Tuesday, 5 May 2009

LETTER FROM DHAKA: HOW CAN WE REINVENT PUBLIC HEALTH?

By HILARY STANDING, Fellow on Health in the IDS KNOTS Team and Director of Realising Rights


Living in Dhaka is a daily lesson in the extremes of human urban existence. This is a city of around 12 million packed into a surprisingly small area. It has huge slum populations and dense housing even in the “smart” areas. There is an uncountable population of domestic livestock of every description. One figure that grabbed my attention is that maximum desirable population density in urban areas is apparently 40,000 per sq kilometre. In old Dhaka it is 150,000.

The city is a serious environmental danger zone. The four rivers which surround and run through the city are so polluted that they are officially dead due to industrial and other toxic wastes. There is a picture in one of the daily papers of a stretch of dark blue river which probably reflects its proximity to a local dyeing factory. There is no functioning sewage system to speak of and the storm water drains are completely choked with garbage. The city’s water supply comes entirely from increasingly polluted groundwater and the top level aquifers are all exhausted. This year it hardly rained at all, a most unusual situation.

In April we experienced a severe heat wave for several weeks which only came to a halt a few days ago. One of the worst immediate results was that large areas of the city had either little or no water, or have been getting heavily polluted water which is too badly contaminated to be made fit for domestic consumption. As a consequence, there has been an epidemic of diarrhoea with significant numbers of deaths.


I am particularly aware of this on a daily basis as ICDDRB, where I am partly based and which is one of our partners, runs the only free hospital in Dhaka which treats acute diarrhoea cases. Since March, it has had double the daily number of admissions and I look out of my office onto what was the car park and which is now taken up with two large tents treating the overspill from the main hospital. And as the mortuary is in our building, it is distressing to see the ones who got there too late being wheeled over to the mortuary.

It is also the seasonal flu season here, with large numbers of people sick with a particularly nasty bug. So when swine flu started to make headlines in Bangladesh, it mainly provoked the wry comment of “how would we know if it hits Dhaka?” Avian flu is already widespread in every district of Bangladesh as poulty farming is such a major source of livelihood. It caused a few headlines at first, now it’s just something you live with. Meanwhile, today, I read in the paper that several children have died this week in a nearby village from pesticide poisoning due to exposure to the mountains of pesticides poured onto vegetable crops grown on local farmland for the urban market.

I have been reflecting on this a great deal lately as it challenges one’s sense of what constitutes “health” and appropriate research about it. This is a place where ill health is the norm. What are priorities when everything is a priority? Where can most difference be made when the numbers affected by infectious diseases, chronic diseases, toxic chemicals and vehicle emissions, climate emergencies, contaminated food and water supplies are all so staggeringly large?

There is a small attempt going on in the School of Public Health here to train government doctors in public health. But current public health curricula seem to reflect the narrowing of the concept of public health since the health economists have taken over the show. What happened to what we used to call “environmental health” or am I imagining a golden age of public health that in reality never existed, where safe and nutritious diet and public parks for exercise and fresh air were integral to our understanding of a healthy environment? Can we reinvent public health and how?

I sat in a WHO meeting a couple of weeks ago and was struck by the mismatch between what people from the countries were trying to talk about, what I see around me in Dhaka and the Geneva based expert talking about “patient centred care in the community with a dedicated family physician.” If this is a typical response to the challenges of global health, it seems neither realistic nor relevant. I see a bit more hope in the rising tide of demonstrations and awareness raising activities being organised by local environmentalists here. But they are puny compared to the interests stacked against them. Please, can anyone help me out on this one?

1 comment:

Anonymous said...

Dear Hilary;
You are so right. There is a gap in understanding not just between the rich and poor but between each step in the low, lower-middle, upper middle and high income coutries and the philosophies that drive them. Sitting in the launch session for my own Healthcare for the Homeless project sort of brought it home-- although the spirit was resoundingly positive, when things are so bad and living conditions so abysmal, how do you prioritize anything at the bottom of Maslow's Heirarchy of Need?