Philanthropic Medicine - Reflections on a visit to Bangladesh

Philanthropic Medicine – Bangladesh visit July 2017

I married 19 year ago. I am Indian origin, my husband is Bangladeshi origin. We met at Nottingham University where he studied Economics and I studied Medicine. We are both born and educated in England. Our mother tongues are different.

This is my fourth visit to Bangladesh. I wanted it to be different to my previous visits. I am not a fan of sitting in relatives homes being over fed as a result of their enthusiastic hospitality.

On one previous visit I remember a relative saying, “Why didn’t you bring your BP machine?”
He had a point. Being a doctor means we are gifted with privileged expertise and knowledge. Here I am, planning a trip to one of the poorest countries in the world…and I have something to offer. Besides, it is a vocation, something that will help me feel a bit more useful on the adventure that always results from visiting Bangladesh.

“The purpose of life is to discover your gift. The meaning of life is to give your gift away.” 

David Viscott

On thinking of this I composed a Whatsapp message with an inventory. I contacted a few GP colleagues to see if they would donate unwanted, working, second hand items for a “pop up GP clinic”. The response was great and within a few days I had a suitcase full of stuff to take including BP machines, BM machines, testing sticks, lancets, sharps box, auroscope, opthalmoscope, simple medications, MIMS etc …I felt ready to see what this half hatched plan would become. I cannot tell you how lifted my spirits became when this plan was coming to fruition. I felt an enthusiasm for the trip I had not felt before. I had developed a strong sense of purpose.

My husband’s ancestral home is a village 7 hours drive from Dhaka. It is in the province of Sylhet 5km from the Indian border. The neighbouring states are Assam and Tripura in India. The state of Sylhet is lush green. I can only describe it as a vast allotment, with well demarcated plots of edible vegetation from rice, pineapples, okra and spinach. Green is almost the only colour you can see, apart from the grey water pools which are home to a wide variety of fish. One conversation amused me. I mentioned (with a hint of a moan) the prolonged power cuts in the village. I was reminded to take the optimistic approach; village life is without power, so a bit of electricity, when it comes, is a big bonus!

We arrived in the Bari (ancestral home) on Saturday 22^nd July. We had spent the previous few days in Bangkok exploring the temples and waterways.

My father in law spends stretches of months in the Bari. He is a well-respected man in the village. My husband and his father have the surname Choudhury. This technically means “landlord”. The villagers do seem to still come to my father in law for counsel, advice and assistance. In exchange, they help him and attend to his care needs. He has moderate dementia and is unsteady on his feet, he needs the help, but he is doing well for an 83-year-old though! One villager named Monu has known my father in Law since he was born. Monu must be about 25 years younger than my father in law. Monu is like a bondsman to him. I find this concept hard to understand, and these days it is not a bond of slavery but of commitment and service. Monu’s family were also very attentive and caring towards us during our visit, even washing my children’s feet after muddy barefoot walks, (my 7-year-old describes the mud walk as a high point, along with catching fireflies).  It was monsoon season in Bangladesh so mud was plentiful!

As I endeavour to treat others as I would like to be treated so I find it hard to accept the concept of servants cleaning up after me. We are equals, so it is hard to accept this in my head, yet I console myself by thinking this is how they make a living, I should let them do this. I am still grappling with it. Anyway, I felt my payback would be to do my best to consult the villagers, sitting side by side, to hold their hands and to examine them with kindness and tenderness. This is my way of showing that I can serve them. One of my husband’s older cousins said after one of my veranda surgeries, “make sure you wash your hands well”. Another of his cousins (who runs a small NGO) told me “Some people here don’t like the poor”. This reverberated in my head, I could not come to terms with it because “the poor” are not a group, they are people, human beings like me. Their predicament is unlikely to be of their doing and how arrogant it is to “not like them”, like they are vermin or something. This pained me immensely.

I did three consecutive morning clinics. Village hearsay spread the message that Mr Choudhury’s daughter in law is a doctor and will see you (free consultation and meds) if you come to the Tongi veranda (bungalow). It wasn’t long before queues of people waited to see me. I understand Sylheti but I don’t speak it very fluently. My father in law helped me with some interpretation. In total, I saw about 50 patients from babies to the elderly. Common complaints included dyspepsia/heartburn, polyarthralgia, poor dental health, cataracts and fungal skin infections. I would assess the condition then go to the pharmacy in the town about 5 miles away and buy medication from the pharmacy (yes, they sell ALL medication over the counter!) Most villagers will drink water from a tube well. This water has been reported to contain mercury and heavy metals. Whilst cleaning my teeth I noted how strongly it tasted of iron. My son said it was like tasting blood! I wonder if this contributes to the high prevalence of gastric problems? Both my mother-in- law (62) and her 60-year-old brother died from gastric cancers recently. Their childhood was spent here.

One man in his late 20’s is usually fit and strong according to my father in law. He slowly walked to the tongi, labouring to reach the veranda and using a stick as a staff. He looked weak and clammy.

I heard how he has been feeling awful for the past three days, no localising symptoms or incidents. His BP was 78/40 and his temp was 39. I felt it could be septicaemia. I told him he needed to go to the community hospital. He could not afford to go. He asked us to call his wife from the village. His wife came and my father in law gave him some money to get to the community hospital. 

I also saw a lovely smiley 3-year-old girl. Her father was anxious as she could not stand unsupported nor speak. It was clear she had developmental delay and maybe an underlying condition like cerebral palsy. She needed a CT scan. My findings were later confirmed by a letter from a paediatrician, that also suggested a CT scan was needed. The big problem is the scan would cost £250, the father only earns the equivalent of about £10-20 a month. So, a barrage of questions ran through my mind, even if she had the scan what would that lead too? More expensive treatments and physio? I am not sure how well the medical infrastructure deals with learning disability and developmental delay. What kind of a future does she have? I hope she will not be abused or treated badly because of her disability, maybe her family see her as a burden?... I hope she maintains her lovely smile.

After some compulsory visits to family members homes (and attempts at over-feeding us) we managed to arrange some visits with a large Bangladeshi based NGO. BRAC is in fact the largest NGO in the world (revenue US$684 million/year) and works across many countries. They are famous for introducing microfinance initiatives to help the poor get out of the poverty trap.

http://www.brac.net/

I had been in email correspondence with a programme visit manager in Bangladesh. I told him I am interested in visiting educational or healthcare related programmes in Sylhet. I had to complete a formal programme visitor form and sent my CV. I was then informed that two programmes could accommodate our visit.

We first visited a non-formal education programme for young children of tea garden workers. The tea estates are often too far from main stream schools. BRAC in association with UNICEF has set up some classrooms within the tea gardens. We visited two classrooms. The children saluted us on entering, they then sang and danced a performance for us. We felt very honoured and were welcomed like royalty. I enjoyed the beautiful scenery in the tea gardens too. I donated to the project after the visit and the educational and management team were thrilled.

Again, with BRAC we followed the tea garden visit with a healthcare programme which is essentially a visiting antenatal care clinic that comes to remote villages every month. I spoke with the ladies in the clinic and the health visitor. Most health education is verbal and pictorial as literacy rates are quite low. Any potential antenatal complications must go to the local community hospital about 40 mins away, many women feel this is too far. Postnatally women are given sanitary pads and iron tablets. Contraception pills can be purchased at cost price and condoms are distributed too. I was interested to note the COC contains ferrous sulphate! The women were given opportunity to ask me anything, I was asked a few questions about menorrhagia and its management.

Our final formal visit was to drop of all the kindly donated medical equipment (in my “pop up GP suitcase”) to the community hospital. It was located about 30 mins drive from Bari. It is run by the UK run charity Muslim Aid (revenue £34 million/year). My husband and I have known Jehangir Malik (the CEO) since well before he was famous!

https://www.muslimaid.org/

It was sobering to see the extensive and comprehensive work the hospital performs BUT under difficult conditions in a building that is run down and damp. You can see from the photographs the damp is in the main stairwell and the operating theatre. They have daily walk in clinics and specialist clinics. The hospital has 30 in-patient beds and performs operations like hernia ops, cholecystectomies and caesarean sections. I met patients on the wards who had these procedures. The treatments are not free, they are heavily subsidised though. Any donated medical goods will not be part of the charge to patients. Apart from the surgeon and specialist clinics the hospital is run by newly qualified doctors straight out of medical school. They earn about £300 a month. I had chance to see the “autoclave” sterilisation room, pathology room and theatres. This hospital provides invaluable, essential treatments. The waiting room was full on the morning we visited.

I tweeted and Facebooked details of their good work in the hope that people would consider donating to this worthy cause. Today I received and email from them and I have informally had a message from the CEO too.

Dear Mr. Sultan Chowdhury and Dr. Sabena Jameel,

Assalamu Alaikum Wa Rahmatullah.

We thank you very much for your recent generous visit and valuable contribution to Muslim Aid Community Hospital, Brahman Bazar, Kulaura on 29 July 2017. Your willingness to support Muslim Aid Community Hospital is inspiring and we do appreciate your endeavours.

Muslim Aid UK Bangladesh Field Office is always available to welcome philanthropists /individuals and institutional donors in serving humanity towards Healthcare, Education, Skills Based Livelihood, Microfinance, WASH, Child Sponsorship and Food Security & Wellbeing Livelihood programmes.

We will keep in touch and look forward to making future collaboration.

Sincerely,

Mahfuz

M. Mahfuzur Rahman

Country Director

Muslim Aid Bangladesh and Indonesia Field Office

Charity Registration No. 295224

I guess on the scale of NGO’s I got to speak to my husband’s cousin Jamil Ahmed Chowdury, who runs a very small NGO (Revenue £15 000/year).

http://www.nssbd.org/

He provides worthy interventions in the form of building latrines (toilets) in school and villages, he provides mid-day meals in village schools on occasions (no meals provided normally) and he funds a few medical camps where he employs doctors for the day (opthalmologists and family medicine practitioners) to go the villages and provide free consultations and medicines. He has also established a few bursaries for children in schools, so they can buy more books for further studies. I also left a modest donation with him and he said he would use it to provide a mid-day meal in a school near Bari.

All in all, I felt it was a fruitful trip and I learnt a lot. I felt I had a purpose and a gift to give. I now want to produce a presentation (maybe for VTS trainees) on the charitable dimension of being a doctor. I hope to explore altruism and exploring going “above and beyond”.

I also learnt one important lesson (especially because I got my fair share of bites);

“If you think you are too small to make a difference, try sleeping with a mosquito!”

3/8/17 for my NHS appraisal portfolio. Dr Sabena Jameel