her problem.

She was insistent, shaking her head from side to side. She also said she didn’t have the money to access the boat anyway. As she said this, the two or three young couples who had surrounded us to watch the situation unfold started laughing. I asked what was so funny, and the health manager answered, with a frown, that people were telling the patient she shouldn’t seek treatment because they’ll cut her open and she’ll die on the table. She’s old anyway, there’s no need to spend resources to fix her. Besides, it’s a curse from Allah. There’s nothing we can do to fix it.

I felt my cheeks get red. The discouragement from her fellow community members made her flee the scene as soon as she got her medicine for headaches. She had two sons who kept their distance, I was told. Additionally, I was informed that if she had daughters instead, they would be oppressed and ousted by the community, just like their mother.

Two things were at play here: 1) the fear and social taboo surrounding getting medical treatment in the form of an operation, and 2) cultural beliefs that the sickness was Allah’s will, and that’s it. Both are things that can be addressed with medical treatment coupled with educational outreach. It’s hard for communities to disprove the legitimacy of such operations and treatments once they see their neighbors healed. The hard part is getting those neighbors to get treated in the first place.

What a last visit. I don’t remember feeling this sad, disappointed, and hopeless in a long time. But one thing is for sure – this brought home for me the vitality of having services in communities in addition to our hospital boats. We can create all the hospitals we want – in planes, boats, buses – but if these health facilities are not used by those that they are geared to heal, then our work is wasted. Uthan boitak, our community health meetings, can be used for adding the roots needed to get these patients to view their health in an empowering way. The capacity is there, we just need to scale up, focus, and fortify.

I head home tomorrow morning. The bus will be a good time to process some of these thoughts and transform them into something positive – namely, a rant on the importance of community outreach in my internship report. I should have plenty of time, as bus strikes have gripped the nation by storm right before Eid.

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Ownership

*August 15, 2011

Sareeta Apa and I had the first part of the day off. It was spent beautifully. We followed our old routine and took a rickshaw ride around Gaibandha. It was an adventure, at the surface, to shop for fruit, but our true unspoken motive was to take in the hidden parts of this bustling little town. We visited the train station, walked rock paths lined with old trees, next to quiet green ponds.

Beautiful scenery

Beautiful scenery

We even visited a small Hindu village inside Gaibandha, which boasted architecture starkly different from the colonial-style buildings we kept spotting. In the center of the village, we entered a Hindu temple where a group of men, sitting on pillows, were debating in a circle. Sareeta Apa asked if it was okay if we could go in, and they smiled welcomingly. What a serene place – so much of what we saw was handmade. We hesitatingly exited the temple to finally head back to the field office for our meeting later in the afternoon.

Poking around in hidden Hindu temples

Back at the field office, the director of community-based programming started the meeting off with an overview of what monitoring would entail at the field level and the expected outcomes. As he talked, I noticed there was a lot of nodding (my translator was studying for exams today!) among the five field officers and paramedics, four of which had been at our first meeting in Gaibandha in July.

As we talked, some voiced concern that monitoring and focusing on quality might make Friendship compromise on the quantity, or vast access, of health services the organization offers. As in, giving more time to each patient might mean more patients turned away. This is a significant concern and one that cannot be dismissed without discussion, but if Friendship operates with the goal of improving community health, there are things we can do through monitoring to maximize our potential without having to compromise on the number of patients we see. The good part of the meeting is that it allowed us to lay down some additional concrete benefits of starting a monitoring culture within Friendship, per request of the meeting attendees.

i)  Creating a monitoring network within Friendship, where different tiers of field workers monitor and provide feedback to each other allows us to learn from each other, improve our services, and recognize/celebrate good performance.  One of the most eye-catching results from the situational analysis showed a lack of feedback loops, or unidirectional feedback. A network allows us to have “loops of feedback” that gives as much information back into the loop as it takes.

ii)  We can present these tools not only as accountability mechanisms for the quality of our services in addition to the quantity, but also to prove our liability to donors and interested parties alike. And honestly, no matter where you are, quality cost$ le$$ (don’t let the dollar signs fool you – costs include time, precious human capital, suffering, and losses to the organization when patients aren’t treated to the best of our capacity).

iii)  Monitoring and supervision allows us to create a paper-base, built-in documentation within our health system, which Friendship can use as a basis for future evaluations and impact assessments of our satellite clinic services.

What I particularly liked about the meeting was that we received a lot of questions and concerns from the field staff, which indicates that they’re actively thinking about all of this. A weakness of the meeting was that as we talked about our monitoring tools, the actual tools sat in the middle of the table, mostly untouched. I had envisioned a meeting where we would get feedback from the group for each of the tools, but alas, we spent most of the meeting actually convincing the field staff that monitoring is a good, worthwhile, and valuable thing. I would have liked to be a bit farther at this point, but at the same time, to have the director give the meeting, voicing some of the very points he had contested weeks ago, was a small victory for me. We attained ownership today, which I hope will be the foundation for Friendship to build upon the outcome of my internship and my time here.

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Char Visits

**Retroactive posts because of low internet again, 2 more to come tomorrow!

*August 14, 2011

Today marked our first day of validation among the chars. We are very lucky that the director of community health services from the Head Office is accompanying us these next few days as well. He brings a wealth of experience and knowledge, about Friendship and about our health services on the field, that neither Sareeta Apa nor I possibly match. His ownership is a pivotal part of this project – without him, we don’t have leverage or the investment needed to finalize and distribute the tools, and advocate for monitoring and evaluation culture, in general.

We were also accompanied by my translator today, a kind-faced young fellow who ended up not only translating for me, but also eagerly took on the role of cultural ambassador, pointing to fish farms and different crops, to villages “where victims of river erosion live,” to bridges destroyed by floods and newly rebuilt. As we drove down to the riverside and hunkered down on the boat (it would take us 3.5 hours on the water each way today, excluding FCM pick-up time from different islands), he leaned over to tell me this was his first time on a boat like this. I smiled, asking: “Why? You live so close to water!” His answer, delivered with a nervous smile: “I’m so, so afraid of the water!” A part of me felt for him, especially when his mother called to ask if he was wearing a life jacket. In that instant, I realized a newfound appreciation for how far I’ve come with my own parents. They still worry, but I also think I’ve set the bar high enough that I can picture my dad being a bit disappointed if I didn’t take on some of the adventures that have come my way. My translator rose above, though, even coming with us to the roof of the boat from time to time.

A gray sky, with periodic bouts of rain, accompanied us on our long journey through the river. We visited two chars today, Mollarchar and Shonnashir Char, where satellite clinics were taking place. Both are stable chars that have had a lifetime of 15 to 20 years.

Because I had a translator, we were able to effectively delegate validation of the tools as the satellite clinic took place. The health meetings (uthan boitak) were delegated to me. On our first char, the FCM had just given birth, so instead the assistant health manager gave the meeting on fever and diarrhea. I pulled out the tool, made up of about fifteen benchmarks, and listened to my translator as he transliterated the lesson. I observed the audience, participation level, and the relationship between the manager and the attendees. One by one, I could see the components of the checklist coming to life! It was an amazing feeling and happy warmth rushed through my body.

The same happened on the second char, where this time the FCM gave the uthan boitak to some attendees. The tool also incorporates a check-in with one of the meeting attendees, a short interview to assess quality conducted on a private basis away from the satellite clinic. On both chars, my translator helped me to ask questions to women beneficiaries regarding the topics discussed, such as if the beneficiary is planning to, or has already used advice that she’s learned at the health meetings, and if she feels comfortable asking questions during the meeting. This went smoothly, as well, with one of the women even saying that because of the health meetings, she now knows how to make oral saline solution at home for her children whenever they have diarrhea. Perfect. That’s what we want!

I noticed some points of dissonance with the checklists, though – for example, the culture of taking attendance had disappeared somewhat from the meetings and needs to be brought back so we can track community involvement.

Once we were back in Gaibandha later on, a check-in with my supervisors revealed that there’d been frustrations about the distance traveled versus the actual amount of time spent at the clinics validating (about an hour each). I didn’t have any control over this and though I agreed, the selfish part of me enjoyed each of the seven hours I got to gaze at the gurgling water of the river, the numerous chars new and old, green and amber.

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On the field again

*August 13, 2011

Our bus from Dhaka to Gaibandha lasted about eight hours today. We tumbled north through the narrow, moldering highways that connect this part of the world to the rest of Bangladesh. As a fourth-timer on such buses, the constant honking and fierce rocking from side to side no longer bother me. As we wobble and sway past rice paddies, quaint villages and verdant countryside, I pretend it’s all some sort of sweet lullaby and this chimera eases me to and from sleep.

From the onset, I can already tell Gaibandha is better off than Chilmari, the region of my first field stay. In the city center of Chilmari, dirt-floored convenience stores, metal roofed cook shacks, one-story makeshift shops and kiosks with crumbling foundations and paint line the streets, whereas in Gaibandha, we strolled past numerous fabric shops, handicraft shops, and shops that even sold TVs and motorbikes, that look better-maintained, more diverse. Gaibandha just seems livelier, too. After iftar at the Friendship Gaibandha office, we joined all kinds of hawkers and pedestrians on the streets, joining a throng of locals going for their evening tea. Actually much of what I know of Gaibandha comes from constant news reports of extreme flooding in this area over the past several weeks.

The purpose of our field visit, scheduled to last for five days, is to validate the monitoring tools completed so far – more precisely, our service checklists for the FCM’s one-on-one family planning counseling, for the uthan boitak or the community health meetings that the FCMs conduct, the checklist for the physical set-up of the satellite clinics and finally, our antenatal and postnatal care counseling. Tomorrow, we’ll visit a couple of chars to validate the tools on-site, and assess whether we are indeed where we need to be (in the ball park). In two days, we have a scheduled meeting with the health program managers and paramedics to go through the tools. Then, we’ll return to the chars for another round of validating and feedback from the on-site health workers and paramedics.

As our group walked around the city center after evening tea, I couldn’t help but ponder how fast time has flown. I’m proud of what we’ve done with this project, despite its ups and downs. Hopefully, our conversations with the field staff will make the tools that much better, that much more relevant. At the same time, on a more personal note, the fact that this might be my last time in the field and among the chars is a heart-breaking kind of realization, and one that resonated within me unstoppably tonight. It certainly makes my final departure from Bangladesh in three weeks that much real-er.

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