June 30th, 2011
As a result of a lucky scheduling coincidence, Sareeta Apa and I traveled to Chilmari by seaplane yesterday. The sprawl of Dhaka seemed endless even from a bird eye’s view; not contrary to my expectations – even from the ground, Dhaka seems in a state of perpetual construction, with bamboo supporting most new structures in lieu of metal rims.
My eyes absorbed a beautiful scene of water and green for the sweet flight duration of forty-five minutes. (I say sweet because the bus would have taken 10 hours). Bangladesh is truly more water than land, with the world’s largest delta system and the greatest flow of river water to the sea of any country on earth.
Towards the end of the flight, the thick white of the monsoon clouds engulfed the plane, before they cleared and we started spotting the char islands through our wide windows. Chars are newly emerged lands from the water as a result of accretion, with an unpredictable lifespan ranging anywhere from one to fifty years. In other words, from our plane, it looked as if some larger creature had taken his fingers and run them through the river, creating these unstable, transient islands.
Anyone who visits the country sees that poverty is a pervasive problem in Bangladesh, but with limited land and other natural resources, added to the messy process of erosion and accretion in the river delta, impoverishment in these chars is truly extreme. Rapid erosion of Bangladeshi farmland renders many people landless (two-thirds of the rural population, to be exact), who then move to these newly emerging chars. These settlers lack secure title and can only occupy the chars with the consent of powerful “land grabbers” who illegally control this public land. Of course, without secure title, char-dwellers become discouraged and unwilling to invest in improving their land or houses.
Chars are usually unfavorable for farming due to salinity and flooding and are especially vulnerable to cyclones and storms. The living conditions are harsh, due to lack of clean fresh water and fuel. Moreover, there are very poor communications and minimal services from government and NGOs, because the chars are physically out of reach and well, in a country where even those in sight aren’t tended to properly, out of sight, out of mind takes on a new form. Climate change threatens to make the scenario even more precarious, exacerbating these vulnerabilities with greater probability of cyclones and storm surges, increased rainfall during monsoon, less precipitation in winter, high temperatures, and sea level rise. Char-dweller livelihood will indubitably worsen.
And then, we spotted it – like a beacon in the night, the hospital boat, EFH, docked along an older char. My home for the next 10 or so days.
Friendship is one of the first NGOs to get involved in providing services to char-settlers, setting the bar high for NGO involvement here. On top of EFH that provides primary health care and specialized secondary health camps (surgeries, more involved procedures) at almost no cost to patients, Friendship holds satellite clinics twice a month in each of our chars. As an organization, Friendship has trained women from these communities to take on the role of community health workers (FCMs), and its these FCMs, along with trained paramedics from the mainland, that run the satellites to provide primary care, health counseling, behavior education, and family planning services to char communities. It’s these services I’ll be closely observing and then working on tools to help Friendship monitor its progress.
We held a meeting today at the Chilmari field office with 10 members of health staff, a conglomeration of the district supervisor, FCMs, paramedics and a paramedic assistant. Our goal was to gain insight on what kind of monitoring is happening on the field presently and note the current gaps and strengths of our community-based services. Like many NGOs meeting imminent needs, Friendship expanded rapidly during its inception in the late 1990s. Retaining many of the intended program components – like constant monitoring and evaluation – through this scale-up became exceedingly difficult. Our current monitoring is scattered and sporadic at best, so I have my work cut out for me.
After the insights of the meeting, Sareeta Apa and I had a brief conversation about the universality of our field. We had both, once upon a time, cogitated a medical career and stumbled upon public health. After hearing many of the concerns of the FCMs and paramedics, we both agreed. Diagnosing patients, however valuable, seems unsustainable if the larger conditions that create their ailments remain undiagnosed.