Tag Archives: Friendship

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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Filed under EFH, Hospitals

Celebrating Janmashtami and some reading

Today marks the birth of Lord Krishna, which means it is a holiday for us at work! It gave me a good opportunity to sit back and do some background reading on traditional healers in Bangladesh. Like I’ve said before in this blog, it seems that it’s pretty widely recognized that these informal health providers have no formal training or education. Mostly, they get their knowledge of medicine through their families – the knowledge trickles down from one generation to the next. These healers don’t usually receive any fees for their treatment, just the price of medicine. If a patient does not have the ability to pay the cost of the medicine, they are exempted, which is another reason for the healers’ popularity in their communities.

Bangladesh has a severely limited public healthcare budget, so the public provision of subsidized healthcare is also limited. Furthermore, in Bangladesh (similar to many other countries in the Global South), there is a persistent shortage of skilled healthcare professionals who are not distributed optimally in rural and semi-urban areas.

Thus, village doctors and healers fulfill a very obvious need. At Friendship, I am wondering how we can better use the existing workforce at the primary healthcare level in these char communities? How do we engage village healers and form a connection between them and Friendship, or them and the formal system? And lastly, how can we creatively link and connect the informal and formal sectors (referral processes, capacity-building) to provide huge returns of healthcare to the rural masses in Bangladesh?

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A truly far-flung life

*July 4, 2011

They have moved seventeen times. Seventeen. While he tells his story, his eyes make contact with mine, even though we can’t directly communicate. This man, I’ll call him “Tom” has four children, two daughters and two sons, all married. His wife, his eldest daughter and her grandmother-in-law, and a relative fill the room. We all sit on beds.

Tom tells me how all the lands he had previously owned had been “eaten by the river” and now he is completely landless because of river erosion. His family moved to the char we’re on about three years ago.

Some river erosion pointed out to me on a walk around one of the chars. It wasn’t there a few days before the walk.

He tells me he is a day laborer, even though he is approximately seventy. Even with his family’s investment in a profit-sharing cow, they make about 100 to 150 taka per day, which comes out to about 3,000 -4,500 taka monthly. To give you a picture of what that means, 1 USD equals about 74 taka.

I asked Tom when he married his wife. He answered, “Before 1974.” My heart sank. I had read the specific importance of this date. The measurement of time is different here. No one can tell you exactly when they were born or when they married. Instead, at least on the chars, events will be classified as either taking place before or after 1974 – the year that marked a most devastating famine in Bangladesh, killing more than a million. The famine resulted from the deathly mix of several factors: flooding along the Brahmaputra, government mismanagement of grains, legislation restricting movement of food from one place to another, among other failures in distribution.

We covered a plethora of topics during our conversation, from their healthcare-seeking decisions to their health care beliefs. For example, I learned that it’s widely believed that the cause of diarrhea is poison in the stomach and that barefooted-ness is a major part of maintaining health, because it maintains their connection with the earth. We also touched a bit on their fears of seeking healthcare from hospitals. The eldest daughter talked about the fear of “cutting her stomach” in a hospital to give birth to her baby. Socially, having a pregnancy that requires a hospital visit suggests that the baby is not normal or healthy. The maintenance of this normalcy is important in Bengali culture even as the baby becomes a child, as symbolized by a single rope or “tabis” tied around the stomach of the child, to prevent any sickness or disease. There are three healers or “daktars” that this char community has access to, who charge next to nothing for their services. All the women tell me they visit Friendship satellite clinics to get ANC care, but for the final birth, they utilize the “informal” community healers.

I found myself thinking about the importance of these beliefs for Friendship, because they give insight into the social embeddedness of the health-seeking actions of our beneficiaries. In a place where there are so many barriers lying between patients and services – social, economic, geographic, economic, and organizational – understanding and documenting this concurrently mixed method of seeking healthcare can only help Friendship operate more effectively in these communities.

After long, exhausting days visiting our chars (it’s exceedingly difficult to get people alone for interviews), we head back to EFH by boat at night, sometimes serenaded by the sweet voice of one of my older colleagues. Life at EFH is going very well. I’ve made some new friends!

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Filed under FCMs, Field, Satellite clinic

Chars, Collection and Communication

*July 3, 2011

I sit on a bed, observing the satellite clinic. A paramedic, donning a worn white coat, sits at one of the longer sides of a rectangular table. One edge of the table is filled with medicine – various small tablets, pills, packages and boxes. The patient records, notebooks, lie in front of her. To her direct right, there is a chair for the community members to sit and tell her their grievances. Listening, she measures their blood pressure or temperature, or talks to them, and prescribes medicine.

The FCMs surround the table. One sits directly behind the patient, helping voice her precise health condition. The house itself is one of the FCMs’. I can’t help but notice an empty white bag, not far from where I am, hung on a bamboo support for the dwelling. “World Food Programme” is printed on its side with huge blue letters, followed by a picture of the Japanese flag. The family had received a ration of rice, as a “gift from the people of Japan.” What a striking situation, to get to see the receiving side.

This is my second day observing the chars and first day of official data collection on this island called Shirajbeg. Sareeta Apa and I will conduct interviews with the FCM, the paramedic, and the paramedic assistant on this char. We’ll also hold a focus group discussion with community members who attend the health meeting, lead and given by the FCM.

Shirajbeg is one of the closer chars to the mainland. It took us about half an hour to get here by boat.

The boat that we take to travel from char to char!

Yesterday, we visited Bozradiarkhata, where we tested some of our survey tools before starting to collect data. It was also on this char that I paid a visit to one of Friendship’s vocational training centers, where women learn how to weave and earn a living doing so, creating beautiful cloth.

Friendship's Weaving Center

Shirajbeg is younger than Bozradiarkhata. It’s sandier and the vegetation is shorter across the island.

Houses in the distance!

Char bank

The house we’re in has all the components of what you would envision would come with a makeshift settlement: hard-pressed dirt floors, a thatched roof and sides of reeds. The hut is small, and it’s clearly leaky during monsoon. Sides of the house are wet from the rain, with buckets strewn about to catch drips of water.

There is a growing line of waiting patients circling the house, all women, facing the heat to visit the satellite clinic (which costs 5 taka, or less than 0.07 cents). The scene is incredibly colorful. Each woman wears bright, catching colors in their saris. (I’ll really miss this about Bangladesh.) I also notice that all of the women come with at least one baby, which they casually carry at the hip. The babies are mostly undressed, except for a rope that they wear at the belly to ward off evil or malign influences. One by one, they sit in front of the paramedic, some to talk about contraception and others to get medicine for their babies. I can tell some of the children have watery eyes from fever, but almost all of the kids around me are incredibly underweight. They seem delicate; I’ve never seen bone on bone like this before.

I have also never been in a place where I am so constantly aware of different components of my identity – white, Turkish, woman, unmarried, Muslim. I have limited communication with the char communities, but they ascertain my status on some of these things pretty well nevertheless. And I’m proud to say I have mastered several key Bangla phrases, so why not use them as much as I can, no matter how ridiculous I may sound? In addition to the Bangla, I communicate in other ways, like yesterday, when a pre-teen girl and I winked back and forth for about three hours. Later today, I met the young daughter of a doctor on EFH. I drew for her a smile on a napkin, and she returned the gesture. What can I say? Like many overly naïve and idealistic travelers have uttered before me, the language of winks and smiles proves universal.

Smiles, smiles

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Filed under FCMs, Field, Satellite clinic

I’m on a boat (but no really!)

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.

Outskirts of Dhaka

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.

Chars in the distance...

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.

Emirates Friendship Hospital (EFH) plus other ambulatory boats!

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.

Meeting at the Chilmari field office

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.

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Filed under EFH, Field, Hospitals, Travel

Dhaka jabo

Close your eyes. Imagine a booming city, busting at the seams, so full of life and vigor, that its warmth encapsulates you in its arms. There’s nowhere else in the world where all of your sensory buttons can be pressed this simultaneously. The sight of colorful rickshaws carrying up to four passengers, buses, and people on the street is the first thing to strike you. You’ve never fit so many people per frame of sight. And sounds match the life of the streets – there is never a quiet moment here. Cars honk constantly, more in a way to say “hello” than to say, “get out of the way,” (sometimes very long hellos), and the call to prayer adds graceful beauty. The cool, fresh wind preceding the daily rains of the monsoon brings relief to your skin. Honestly, parts of Dhaka don’t smell very good, a mix of trash and exhaust, but step inside any house and Bengali food spices greet you. The taste of these spices, of dal, of fresh mango juice, is just exquisite.

View from my room window near Friendship

Mughal rulers made Dhaka the new capital of Bengal in 1608, and it stayed so until 1717 when the capital was relocated to West Bengal. Dhaka was almost reclaimed by jungles until the British took control of Bengal in the 18th century. In an effort to make political ties with the Muslims in East Bengal to counterbalance the growing power of Hindu elite in the West, the British designated Dhaka as the capital of East Bengal after the Bengali partition of 1905. The separatist Muslim politics that plagued Indian politics for several decades afterwards began here. The British rule finally came to an end in 1947, and Dhaka was proclaimed capital of East Pakistan for 24 years, though it was the center of agitation against Western Pakistani rule during that time. After nine months of the Liberation War, Bangladesh was born in 1971. So came Dhaka, finally the capital of its own country.

Today, Dhaka is a city of unparalleled dynamism, and home to the most genuine smiles I have ever seen. My first day was full of introductions at the Friendship Head Office, a magical place with glass separating different departments from one another. It seems such an open and welcoming place to work, with fish-tank meeting rooms. I am so looking forward to spending time here.

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“The world…is not an inn, but a hospital”

Hospitals have always intrigued me.

I remember, as a child, being captivated by the massiveness and grandeur of the hospitals that I saw through taxi windows in Istanbul. I experienced hospitals through the eyes of a patient as a teen, so I have also felt their unique power to evoke fear. As a family member of a hospital patient later on, I became frustrated with the various doors and curtains that separated the world of the knowing from my world of the waiting. Serving as a volunteer and working as a barista in a local hospital all throughout high school, hospitals transformed into a sacred space for me, guiding patients from sickness to health. Sometimes. If they could pay.

Sir Thomas Browne wrote in 1643, “the world…is not an inn, but a hospital” – a pretty surprising and discouraging statement from the acclaimed author of Religio Medici. Or as Amartya Sen has so wisely put it, an optimistic thought considering that many people who are most ill in the world today get no treatment, nor any access to effective means of prevention.

For a long time, I’ve known my future would somehow or another involve…hospitals. I am so interested in this idea of humans harnessing the sciences and putting them to use to fix each other biologically, and helping each other sustainably.  At UNC, I have dedicated the past three years to learning and discovering the different ways this can really be done. No surprise – I’ve found that multi-layered and diverse problems can only be addressed with multi-layered and diverse solutions.

From what I know, Friendship operates under this very premise in Bangladesh, approaching health equity not with the view of “health” in isolation, but with all of the social and economic embeddedness that comes with it. For details, take a look at the “Friendship Info” tab above, and/or watch the video below (focuses on reconstructive surgeries at Friendship but gives a solid overview of the organization and where it operates).

I am incredibly excited to start my internship with Friendship! Though my role will undoubtedly change and evolve, I’ll be evaluating Friendship’s current community-based healthcare services in the areas of family planning and reproductive health, in addition to looking at health-care seeking behavior in the chars. I will get to see Friendship in action – observing the satellite clinics and experiencing the work of the hospital boats first-hand.

I know I have an exciting journey ahead of me – one filled with copious amounts of learning, growth, adventures, new faces and stories, and even more learning. Six days to go!

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Filed under Pre-Departure