Health and Health Sciences  the medical sector in Bangladesh traditionally consists of two components: healthcare services and medical education. Health being a basic need, access to healthcare services is a fundamental human right. Despite some achievements in the health and population sector, the country is far from reaching its targeted goal 'health for all'. With growing awareness of the people, health and other related sectors are however gradually seeing positive changes. Described below are some important aspects relate

History
Healthcare
Diseases and disorders
Health policy
Health manpower
Medical education and research
Nutrition education and research
Pharmacy education and research
Pharmacy Ordinance, 1976
Health economics
NGOs in health services

History Ancient medicine started its journey thousands of years back. Primitive man attributed disease and other calamities to curse of God, and immersion of body by evil spirits or the malevolent influence of stars and planets. Medicine practised later by prehistoric man improved, stone and flint instruments were used to perform circumcisions, etc.

From the ages of the Vedas (c 1500-500 BC) the real practice of Indian Medicine is known as Ayurveda, meaning the 'Science of life'. Atreya (about 800 BC), Charaka, Susruta, and Vaghbate, were famous authorities in Ayurvedic medicine. Atreya, first Indian physician and teacher was a resident of Taxila in Pakistan. Charaka is still the most popular name in Ayurvedic medicine, was the court physician (200 AD) to the Buddhist King Kaniska. Charaka's famous treatise on medicine is known as Charak Samhita. Susruta, a resident of Benaras wrote Susruta Samhita, which is known as the main source of surgical treatment of disease in India. Ancient Indian 'doctors' were skilled in repairing and resetting fractured or/and dislocated limb joints, removal of tumours, repairing of hernia, removal of cataract affected lens through couching, etc. With the Muslim conquest of India (600 AD), Ayurvedic medicine gradually diminished yielding place to Unani Tibbi medicines which had the patronisation of the Pathan and Mughal kings. The Unani Tibbi medicine continued developing till the eighteenth century, the inception of British Empire. The development of Unani medicines centred around the cities of Delhi, Agra, Aligarh, Lucknow and Hyderabad. Between 1810 and 1839, the Homeopathic system of medicine, invented by the German physician Samuel Hahnemann, gained acceptance in India, and these systems are still in great public demand.

The allopathic system of medicine was introduced in the region that comprises Bangladesh during the British Raj. In the beginning, there were only a handful of trained allopathic doctors. However, with firmer administrative hold over the colony, the British felt the need of appointing good English doctors and introduced changes in the health sector. A Royal Commission of inquiry was sent to India in 1859 to inquire about large-scale death of civil population and military personnel. The commission recommended the establishment of a commission of public health in each presidency. In 1864 three sanitary commissions having 5 members each were established in Bombay, Madras and Bengal presidency. Civil Surgeons were appointed as ex-officio District Health Officers.

In 1869 the medical officers were renamed Sanitary Commissioner. In that year some sanitary commissioners were appointed in the centre and other states. In 1873, registration of birth and death was made legal obligation. In 1880 Act requiring vaccination against smallpox was passed. In 1881 the Indian Factories Act was introduced for the first time. Thousands of people died of plague in 1896 and the government appointed a Plague Commission. The epidemic act was declared in 1897, and the Plague Commission report published in 1904 recommended widespread reorganisation of the public health organisations. Like other province, the Sanitary Commissioner of Bengal became the chief of public health department and his office remained out of the control of the Surgeon General. The Sanitary Commissioner was made responsible directly to the central government.

Important health care activities undertaken during the twentieth century are the following:

During 1980s Shahid Suhrawardy Hospital complex accommodated the National Institute for Cardiovascular Diseases (NICVD) and National Institute for Ophthalmology. National Institute of Preventive and Social Medicine (nipsom) was also established in late 1980. However, Institute of Diseases of the Chest and Hospital (IDCH), Infectious Disease Hospital (IDH), Institute of Public Health, and the Cholera Research Laboratory were established in Dhaka between 1960 and 1970s. During 1980s the Cholera Hospital became International Centre for Diarrhoeal Diseases Research, Bangladesh (icddr,b). Around this period the Bangladesh Institute of Research on Diabetic and Metabolic Disorders (birdem) Hospital of the Diabetic Association came into being. [Maswoodur Rahman Prince]

Healthcare In Bangladesh healthcare during the past 40 years did not create an equitable distribution of health services. Health chapter of the Fourth Five-Year Plan (1990-95) began with the theme that access to health is a fundamental right of a person. The Fifth Five-Year Plan (1997-2002) states: 'Providing medical care is the constitutional obligation of the government'. In response to the changing health situation of the country, reforms in the health sector, particularly in the areas of management structure, service delivery mechanisms and utilisation of both public and private sector resources are called for urgently.

The spectrum of health situation has also been changing in Bangladesh with the global scenario changes in health over time. The major contributors to these changes are rapid population growth, increasing urbanisation and major shifts in disease patterns prevailing in the country. Resurgence of malaria, kala-azar and other emerging and reemerging diseases such as dengue, filariasis, tuberculosis are a few example of these changes, whilst the risks of Sexually Transmitted Diseases (STDs), Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS), and other infectious diseases menacing public health are increasing. Increase in the incidence of cardiovascular disease, renal disorders, mental illness, cancer, and conditions related to substance abuse, smoking, and alcoholism has been noted. Increased arsenic in sub-soil water in many areas also poses a potential danger to public health. It is likely that Bangladesh will continue to experience epidemiological transition and witness the phenomenon of coexistence of both age-old infectious and emerging new diseases. Diseases related to metabolic disorders, malnutrition, tuberculosis, reproductive health, diarrhoea, respiratory tract etc continue to influence the health status of the population.

In reviewing the Fourth Five-Year Plan's health and family welfare sector the fifth five-year plan states that over the 25 years of independence, the health situation of the population has improved quite remarkably. Smallpox, cholera and malaria have been eradicated or are no longer major killers. Life expectancy rose from 45 in 1970 to 60.8 in 2000. Total fertility rate was reduced from 6.3 in 1975 to 3.4 in 1995. The crude death rate dropped from 12.0 in 1990 to 9.0 in 1995 and is declining further. extended immunization programme (EPI) coverage had been over 66 percent in 1995 and infant mortality rate declined to around 78 per thousand live births in 1995. Similarly the under 5 mortality dropped from over 210 in the mid 1970s to 133 per thousand live births in 1995.

The key challenge in health and family planning is to expand access to basic services and improving the quality of services both in the public and private sectors. An immediate recent major achievement has been the preparation of a Health and Population Sector Strategy (HPSS) by the government (under implementation since 1998) which will fill the gap by providing a strategic framework for the development of the sector during 1998-2003. The HPSS was developed through a wide participatory process involving various stakeholders. The government, after approving it, has started implementing the Health and Population Sector Programme (HPSP 1998-2003) under the Health and Population Sector Strategy (HPSS) from July 1998. There has been another remarkable achievement in the health sector between 1998 and 2000. For the first time in Bangladesh, the country has formulated and approved a national health policy. It is understood that though the HPSP pre-empted the national health policy, the HPSP has been cut according to the new national health policy. It was possible as the formulation of the HPSP and the National Health Policy (NHP) began almost simultaneously.

Health status A recently conducted Health and Demographic Survey indicated that 41 percent of rural people who were sick lost an average of 10 days of work per person. Annual per capita treatment costs were relatively high, at about Tk 900 in urban areas and Tk 600 in rural areas. In both urban and rural areas, this amount is equal to or higher than the regional monthly poverty lines.

Fertility has decreased; child immunization has reached more than 70%. From 1981 to 1992 the population to doctor ratio fell by half ie 1:5242 and at the end of year 2000 it stands at 1:4719. The population to nurse ratio stands at 1 nurse for 8226 persons. The number of registered doctors in 2000 stands at 27,546 for a population of about 130 millions and the number of registered nurses is 15804. In 2000, the number of hospital beds were 40,793 of which 29,402 are in the government hospitals. The number of medical colleges in private sectors is 13 and in the public sector it is also 13. The World Bank report entitled In Search of Healthy Bangladesh: Expectation in the Twenty-first Century says that Bangladesh is at the top of the list with regard to malnutrition, and child mortality. Reasons for these, as identified are poverty, illiteracy and largely inadequate health care. In Bangladesh 70% mothers and children suffer from malnutrition. Everyday about 600 children die due to malnutrition and every year about 28,000 mothers die due to pregnancy related diseases and complications. More than 3 million children are born annually out of which about one third are born with lesser than normal birth weight. During childbirth, 5 expecting mothers die out of 1000 births. One out of nine children dies before the age of five. Among the most poor, this rate is one out of six. Pneumonia, diarrhoeal diseases, malnutrition, measles, and Tetanus, at the time of birth, are the main causes of child mortality.

Number of below five children is 20 million in the country. Out of this 20 million, 3,80,000 die every year: 1,20,000 die due to pneumonia, 95,000 due to diarrhoea, 19,000 due to tetanus and 15,000 due to measles. Low birth weight of the child is one of the major causes of child mortality in Bangladesh.

Table Public health infrastructure in Bangladesh

Despite sound infrastructure the health care services remain out of reach of the majority people. The primary reason, experts believe, is that government commitment for allocation for the health service sector never got a priority. According to a recent study conducted by the health economic unit of the Ministry of Health and Family Welfare, only 34 percent expenditure in health was financed by the public sector, 64 percent by the household and a mere two percent by non-government organisations (NGOs). In 1997-98 government allocation was Tk 1480 crore which was equivalent to 1.3 percent of GDP or Tk 117 per person per year. It is noted that the highest number of problems (22%) in health sector are related to inadequate number of physicians, wrong treatment, negligence towards patients, non-attentiveness, irresponsibility, absence from duty, and unwillingness of doctors to stay at rural areas and small towns. The other problems are related to supplies, equipment, beds etc (21%). Some other major problems often discussed also include lack of ambulance services as well as proper referral services, which are almost non-existent. The problems related to health bureaucrats, employees and nurses are also very significant. These are the state of affairs at the government hospitals.

The district hospitals are generally overcrowded with capacity unequal to demand. But facilities at the lower level are characterised by underutilisation and this is mainly due to lack of people's confidence. The new five-year health and population sector programme (HPSP) based on the Health and Population Sector Strategy (HPSS) already under implementation since July 1998 calls for providing an essential service package (ESP) or a community based healthcare scheme to the entire population at four different levels of delivery. The levels are: community out-reach, health and family welfare centres/rural dispensaries, upazila health complexes as first referral system and district hospital as second referral system. The public-private partnership in health (PPPH) programme is one of the components of the HPSP which aims to improve the access to the poor of good quality essential services especially to women and children by engaging the private sector. ESP includes child health, reproductive health, adolescent health, family planning, infectious diseases and curative services. These are the priority primary healthcare services for Bangladesh. The purpose of this is to develop a delivery system for primary care services for people of rural Bangladesh who have less access to healthcare services.

The non-government sector has successful stories in implementation of health and population programmes in accessing the poor to good quality essential services, especially the women and children. Bangladesh Rural Advancement Committee's (BRAC) community based health and population programme that utilises community health workers and makes use of community partnership is one such successful example of extending all elements of ESP through community partnership. Over the decades brac has been successfully implementing healthcare services at household level as well as from periphery static service delivery sites through strong involvement of community. Some of the successful stories of BRAC's healthcare services include Extended Programme of Immunisation, DOT tuberculosis programme, family planning, and post and pre-natal services.

Grameen health centres are operated by physicians and their sub-centres by paramedics. The centres' care is focused on patients with acute illness and referral arrangements with three non-profit private hospitals in and around Dhaka City. A pre-payment health scheme has been developed which accounts for one third of the cost of the centres' operations. Locally generated income accounts for 66 percent of the total costs. The annual per capital recurrent cost is only about US$ 0.37.

Gonoshathaya Kendra operates community healthcare services through four sub-centres. Paramedics mainly staff these but a physician pays visit to the centres twice a week. These centres are closely related to the Gonoshasthaya Kendra Hospital, which manages referral cases sent from these centres. The paramedics of the sub-centres also make home visits and provide basic health care services and health education.

Dhaka Community Hospital operates rural primary healthcare clinics and maintains a 50-bed facility in the capital for referral. The clinic programme is completely self-reliant. In the rural clinics each member contribute Taka 10 monthly to the programme and in return receives periodic home visits from health workers as well as free consultation from a physician at the clinic.

The International Centre for Diarrhoeal Disease Research, Bangladesh has extensive experience with operation research and with the implementation of innovative approaches. The Matlab MCH-FP (Mother and Child Health- Family Planning) project is the longest and most thoroughly documented experience in Bangladesh with the provision of most of the elements of ESP at the community level. icddr,b's commendable experience in developing reproductive health programmes including the promotion of safe motherhood and detection of treatment of reproductive tract infections for the past two decades are some of the achievements.

Currently the traditional healers (about 80%) are the major healthcare providers in the country. They are the first source of care for rural people with acute as well as chronic illness. These traditional healers need improved knowledge of medical science.

Resource allocation of medical and surgical requisite (MSR) to healthcare across different levels remains neglected, which needs to be taken care of to salvage the collapsing tertiary and secondary healthcare system in the country. All hospitals attached to medical colleges receive an annual allocation to Tk 25,000 (about US $ 500) per bed per year, which bears no relation to the reality. The district level hospitals receive Tk 18,000 per bed per year while the upazila health complexes receive Tk 10,500 per bed per year. The urban dispensaries get Tk 70,000 for each hospital. The union health and family welfare centres get Tk 40,000 each year. The central medical store gets a lump allocation of 20% of total fund for buying medical equipment, apparatus and other capital goods. The country over the past few years has seen development of modern hospitals capable of providing quality medical services. To name some of them, the National Heart Foundation, Sikdar Medical College and Hospital, Central Hospital, Japan-Bangladesh Friendship Hospital, Bajitpur Medical College and Hospital, and Dhaka Community Hospital.

The hospitals in the government sector are going to be placed under the Hospital Improvement Initiative Programme (HIIP). This would involve behaviour change of hospital staff and administration officials, improvement of structures and addition of new facilities for better service delivery.

According to the State of the World's Children 2001 published recently by UNICEF out of 181 reported countries, Bangladesh stands 53rd from the bottom up in terms of child mortality rates. Regionally Bangladesh is reported to be doing better than other countries such as India and Pakistan, which come out 49th and 39th respectively. Parameters such as immunization coverage access to 'safe' drinking water, sanitation, rate of school enrollment especially of girls and completion of primary education are slowly but definitely showing an upward and positive trend. If the validity of these statistics hold, these are something that Bangladesh has achieved in the last three decades. [Md Anwarul Islam]

Bibliography  Khan, Naila, Health in Bangladesh in the new millenium; Haq, Naimul, Innovative approaches to healthcare and family planning services; Peters, Gordon, Healthcare in Bangladesh: the missing link; Prince, MR, Healthcare in Bangladesh: beyond 2000, The Daily Star, 30. 1. 2001.

Disease and disorder

Allergic disorder state of hyper-sensitivity, usually characterized by difficult respiration, skin rashes, etc. In Bangladesh the main allergy producing substances (allergens; antigens) are house dust, pollen, foods, and smokes of various origin.

Surveys have shown that at least 10 percent of the population suffers from allergic disorders in either acute or chronic form. Heredity seems to play an important role. There are people with a familial predisposition to allergic disorders such as hay fever, atopic asthma, contact dermatitis etc. The common types of allergy in Bangladesh are sneezing, running nose, and red teary eyes of hay fever, caused by pollen, mites, mould of fungi, household dust, etc. Food that most commonly cause reactions include milk, egg, hilsa fish, beef, peanuts, wheat, etc.

Food preservatives and dyes sometimes create problems. Patients with food allergy show symptoms like nausea, vomiting, abdominal pain, or diarrhoea. There may be associated swelling of lips and tingling of the mouth or throat. Other patients may have different presentation including anaphylaxis, asthma, running nose, hives, eczema and joint pain. Among the many other causes of adverse reactions to foods are the toxic or pharmacological effects of bacterial toxins, chemical additives, psychological reactions and intrinsic gastro-intestinal diseases. Elimination or avoidance of the offending food substance from the diet is the major approach to the treatment of patients with food allergy. Atopic dermatitis (atopic eczema) is a common itchy skin disorder usually begins in infancy and has a chronic fluctuating course with seasonal variations. Most patients have immediate skin reactivity to a variety of environmental allergens. It often occurs in combination with other atopic diseases such as asthma or hay fever. Acute urticaria is commonly seen with viral infections and associated with parasitic, fungal and certain fungal infections. Hymenoptera stings, drugs and foods (eg eggs, milk, beef, fish, nuts) are other common causes of immunoglobutin E (IgE) mediated urticaria and angioedema. Between 0.5% and 5% of the population experience a systemic reaction after a sting, but death from insect allergy is rare. Anaphylaxis is a severe form of allergic reaction.

It is an acute, life threatening systemic reaction caused by an IgE mediated hypersensitivity reaction and characterized by urticaria, acute airway obstruction and circulatory collapse. The most common causes are antibiotic (penicillin) injections, bee stings, foods, etc. However, any foreign substance can cause anaphylaxis. Careful examination of skin, eyes, ears, nose, throat, chest and abdomen gives important clues of allergic disorders. The treatment of allergy, in many instances, consists simply of avoidance of the cause. Drugs used to treat allergies act at various stages of the IgE mediated reaction. Most commonly used drugs are various brands of antihistamines, which block the effects of histamine. Mast cell stabilizer drugs are helpful for prophylactic purposes. Severe allergic reaction is treated with hormones (eg glucocorticoids, adrenaline). [ARM Saifuddin Ekram]

Blood disorder disease or any ailment related to blood. Disorders of blood can be of two types - acquired and inborn. The former disorders are caused by germs, life style and habits of the individual and by factors pertinent to the physical environment in which the individual lives. The latter category originates as genetic endowment at birth from the parents. Acquired blood disorders include changed profile of blood called complete blood count (CBC) caused by an infection in any part of the body, haemorrhage due to bacterial and viral infections, and anaemia (lower haemoglobin level) which can be caused by both infection and malnutrition. The more serious disorders of blood in humans are the inborn disorders of which there are many types including abnormalities in haemoglobin function (haemoglobinopathies), blood-clotting defects that result in the illness called haemophilia, and malignancy of blood cells or leukaemia.

Bangladesh with its 130 million people and scarce economic resources admittedly have to carry the burden of a sizeable population below the poverty line. Conservative estimates of hard-core poor in the country run to the order of 35 million. This population consumes less than 1,805 calories per day where World Health Organisation's minimum requirement is 2,122 calories.

Needless to say, the extent of anaemia in this population due to nutritional causes may be quite high. Furthermore, a large fraction of children suffers from various parasitic diseases including intestinal helminths that are frequently associated with anaemia. There is no significant data on the incidence of blood disorders in the people of Bangladesh except for the fact that 'acquired' anaemia- anaemia caused by infections and malnutrition is fairly common. About 50% of blood samples tested are seen to contain less haemoglobin (by 2-3 percent) than the reference value. Recently, an organisation has been created in the NGOs sector with interest in blood disorders, particularly thalassemia where the afflicted individuals are all children because the disease, caused by two copies of recessive genes, is manifested soon after birth and the affected children have to be on regular RBC transfusion, a service not readily available in Bangladesh at present. [Zia Uddin Ahmed]

Cardiac disorders ailments or diseases of heart, the central pumping organ for blood circulation. Cardiac disorders originate from several causes. Some defects are congenital, that is, the individual is born with the defect, usually comprising structural abnormalities in the heart. Some disorders are associated with infections such as rheumatic fever that is caused by bacteria. Physiological abnormalities involve blood pressure and disturbed rhythm in the pumping action of the heart. And, a very common disorder is the narrowing of artery due to cholesterol and fat deposit in the artery called plaque, which interferes with the flow of blood in degree that is proportional to the size of the plaque.

Recent studies indicate that common cardiac disorders show a relationship with economic growth of a country. In a developing country the disease profile shows during the early phases of growth a preponderance of infectious diseases and diseases due to malnutrition. As the economy slowly transits into an elevated level the disease profile changes. Infectious disease load decreases due to improvements in health and sanitation and better availability of drugs and vaccines to treat and control such diseases, while disorders due to mental stress arising from the complexities of urban life and those related to improper eating habits etc begin to gain in prominence

Congenital Ventriculur Septal Defect

. The latter category, the so-called transition diseases, includes cardiac disorders. Indications of this transition phenomenon are now evident in Bangladesh particularly in the upper middle class living in major cities and towns.

The common cardiac disorders encountered in Bangladesh include congenital heart disease, hypertensive heart disease, ischaemic heart disease, mitral stenosis, and rheumatic heart disease. Statistics on the incidence of different types of heart ailments is not available for the population of Bangladesh. Sporadic survey, institutional research or records collected from hospital sources indicate that about 2.92% of the population has some form of heart disease. Hypertension (blood pressure) is found in about 1.1% of the population. Rheumatic heart disease, ischaemic heart disease, and cardiac arrhythmia were detected in 0.75%, 0.33% and 0.22% of the tested persons respectively. Congenital heart disease was found in 0.18% individuals and 0.25% were suffering from cardiomyopathy. Rheumatic heart disease is more common in poor people of younger age, while ischaemic heart disease seems to be prevalent in well-to-do people, although poor people, are not immune to this disease.

Treatment of hypertension is commonly done by family physicians involving use of medication that is to be taken regularly. In smaller cities and in rural areas there are no good record on the prevalence of medically treatable hypertension but it is widely believed that the incidence will be lower. For blocked arteries the treatment option usually is a 'by-pass surgery' where portion of vein removed from a leg is used to join surgically two points of the artery to by-pass the block or 'balloon angioplasty' where the plaque is loosened by repeated inflation and deflation of a balloon guided in the blocked region. These procedures are technically more demanding, facilities for which were lacking in the early 1990s but are now available in a small number of government hospitals such as the National Institute of Cardiovascular Disease and the army establishment, the Combined Military Hospital (CMH). In recent years a few hospitals in the private sector have been equipped with facilities for such procedures. [Syed Azizul Haque]

Congenital heart disease abnormality or defect of the heart that exists from birth. This disorder accounts for approximately 1 percent of all live birth. About half of the affected babies die during the first year of life if untreated. The presentation of the diseases may be during the first year of life or may present at any stage of life. Defects, which are well tolerated eg atrial septal defect may cause no symptoms until adult life or may be first detected incidentally.

The most common congenital heart diseases are Ventriculur Septal Defect (VSD), Atrial Septal Defect (ASD), Parsistent Ductus Arteriosus (PDA), Coarctation of the Aorta, Pulmonary stenosis, Aortic stenosis, and Transposition of the Great Arteries (TGA). Symptoms may be absent or sometimes the child may be noticed to be breathless, cyanotic or fail to attain normal growth and development. Clinical signs vary with the anatomical defect. Cyanosis and clubbing is found in cyanotic heart diseases. Cerebrovascular accident, cerebral abscess or syncope may be found in severe cyanotic congenital heart diseases. The overall prevalence patterns in Bangladesh are VSD 25-30%, ASD 15-20%, PDA 10% and TGA 5%.

To prevent these diseases, avoidance of different etiological factors especially in the earlier part of a intrauterine life is very important. Nowadays, genetic lesion also could be diagnosed in early fetal life, when termination of pregnancy can be done. Prevention of congenital heart disease is very important specially for a country like Bangladesh where people as well as country faces difficulty to bear the high expense of definite curative treatment.  [Syed Azizul Haque and AKM Mohibullah]

Hypertensive heart disease a condition in which a person has a higher than normal blood pressure. Hypertension is the single most important disease that the civilization has suffered from and needs special consideration because of its complications. Hypertensive heart diseases are the commonest cardiovascular problems and a major cause of mortality and morbidity. It is one of the important risk factor for coronary artery diseases and predisposes to myocardial ischaemia, myocardial infarction and sudden death. It was found that the risk of developing coronary artery diseases was twice as high among hypertensive patients compared to normotensive subject.

Hypertension accelerates the process of atherosclerosis in the coronary artery as well as increases the workload of the heart. As a result hypertensive patients are at risk of myocardial infarction. Hypertension is directly or indirectly responsible for 10-20% of all deaths and the commonest cause is coronary artery diseases. Several studies have shown that this disease is more prevalent in educated working population having mental stress or agony. However, vast majority of our hypertensive population remains undiagnosed and untreated.  [AKM Mohibullah]

Ischaemic heart disease (IHD) also known as coronary artery disease (CAD) or coronary heart disease (CHD), results from the lack of oxygen supply to heart, with consequent altered cardiac function. Clinical presentations of the disease are unpredictable, may be asymptomatic or may present as stable angina pectoris, unstable angina, acute myocardial infarction, heart failure, arrhythmias and even sudden death. Ischaemic heart disease is a multifactorial disease, more common in male. The incidence and mortality increases with the age. It is the most important single cause of death throughout the world.  [AKM Mohibullah]

Mitral stenosis narrowing of the mitral valve obstructing free flow from atrium to ventricle of the heart. Mitral stenosis is one of the commonest valvular heart disease. Almost always it occurs as a consequence of rheumatic fever and very rarely may be of congenital origin. In patients having this disease, the mitral valve orifice is slowly reduced by progressive fibrosis and calcification of valve leaflets, fusion of the valve cusps and subvalvular apparatus. The normal initial valve orifice is about 4-5 cm2 and it may be reduced to 1 cm2 or less in severe mitral stenosis. Due to narrowing of the orifice the flow of blood from the left atrium to left ventricle is restricted. Left atrial pressure rises leading to rise of pulmonary venous pressure and pulmonary venous congestion. There is dilatation of the left atrium. Mitral stenosis is more common in women. The patients with mitral stenosis remains symptom-free until the narrowing is moderately severe.

Patients with symptoms may be treated medically with diuretics, digoxin and prophylactic antibiotic but the definitive treatment of mitral stenosis is mitral valvotomy or balloon valvuloplasty or mitral valve replacement. Being a common valvular disease seen in Bangladesh, all types of its treatment are available in the country. [AKM Mohibullah]

Myocardial infarction myocardial necrosis or death caused by complete cessation or interruption of blood supply to a portion of heart. Behind every myocardial infarction (MI), a dynamic interaction should occur among several or of the following factors: (i) severe coronary atherosclerosis (a variable combination of changes of the intima of the arteries due to accumulation of lipids, complex carbohydrates, blood products, fibrous tissue etc); (ii) an acute atheromatous plaque change (fissuring, ulceration, rupture); and (iii) superimposed thrombus formation or vasospasm. Ultimately there may be a total obstruction/occlusion of the coronary artery or arteries.

Exact data about incidence and prevalence of myocardial infarction in Bangladesh is lacking. Incidence of ischaemic heart disease (IHD- which includes, angina pectoris, unstable angina, myocardial infarction) was about 3 per thousand until 1976. A study in 1985, revealed that the incidence of IHD was about 14 per thousand. Prevalence of IHD in urban population was reported to be as high as about 100 per thousand. Myocardial infarction is the leading cause of death in Bangladesh, mostly in the 4th decade of life.

All patients of acute myocardial infarction should be hospitalised preferably in a coronary care unit (CCU). Immediate management includes, rest in bed, initial evaluation, oxygen inhalation, intravenous access and administration of aspirin or analgesic (pain relieving drugs like morphine). Further management includes regular follow up, early mobilization, risk factor modification, and use of drugs like beta-blocker, etc to be continued till discharge.

Before discharge, assessment of left ventricular function, detection of residual ischaemia, assessment of risk of grave arrhythmia should be done.  [Syed Azizul Haque]

Rheumatic heart disease a condition resulting from the damage produced by recurrent attacks of rheumatic carditis. The changes are largely confined to the valve structures of the heart but in some instances myocardial damage may also be severe.

More than two-thirds of patients who have experienced rheumatic fever eventually develop chronic rheumatic valve disease. The predominantly affected valve is the mitral valve - in about 90% cases followed by aortic valve. Tricuspid and pulmonary valves are uncommonly affected. The lesion develops 10-20 years after the attack of rheumatic fever in western countries, but it is much earlier in developing countries.

Stenosis of a valve is not usually critical until the affected valve is reduced to less than quarter of its normal size. Regurgitation of a valve may be important from the time of the attack of acute rheumatic fever but its appearance as a symptomatic disorder is likely to be delayed. So the signs of mitral and aortic regurgitation may be present in childhood or early adult life but its symptoms seldom develop until 3rd or 4th decade.

The common features of these diseases are shortness of breath initially - on exertion and later on even at rest, cough, palpitation and organic heart murmurs. Sometimes frank left and or right heart failure may develop.

Diagnosis of the valvular lesion may confidently be done by two dimensional and colour Doppler echocardiography (ECG). ECG and X-Ray of chest may also contribute to the diagnosis. Prevention of the disease is very important and prophylaxis against rheumatic recurrence is essential. [AKM Mohibullah]

Dissociative disorder a mental condition developed due to changes in a person's sense of identity, memory, or consciousness. This type of disorder is often divided into four categories: dissociative amnesia, dissociative fugue, dissociatve identity disorder, and depersonalization disorder. An inability to recall important personal information usually after some traumatic experience, is diagnosed as dissociatve amnesia. In dissociative fugue, the person moves away, assumes a new identity, and is amnesic for his or her previous life. The person with dissociative identity disorder (formerly called multiple personality disorder) possesses two or more distinct and fully developed personalities, each with unique memories, behavior patterns and relationships. In depersonalization disorder the person's perception of the self is altered, he or she may experience being outside the body or changes in the size of body parts. Clinical presentation of dissociative disorders is somewhat different in Bangladesh as compared to western countries. In Bangladesh a study shows that of the 400 patients, 6-9% suffering from this type of disorder, are frequently presented with hysterical symptoms. Except for dissociative amnesia, the other types however are relatively uncommon in clinical practice. One reason may be that people are still not aware of the availability of the psychiatric services in Bangladesh. So very selected and limited number of patients and only those with somatic or hysterical complaints are brought by family members for treatment. All dissociative disorders are instances of a massive repression. Therapy is focused on teaching patients to cope better with challenges of life. [Parveen Haq]

Genetic disorder any disease caused by innate defects in the victim's genetic components. Genetic disorders can be caused by defects in one gene, called single-gene defects, or these may result from the interaction, of several defective genes, called multi-gene defects, or presence of extra chromosomes or lack of one.

Colour blindness is one such common single-gene disorder. A colour blind individual cannot distinguish between red and green colours. A recessive gene also causes inherited condition called albinism, complete lack of the brown pigment melanin from cells of skin, hair and iris of the eye. In Bangladesh as regards incidence of genetic disorders, information is scanty. Even the easy-to-detect single-gene disorders among the people of Bangladesh there are no significant data available, although one would expect that many single-gene disorders will occur in the rather large population base with inbreeding that the high population density will favour; many of the cases may even provide new genetic diversities of both academic and practical interest.

The lack of interest in studying genetic disorders cannot be seen in isolation from the perception that diagnosis is often the end of the scientific effort, virtually nothing can be done to cure or ameliorate these illnesses. Nevertheless, human karyotype analysis- that is, study of chromosome morphology at mitosis to arrange homologous chromosomes- was undertaken by the birdem during the 1980s. In this effort, collaboration with the department of Botany, University of Dhaka, where studies on karyotype of plants are routinely carried out, proved productive. Genetic disorders due to changes in chromosome number could be confirmed at birdem, but systematic study of incidence of such cases in the population has not been undertaken.   [Zia Uddin Ahmed]

Iodine deficiency disorder an ailment or disorder arising from severe and chronic dietary iodine deficiency. Dietary iodine deficiency is now recognized as a global public health problem, since it causes adverse effects on all stages of human growth and development. The deficiency in the diet may lead to simple goiter characterized by thyroid enlargement and hypothyroidism. In young children, this deficiency may result in retardation of physical, sexual, and mental development, a condition called cretinism.

Globally, an estimated 1.57 billion people are at risk of iodine deficiency disorders (IDD), 655 million are goitrous and 20 million suffer from varying degrees of mental retardation caused by iodine deficiency. In fact, iodine deficiency is the most common preventable cause of mental handicap in the world.

The widespread prevalence of goitre in Bangladesh was first revealed by the nutrition survey of 1962-64 by the Department of Biochemistry, University of Dhaka. The national goitre prevalence study conducted by the Institute of Public Health and Nutrition (IPHN), Dhaka in 1981-82 reported that the overall goitre prevalence was 10.5%. The survey was done on 214, 608 subjects and the prevalence varied between 2.6% and 29.3%.

A nation wide comprehensive IDD survey was conducted by a Dhaka University team in 1993 to assess the current status in the country. It revealed a severe IDD situation; the current total goitre rate (TGR) in Bangladesh is 47.1% (8.8% visible and 38.3% palpable), and the rate of cretinism is about 0.5%. The survey also showed that about 68.9% are biochemically iodine deficient. Children and women are the worst sufferers.

Iodine is the heaviest member of the halozen group. It is carried around the body in the blood as iodide and is absorbed in the thyroid gland in the neck where it is converted to the hormones thyroxine and tri-iodothyronine. These two important hormones are concerned with the general metabolic activity of the body and control the rate of energy production in all cells. The body normally contains only about 2-50 mg iodine and the amount required daily in the diet is very small indeed, about 0.15 mg being sufficient for normal needs. When the diet provides insufficient iodine, the thyroid gland may increase in size in an attempt to compensate for the deficiency showing the characteristic swollen neck, or goitre. Goitre still occurs in some parts of the world, especially mountainous and inland areas, where iodine level in the soil, and hence in vegetation, is low. Its incidence in developed countries, where preventive measures can be taken, is low. In Bangladesh certain northern districts, particularly Rangpur, Gaibandha, Nilphamari and Dinajpur are considered as goitre-prone areas.

Small amounts of iodine may be present in drinking water, and it is also obtained from food, seafood being the richest source. Thus cod, salmon, and herring are all useful sources of iodine, although the best marine source is cod-liver oil. Milk and other dairy products are important dietary sources of iodine. Vegetables grown on iodine-rich soils also contain available iodine but most cereals, legumes and roots have low iodine content.

Some vegetables are said to be goitrogenic, ie capable of causing goitre. Cabbage, cauliflower, and sprouts can all interfere with the uptake of iodine by the thyroid gland and thus cause goitre. This is only likely to occur, however, if substantial amounts are eaten and the iodine content of the diet is very low.

Some seaweed concentrate iodides from seawater and are, therefore, a useful reservoir of combined iodine. In some parts of the world certain seaweed are regarded as valuable foods for humans and cooked seaweed, known as laverbread, is eaten.

In areas where the iodine content of the diet is low, a satisfactory way of increasing the intake of iodine is the use of 'iodized salt'. This is prepared by adding about one part of potassium iodide to about 40,000 parts of salt. Potassium iodide is soluble in water and is rapidly absorbed into the blood, any surplus being quite harmless. The use of iodized salt is a simple and harmless way of supplementing the iodine obtained from food. Bangladesh government has made it mandatory to market iodised salts. [SM Humayun Kabir]

Neurological disorder disorders or malfunctioning of the nervous system. It can be grouped under two headings- disorders in which organic damage of the nervous system is involved due to injury or infection, and disorders where no obvious organic damage is apparent but are due to imbalance of important chemical substances that regulate functioning of the system. Major neurological disorders that involve organic damage include paralysis caused by vascular disorders such as stroke or by poliovirus infection or due to damage in motor cortex with the condition known as cerebral palsy; meningitis (inflammation of the layers of tissue covering the brain and the spinal cord) resulting mostly from viral or bacterial infection; encephalitis (inflammation of brain) mainly due to viral infection; myelitis (inflammation of spinal cord); neuritis (inflammation of nerve); and concussion and fainting (brief unconsciousness due to sudden movement of the brain) caused mainly by injury.

Neurological disorders associated with obvious damage to the nervous system such as represented by the above categories constitute the class of disorders that are frequently reported from the country's hospitals and clinics. In the country's government medical colleges and most of the private medical colleges that have been established in the 1990s, there are neurology departments in only a few. Only in 7 of the 13 government medical college hospitals there are neurology departments. Among the hospitals in the private sector two (both located in Dhaka) such as BIRDEM Hospital and Holy Family Hospital operate neurology departments. It is estimated that in the country there are at present only about 25 specialist neurologists, majority in Dhaka and a small number in Chittagong. The picture that emerges for neurological treatment facilities in the country is thus quite unsatisfactory. With respect to neurosurgery-neurological treatment requiring surgery of brain and the spinal cord and of the peripheral nervous system-the picture is even more unsatisfactory. There are at present 20 or so neurosurgeons working in the country, but most are located in Dhaka and among them nearly one-third work in the former Institute of Post Graduate Medicine and Research (IPGMR), which is now the bangabandhu sheikh mujib medical university (BSMMU) Hospital. Other government hospitals where neurosurgery is carried out include Sir Salimullah Medical College Hospital, Dhaka Medical College Hospital, and the Combined Military Hospital.

Neurological disorders associated with imbalances in neurotransmitters are frequently seen in the country, but there is no statistics as to their incidence. In a country with about 130 million people there is little doubt that the number of people with such disorders will be quite high but there are no specialised centres for treatment of such disorders. The neurology departments in the country's government and private sector hospitals are mainly involved in treating organic disorders of the nervous system.

Many neurological diseases that involve imbalances in neurotransmitters and congenital neurological ailments such as schizophrenia, etc. are often passed in the villages as superstitious belief such as effect of bad wind or the like. These cases are left medically unattended with the result that young patients suffering from these disorders are unkindly treated as lunatics and they become a burden to the family. Admittedly many of them perhaps die at an early age. [Zia Uddin Ahmed]

Deficiency disease a condition due to lack of a substance essential in the body metabolism. The deficiency may be due to inadequate intake, digestion, assimilation or absorption of different nutrients in food. Growth and development of human beings, as for all other forms of life, depend on proper availability of certain essential substances through food. Protein is the source of amino acids that are necessary for making proteins of specific types that an organism needs for building different parts of the body, vitamins are necessary for a disease-free body, and the numerous biochemical reactions that body is required to carry out could not be carried out without the participation of some key minerals. These are obtained from the different types of food that we eat. Deficiency of any of these three types of ingredients leads to diseased condition, and the spectrum of such diseases together are called deficiency diseases.

There are two means by which a certain deficiency is caused in the human body- one is that the particular ingredient is not available to the body through food, and the other is that it is available to the body but the body cannot absorb or utilise it because of some metabolic defects. Such defects are often genetically determined. In developing countries, the profiles of deficiency diseases are generally similar. These include diseases due to deficiencies in vitamins, minerals and amino acids. Of these, vitamin deficiencies are readily detected. Of the 13 vitamins that are essential for good health, deficiencies in vitamin A, B, C and D are known to cause clinical disease. Vitamin A deficiency leads to night blindness, B to beriberi and pellagra, C to scurvy and D to rickets. Mineral deficiency and amino acid deficiencies are also common; Iodine deficiency for instance leads to goitre, iron deficiency to various forms of anaemia, zinc and copper to various metabolic malfunctions, some leading to skin lesion and hair malformation.

Most rural children run a high risk of vitamin A deficiency because of inadequate dietary intake of the vitamin, due largely to poverty and partly due to poor eating habits resulting from ignorance. Surveys that have been carried out in recent years suggest a prevalence of vitamin A-associated night blindness in children of 1-6 years of age, of about 2%. Each day, nearly 88 children become blind in Bangladesh due to vitamin A deficiency. For infants, it has been found that the Bangladeshi lactating mother can provide nearly 70% of the infants vitamin A requirement. Vegetables and fruits are very rich in vitamin A. Homesteads in rural areas can serve well in producing green vegetables for the family with little cost and effort in our country since the weather is congenial for cultivation of some vegetables and fruits throughout the year. However, with increasing family size, household land is shrinking with the result that rural people have much reduced per capita vegetables consumption now than what it used to be a few decades ago.

To ameliorate this, the government has undertaken serious awareness creation programmes and promotional messages as to how best is to maximise vegetables production with whatever small amount of land is available, have been given to the community with some success. But a noteworthy success has been the administration of high potency vitamin A capsule to children under 5 years of age as part of the Expanded Programme of Immunisation. However, coverage achieved in different parts of the country is not satisfactory, ranging from 16 to 85%. Nevertheless, it is expected that because of this programme coupled with awareness creation on dietary vitamin source may reduce vitamin A deficiency among children with time. Incidence of other vitamin deficiencies is also quite common particularly among the rural people due to poverty and malnutrition but proper statistics are not available.

Another major deficiency disorder in Bangladesh is iodine deficiency disorder. Dietary deficiency of iodine causes impaired function of thyroid gland and often results in a clinical condition called hypothyroidism. Severe chronic deficiency of iodine causes swelling of the thyroid gland resulting in goitre- ound growth of the thyroid gland which is visible on the throat. It can be quite large, sometimes almost the size of the head or even more. Iodine deficiency in Bangladesh is quite common. The first systematic survey of iodine deficiency in Bangladesh was carried out in the early 1960s which revealed certain areas (Jamalpur district) where every infant, child, man and woman examined had goitre. People with goitre are seen in the villages quite frequently. Accurate statistics about the incidence of goitre are not available, but its incidence is more in the inland hilly areas of the country. It is estimated that 69% of the population is biochemically deficient in iodine and 47% suffers from clinically detected iodine deficiency and thyroid malfunction problems.

Iodine containing salt, commonly called iodized salt, is useful in providing the necessary iodine in the diet. The Parliament of Bangladesh adopted the Iodine Deficiency Prevention Act in 1989 requiring universal iodination of salt by the year 1995. During the early 1990s, a programme for production of iodized salt was undertaken by the government with the help of international agencies notably WHO. The programme has been successful in marketing iodized salt through the private sector, although actual iodine level in various preparations is not always strictly regulated and some preparations may not be up to expectation.

Iron deficiency may lead to anaemia, a condition quite widespread in Bangladesh, and this again is in a large measure related to poverty and malnutrition. Zinc deficiency can be seen in infants with severe diarrhoea that is manifested as white patches in the skin. Several studies carried out by the International Centre for Diarrhoeal Disease Research, Bangladesh carried out in the 1990s showed that zinc deficiency may be common in Bangladesh. Zinc being required for over a hundred important enzyme functions in humans it is not unlikely that this may represent an 'unseen' mineral deficiency in our population. Diseases due to other mineral deficiencies may also be common in the population but these remain largely undetected and do not usually draw attention of the public health programmes of the government, as the per capita health expenditure in Bangladesh at present is only about $3 and thus only the most pressing health problems can be addressed. There is no information available as to the prevalence of deficiency diseases due to genetic defects in Bangladesh.   [Zia Uddin Ahmed]

Diabetes and endocrine disease a general term for diseases caused by hormonal and metabolic disturbances. Among the endocrine diseases, diabetes, usually marked by excessive thirst and urination is the most common afflicting millions of people throughout the world. Diabetes also known as diabetes mellitus, is caused by lack of the hormone insulin produced by some cells of the pancreas. The insulin molecule is a small polypeptide that is responsible for regulating the entry of glucose from the blood to most of the body's cells. Inside the cell glucose is broken down by oxidative reactions to produce energy. In the absence of insulin, the entry of glucose into the cells is impaired. The result is that the complex carbohydrate-food eaten by the afflicted individual is broken down by body's metabolic machinery into simple sugar such as glucose. The glucose is then absorbed by the intestine and passed on to the blood where in the absence of insulin the glucose cannot be further metabolised so that glucose concentration in the blood builds up to dangerously high levels. Since glucose cannot enter cells and be metabolised, there is little generation of energy. The consequences of these are manifold and form the basis for the great complexities of the disease.

In Bangladesh many of the endocrine diseases remain largely ignored because their effects are slow and hence medical attention is also of reduced priority. This is not, however, intentional but is the result of financial constraints. The pioneering work of a physician of Bangladesh, Mohammad Ibrahim, widely remembered as a visionary and a most dedicated physician, translated into the establishment in 1956 of what is today a highly prestigious biomedical research institution the BIRDEM. It is popularly known as the Diabetic Hospital since the vast majority of its patients are the diabetics living in Dhaka and many also coming from other parts of the country.

There are two major types of diabetes, insulin-dependent or type I and non-insulin-dependent or type II. The type I diabetes is difficult to manage since the patient has to be given insulin injection daily, often 2-3 times a day, in order to control sugar level in blood. Type II diabetes can be managed by a combination of diet control and regular exercise in order to burn excess calorie. The incidence of type II diabetes is much higher than type I diabetes. In general, diabetes has a certain degree of heritability, but heritability is stronger in the case of the type I disease than type II, although environmental factors also play an important role in the disease. [Zia Uddin Ahmed]

Diseases of digestive system Human digestive system is exposed to disease-causing agents when such agents get into the system with food and drink. In addition, there are non-infectious diseases caused by metabolic causes and stress. As one would expect in a developing country with poor health and sanitation system and scarcity of pure drinking water, the major category of illness affecting the digestive system is diarrhoea. Diarrhoea is caused by various bacterial and viral pathogens and by intestinal parasites. Of the different types of severe diarrhoea, cholera and bacillary dysentery or bloody dysentery are most common that occur throughout the year and often shows explosive epidemic outbreaks. Somewhat less severe diarrhoea but with yearly total cases quite high is caused by some pathogenic colon bacillus, E. coli.

Typhoid fever caused by Salmonella typhi is an infection that also takes place through the digestive system with the bacteria entering the system with food and then passing into the blood circulation. Amoebic dysentery and infections with intestinal worms and parasites are also common particularly in rural children. Diarrhoeal diseases account for approximately 14% of all diseases in the community, intestinal worms 10% and peptic ulcer 6%. Irritable bowel syndrome, an illness of the digestive system that involves heartburn, stomach pain, and abdominal cramp but often without development of ulceration, is quite common. Recent studies indicate high prevalence of the newly described stomach bacteria Helicobacter pylori that is implicated in stomach ulcer and also in gastric cancer in people suffering from gastritis and peptic ulcer. Although gastritis is a very common medical complaint in Bangladesh population and many cases of such gastric disorders may be caused by inflammation in the pancreas (pancreatitis), the extent of this in the population is not known.

More serious diseases of the digestive system such as diverticulosis (outpouching of part of intestine due to weakened intestinal wall), ulcertative colitis (ulcer in colon and rectal region) and colorectal cancer (cancer in colon and rectum) are reported from hospitals from large cities and towns but their extent in the population is not known. It is believed that due to the largely vegetables-based food habit of the population the incidence of these diseases may not be as high as these are seen in many western countries. [Zia Uddin Ahmed]

Diseases of eye Broadly eye diseases are classified into (a) Congenital- diseases with which a child is born either due to hereditary genetic defect (familial disease) or due to certain material disease during pregnancy; and (b) Acquired- diseases that may affect a person during life time due to injury, malnutrition, infection by parasite, bacteria, virus, bacillus, and fungus. Professional hazards and aging (senile degeneration) may also lead to certain eye disease.

In Bangladesh it has been found that the most common cause of blindness in the adults is cataract, whereas in the children it is corneal affection. Trauma constitutes about 27% of blindness in children and about 10% in adults. Glaucoma is responsible for about 16% blindness in the adults. The overall prevalence rate of eye morbidity in rural community is about 5%. The vast majority of eye disorders are noted in the poor income groups. [MI Choudhury]

Infectious disease any disease caused by infectious agents such as viruses, bacteria and other parasitic or pathogenic microorganisms. These diseases are contagious and spread within the community through various means- air, intake of contaminated food and water, and through person to person contact. The infectious agents thus spread less rapidly under conditions of good personal hygiene and sanitation practices, clean environment and clean hygienic eating habits. Some infectious diseases spread under over crowded conditions such as at places of worship, schools, indoor gatherings, market place etc while diseases like AIDS and sexually transmitted diseases spread through intimate personal contact.

The profile of infectious diseases in Bangladesh is similar to that seen in many developing countries of the tropics. Among the water-borne infectious diseases diarrhoea, cholera, bacillary dysentery, typhoid and some types of jaundice are important; those transmitted through air include influenza, pneumonia and tuberculosis; diseases spread through intimate personal contact include gonorrhoea and syphilis and of course the menacing viral disease, aids. The incidence of AIDS in Bangladesh will assume epidemic proportions as predicted by experts in the near future, but perhaps due to religious culture and a strong awareness generation campaign which the government has been waging for the past several years with the help of external agencies, the number of AIDS cases so far has been very low but as experience in other countries has shown, there is no reason for complacence. Strong measures towards awareness creation as to the mode of transmission of the disease is essential for containing the spread of the disease where religious restrictions inherent in our culture may of course greatly complement such efforts.

Disease profile in a developing country shows a characteristic pattern. At high poverty level associated with poor health and sanitation practices, over-crowding, unsafe drinking water- in short a germ ridden environment contributes to the preponderance of infectious diseases. Among infectious diseases, the top five in Bangladesh, in order of relative abundance shown as percentages, are diarrhoea 15%, intestinal worms 10%, skin diseases, anaemia and acute respiratory infections each about 8%. [Zia Uddin Ahmed]

Pollution-related diseases diseases caused by contaminated air, water and soil with materials that affect human health and mostly created by human activity. In Bangladesh due to large population size and absence of proper system of sewage disposal, surface water historically has been most vulnerable to contamination with germs such as bacteria and viruses, with antecedent occurrence of water-borne diseases such as cholera, typhoid fever and other diarrhoeal diseases. In the past, epidemics of cholera used to literally wipe out entire villages because no remedial measures were known. At present knowledge about cholera and other diarrhoeal diseases is much better in which the International Centre for Diarrhoeal Diseases Research, Bangladesh created in 1960 has made pioneering contributions saving millions of lives globally every year. Even with improved water quality and greater public awareness of health and sanitation practices, Bangladesh still has to carry the burden of about three-quarter of a million cases of diarrhoea per year caused by contaminated drinking water.

Soil contaminated with germ and intestinal parasites due to unhygienic defecation practice are also responsible for many diarrhoeal diseases. The extent of contamination of soil with chemical contaminants such as residues from insecticides and chemical inorganic fertiliser is not known but believed to be quite high. Soil contamination with toxic chemical substances often affect human health through their being incorporated into the food chain and hence such diseases take a long time to be recognised as obvious health problem.

Air pollution-related diseases have come to present a major concern in the capital city of Dhaka in recent years due to rapid increase of automobiles. Altogether over 200,000 motorised vehicles ply in the city of Dhaka. A large proportion of this comprises old three-wheeled auto-rickshaws driven by two-stroke engines, old and poorly maintained buses and large number of trucks. Quantity of the heavy metal lead in city air is 50-100 times higher than the maximum permissible level. Automobile smoke and the level of noise in Dhaka are far above the admissible levels. Shop owners along the main roads are also among the most vulnerable to the adverse effects of these contaminants because they keep their shops open for about 12 hours a day, six days a week and are exposed to these harmful contaminants throughout the year. Varying levels of hearing impairment and respiratory illnesses such as asthma and bronchitis are common among people who are so heavily exposed to automobile exhaust and noise. An equally vulnerable group is the autorickshaw drivers about 30% of whom suffer from hearing problems.

The level of lead in blood is alarmingly high in both children and adults that have been surveyed (1998 - 99) on the vulnerable groups, that is, those living near the high automobile-traffic roads. This is mainly due to use of unleaded and inadequately refined gasoline, which is also the source of high level of sulphur in air. Diseases caused by high levels of lead and sulphur may present with varied symptoms. [Zia Uddin Ahmed]

Respiratory diseases Bangladesh being a tropical country with high humidity and excessive rainfall in summer, and dry cool weather in winter, many people are prone to develop various respiratory disorders. Air pollution, unhygienic living conditions, and malnutrition often aggravate these maladies.

Common manifestations of respiratory diseases are cough, purulent, sputum, haemoptysis, chest pain, dysponea, wheezing, hypoxaemia, hypercapnia, and respiratory failure.

Common respiratory diseases are acute coryza (common cold), influenza, pneumonia, tuberculosis, allergic rhinitis, and bronchial asthma. [Md. Rafiqul Islam]

Sexually transmitted diseases (STDs) infectious diseases acquired primarily through sexual contact with an infected partner. Sexually transmitted diseases also known as venereal diseases (VD), are caused by bacteria, viruses, fungi, protozoans, mycoplasma, and parasites that thrive on the warm, moist mucous membranes of the genital area, mouth, and throat. STDs include gonorrhoea, syphilis, chancroid, granuloma ingunale, herpes genitalis, trichomoniasis, genital candidiasis, nonspecific urethritis, AIDS, etc.

The real magnitude of STDs in Bangladesh cannot be substantiated and the actual figure of the whole country is not available. Bangladesh Dermatological Society estimates that more than 30% of patients attending various hospitals and health centres out patients, are suffering from skin diseases and STDs and the number of patients suffering from STDs are increasing day by day. A preliminary study revealed that among the reported cases, the incidence of non-gonococcal urethritis was 31%, gonorrhoea 25%, syphilis 20%, chancroid 12%, herpes genitals 3%, and other sex related disorders 10%. Fifty percent of the affected group were students of age varying from 21-30 years. Sources of infection were prostitutes in 80% of cases. The facilities for the diagnosis and treatment of STDs patients are available in a limited number of hospitals and centres located in Dhaka and other big cities of the country.

As regards HIV infection AIDS, Bangladesh is very much in a vulnerable situation as our neighbouring countries already have a large number of positive cases and the population movements between these countries are quite frequent. In Bangladesh the first case of AIDS was detected in 1989. Till June 1998, 102 persons have been found to be HIV positive and 10 were found to have AIDS.

A high prevalence of STDs among the sex workers was noted in several studies. According to a study conducted in early 1990s, the occurrence of syphilis ranged from 28% to 67.5%, gonorrhoea from 14.3 to 27%, and hepatitis-B 18%. None of the sex workers was found to be HIV positive. A comparative study among the institutionalized and floating sex workers of Dhaka city, revealed the prevalence of syphilis to be higher (56%) among the floating sex workers than that of the institutionalized ones (39%), and none having been HIV positive.

Studies carried out among the professional blood donors (PBD) revealed that 19.4% of them have been suffering from syphilis. Despite knowing that they were carriers of syphilis and hepatitis-B, the professional blood donors were found selling blood. The prevalence of syphilis among the prisoners was found to be 8.2%. [Md. Shahidullah]

Vector-borne disease a disease transmitted by an animal carrier. Most of these carriers are insects, ticks, and mites, but in an important group of diseases, snails are involved. Most vector-borne diseases are tropical and are most prevalent in developing countries. Among the vector-borne diseases recorded in Bangladesh, the important ones are malaria, filariasis, kala-azar, dengue fever, and some viral types of encephalitis.

In Bangladesh, malaria has always been a major public health problem. The disease is still endemic in the northern and eastern parts bordering India and Myanmar. The malaria situation is deteriorating since 1988. Incidence rose from 33,824 cases in 1988 to 60,023 cases in 1998. About 70% of them were falciparum infection; nearly 90% of the cases were recorded in greater Chittagong and Chittagong Hill Tracts Districts. The districts most affected by falciparum malaria are Rangamati, Khagrachari, Bandarban, Cox's Bazar and Chittagong. It is observed that malaria morbidity and mortality are high among the people who are transferred from non-endemic zone and are settled in the greater district of Chittagong and Chittagong Hill Tracts. Even in Dhaka City cases are often reported. In fact most cases of this disease go unreported and many patients fail to contact with an organised health service of any sort.

Filariasis is the disease which produces the most spectacular of all the mutilations that man is subject to, elephantiasis, in which various parts of the body swell to enormous proportions. In areas of high transmission, as much as 30 percent of the population may be affected by such swellings.

Filariasis is prevalent with different degrees of endemicity in different parts of Bangladesh. High prevalence rate is found in northern districts, such as Thakurgoan, Dinajpur, Rangpur and Nilphamari. All the filaria cases in these areas were due to the parasite, Wuchereria bancrofti.

Virtually there exists no filaria vector control programme in Bangladesh. Few city corporations carry out some anti-mosquito measures, which also kill the vector of filariasis, Culex quinquefasciatus.

Kala-azar is an infectious disease caused by an intracellular flagellate protozoan Leishmania donovani, common in rural parts of the tropical and subtropical countries of the world. The disease, also known as visceral leishmaniasis, is characterized by lesions of the reticulo-endothelial system, especially the liver and spleen, and is often fatal. Children are more susceptible to this disease. Kala-azar is transmitted to man by the bite of infected female sand fly Phlebotomus argentipes. The incubation period is generally 2 to 6 months. This disease has been a public health problem since 1940's being endemic in Bangladesh. As a collateral effect of DDT spraying under Malaria Eradication Programme (MEP), the incidence of kala-azar almost disappeared, because of high susceptibility of vector sand fly to DDT. However, the disease showed resurgence in the late 70's.

Most of the cases of kala-azar were reported from greater Mymensingh, Rangpur, Rajshahi, and Comilla districts. Some incidences were also detected in Dhaka, Jhenidah, Patuakhali and Narayanganj districts.

According to a recent study conducted by the Institute of Epidemiology, Disease Control and Research (IEDCR), the disease is spreading at an alarming rate. Ten years ago, it was confined to some northern districts only. It has now spread to more than 30 districts. There is no regular kala-azar vector control activities in Bangladesh. Areas with large number of cases and outbreaks are sometimes sprayed with DDT as the vector sand fly is still found susceptible to DDT. In some areas insecticide-treated bed nets are being tried to control kala-azar and found effective. Elimination of breeding grounds of the flies is helpful in reducing kala-azar incidence.

Dengue is an acute infectious viral disease found mostly in tropical countries mainly in Asia. Major epidemics however, involving hundreds of thousands of people have occurred in the Caribbean (1977-1981), South America (since the early 1980s), the Pacific (1979), as well as in Africa. The first outbreak of dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) occurred in Manila in 1953-1954; by 1975 it was occurring at regular intervals in most countries of Southeast Asia. The disease occurs more commonly in urban areas. Four different antigenic varieties of the dengue virus are recognized and all are transmitted by the daytime-biting mosquito Aedes aegypti. Mosquitoes become infective about two weeks after feeding and remain so for the rest of their lives. The clinical symptoms of classical dengue include abrupt onset of fever, malaise, retrobulbar pain that worsens on eye movements, conjunctival suffusion and severe backache. Skin rashes may also occur. It appears on the limbs and then spreads to the trunk.

In Bangladesh, dengue is considered as a re-emerging disease. Globally, 50 million cases are reported every year. Official figures show that in recent years dengue infection reached its peak in the period between late July and mid August with an average daily admission of 70 to 80 patients. The Health Directorate reported 2,451 cases by 31 August 2000, of which 247 suffered from Dengue Haemorrhagic Fever and 13 Dengue Shock Syndrome. Nearly 50 persons died. The sudden emergence of dengue carrier mosquitoes in a crowded city like Dhaka is a matter of great concern because mosquito habitation is growing almost unchecked.

Japanese encephalitis is a mosquito-borne viral disease. Symptoms include headache, muscle stiffness, sore throat, and upper respiratory tract problems. This disease is not endemic in Bangladesh, outbreaks occur only occasionally reaching epidemic proportions. Prior to 1977, there was no information on Japanese Encephalitis (JE) in Bangladesh. In mid-1977, an outbreak of an unknown disease was reported from Madhupur forest area in Tangial district by the Missionary Hospital situated in the Garo-community. Later, this was diagnosed to be JE. Since then, no information was reported on JE. Encephalitis however may be due to a specific disease entity, such as rabies. It may occur as a sequel of influenza, measles, chickenpox, smallpox, or other diseases. The vector mosquito usually breeds in large water bodies especially in rice-plantation areas. As such, water management in rice culture, irrigation practices, and use of insecticides for the control of rice pests should also be directed against mosquito vectors. [SM Humayun Kabir]

Diseases of children A child is highly vulnerable to two categories of acquired ailments; one is a heavy load of infectious diseases and the other, those diseases that are caused by inadequate nutrition. The profiles of childhood diseases in Bangladesh are generally similar to those of other developing countries in the tropics such as Asia, Africa and South America. There are six childhood diseases for which effective vaccines are now available. These are diphtheria, pertussis (whooping cough), tetanus, polio, measles, and tuberculosis. As a result of use of these vaccines through the WHO sponsored Expanded Programme of Immunization (epi) throughout countries of the developing world, incidence of these diseases is rapidly declining. Major childhood diseases for which no effective vaccines are available include: diarrhoea caused by bacteria and some viruses, enteric fever such as typhoid, respiratory infections such as viral influenza and bacterial pneumonia and parasitic illnesses such as intestinal helminth diseases and malaria.

Among the infectious diseases, diarrhoeal diseases are perhaps the most common illness in children in Bangladesh due largely to unsafe drinking water and poor health and sanitation practices. The next major category of illness involves the respiratory system, the most severe being acute respiratory infection (ARI) of which pneumonia is the prototype. Intestinal parasitic diseases caused by helminths and parasitic diarrhoea caused by the intestinal protozoa Giardia are also common particularly in rural children and children living in urban slums.

Many children become victims of nutritional deficiency diseases early in life due largely to poverty-related inadequate food intake and also partly due to lack of knowledge about common and inexpensive food items (vegetables and fruits) that could prevent important vitamin and mineral deficiencies. Vitamin A deficiency that causes night blindness is very common in Bangladeshi children. This deficiency can be easily prevented by dietary manipulation, for instance, eating adequate quantities of coloured vegetables and fruits. Iron deficiency commonly measured as low blood haemoglobin is very common in children which is partly due to inadequate diet and partly due to intestinal parasites. Sporadic cases of zinc deficiency are seen in children with diarrhoea at the International Centre for Diarrhoeal Disease Research, Bangladesh, but its overall incidence is not high. Incidence of malaria and tuberculosis is increasing. For malaria, there is as yet no vaccine available, but for tuberculosis a vaccine is used through the EPI programme. More worrying is the fact that the pathogens causing malaria and tuberculosis are increasingly becoming drug-resistant which makes treatment options limited, a major impediment to both saving lives and to control these diseases. Common genetic diseases or congenital abnormalities occurring among Bangladeshi children include albinism, spino bifida, colour blindness, Down's syndrome, etc. [Zia Uddin Ahmed]

Occupational and environmental health Two broad categories of environmental hazards are obvious. One is constituted by living organisms that are pathogenic, mainly bacteria, viruses and parasites. The other by physical and chemical agents such as smoke, harmful toxic particulate matter and hazardous chemical substances. Three main routes can cause human diseases - by pathogenic organisms, through deliberate often subconscious self-inflicted assaults exemplified by drug addiction and those caused by factors in the environment. Thus, illnesses caused by non-pathogenic agents such as harmful substances in the environment are defined as a class of diseases under the term environmental diseases. Environmental diseases can again be put into two categories-those related to occupation of the individual such as the nature of work and characteristics of the workplace and those that are caused by overall pollution of the environment and thus affect larger number of people who are exposed to the particular environment.

The extent of occupational and environmental diseases in Bangladesh is believed to be fairly large, but accurate statistical data on these are very inadequate. The spectrum of occupational and environmental diseases in the cities and the villages is different.

Urban centres In Dhaka incidence of environmental diseases and also occupational diseases is high because a large population of unskilled workers who come from villages for earning, are exposed to the hazards of the environment and occupation. Automobile smoke, level of lead in air, and noise level in Dhaka is far above the admissible levels. In one study it was found that approximately 30% of the 113 autorickshaw drivers had varying levels of hearing impairment due to exposure to high level of noise both from their own vehicles and the noise level of the areas through which they operate their vehicles for a duration of about 12 hours a day. Shop owners along the main roads are also among the most vulnerable to the adverse effects of contaminants because they keep their shops open for about 12 hours a day, six days a week and are exposed to this deadly environment for most of the year and year after year.

The level of lead in blood is alarmingly high in both children and adults that have been surveyed recently in 1998-99 on the vulnerable groups, that is, those living near the high automobile-traffic roads. This is mainly due to use of unleaded and inadequately refined gasoline, which is also the source of high level of sulphur in air.

Health service providing clinics are themselves the causes for concern to clinic workers particularly in the use of x-ray machines. In recent years, use of x-ray in clinical diagnosis has increased dramatically due to liberal import rules and low price of the x-ray machines. Operators of these x-ray machines work for long hours without any monitoring devices being used to ascertain the level of radiation that they are exposed to over a period of time. Use of radioisotopes in medicine and laboratory research, however, is not extensive in Bangladesh at the present time and as such this does not pose any significant health hazard to professionals working in the area. Factories often do not have high operating standards to minimise health risks to the workers. The nature of occupational risks and actual injuries sustained by workers in various factories and industrial units, particularly the small factories and industrial units, are not monitored and no data are available to ascertain the extent of the problem.

Rural areas Common occupational injuries sustained by the farm workers in rural areas of Bangladesh are due to use of traditional agricultural tools such as ploughs, sickle, etc., injuries inflicted by cattle and buffaloes used in tilling the land and those sustained during harvesting and threshing of grains. The rice harvesting process presents a few specific occupational hazards. These include superficial cuts in the skin caused by sharp leaf blades of the rice plant. Rice is exclusively harvested by hand cutting of the plants and manual transportation of the harvest to the household where it is threshed. Nearly 22 million metric tonnes of grains, the total annual grain (mainly rice) production of the country at the present time, are harvested from the field every year entirely by human hands and the associated injuries in terms of number may thus be quite high. The harvesting season witnesses a high incidence of eye injuries, mainly cuts in cornea by the sharp edge of mature leaf blades of rice which in many cases also gets infected with fungi that are associated with the rice plant.

The extent of contamination of the rural environment by fertiliser, insecticide and other pesticide residues is not seriously monitored nor is there any information on diseases that may be caused by these environmental agents. The use of these agricultural inputs has been increasing rapidly with the need for keeping the level of food production matching the rapid growth of population. The most significant environmental health problem to the millions of rural people of Bangladesh is arsenic contamination of ground water. Extensive use of underground water for irrigation is believed to have caused certain physical changes in the aquifer underneath possibly creating conditions of greater oxygen availability and oxidation of certain arsenic containing rocks with the release of free arsenic into the water. It is estimated that about 52 of the 64 districts of Bangladesh now confront arsenic problem where arsenic level in drinking water exceeds the WHO recommended maximum safe level of 50 g per litre. It is estimated that about 50 million people are at risk of arsenic toxicity and an estimated 4 million people are suffering from arsenic-related illness in the country at present.

arsenicosis is a general term given to adverse clinical conditions resulting from arsenic toxicity. Clinical manifestations of arsenicosis include melanosis (dark patches on the skin), leukomelanosis (white skin patches), and keratosis (hardening of skin). In one recent study involving 6000 individuals with symptoms of arsenicosis, it was found that melanosis is the most common manifestation occurring in approximately 94% cases, followed by keratosis in 68 %, leukomelanosis in 39% and hyperkeratosis (severe degree of skin hardening) in 37% cases.   [Zia Uddin Ahmed]

Health policy The national health policy of Bangladesh has a long history mostly of development through intellectual input of physicians and scientists, but as yet (year 2001) no formal policy has been enacted by the parliament. After the independence of Bangladesh in 1971, nearly a decade elapsed during which the government had to dedicate efforts to providing health services under the existing administrative structures that were inherited from Pakistan. During the early 1980s, however, a drug policy was adopted by the executive decision of the government. It attempted to rationalise drug use manufacture and import. The policy put some restrictions on multinational drug companies as to the types of drugs they need not manufacture, and prohibited altogether the manufacture of certain drugs that had been in use in the country for a long time. The drug policy was followed by the preparation of a national health policy document in the late 1980s, which was again adopted and certain parts implemented through executive power of the government, not enactment by the parliament.

During the early 1990s, major political and economic changes took place in the country. Of particular significance was the adoption of a strong free market policy and transition of the country to parliamentary democracy. These naturally put both the drug policy and the health policy in a newer context and throughout the later part of the 1990s, work on development of a National Health Policy has been in progress in the light of changed national and global circumstances. The draft policy has been reviewed by the Cabinet and approved, but its consideration by the Parliament has not yet been initiated. [Zia Uddin Ahmed]

Health manpower trained personnel that include doctors, medical technologists, nurses and paramedics. In Bangladesh and in many other developing countries, another category of workers is closely associated with delivery of health services to the villages. These comprise field-level health workers who are trained in specific areas, generally non-technical, and are dedicated to offer specific services related to community health, reproductive health and family planning, including awareness creation activities. In addition, there are homeopathic doctors and doctors practising Ayurvedic medicine. Bangladesh has a population of about 130 million.

Table Manpower in health sector, 1998

At present, most doctors are based in cities and towns serving a meagre 20% of the population. The bulk of the population of Bangladesh lives in rural areas and is thus away from easy access to the service of these trained doctors. The reason for this is poor economic condition of people living in rural areas.

The bulk of the nation's health manpower is under government control because provision of health care is government's responsibility. Only in cities and towns there are doctors available in private practice and in recent years, diagnostic services and hospital care have witnessed good growth in the private sector particularly in the capital city of Dhaka and a few other major cities. The bulk of the population living in rural Bangladesh and too poor to afford private medical facilities have to be cared for by government facilities which admittedly are victims of chronic funding and manpower shortage. Most rural hospitals operated by government lack adequate number of doctors and technicians; moreover, the doctors are permitted to engage in private practice which often takes away their time, time that they could otherwise devote to hospital work and medical research. Biomedical research manpower is one of the least developed sectors in the country's health manpower scenario. [Zia Uddin Ahmed]

Medical education and research The major component of health education system in Bangladesh is the country's 13 government medical colleges. These offer a 5-year MBBS degree to students who have passed higher secondary examination representing 12 years of study or equivalent to class XII in the North American system of education. This is followed by a 1-year internship before the MBBS graduates are allowed to enter into private practice. These government medical colleges have been established over a period of nearly half a century. Traditionally all of these colleges except one (Sir Salimullah Medical College named after the then Nawab of Dhaka) have been named after the name of the city where it is located. The government medical colleges are: Dhaka Medical College; Sir Salimullah Medical College (in Dhaka); Chittagong Medical College; Rajshahi Medical College; Sylhet MAG Osmany Medical College; Mymensingh Medical College; Dinajpur Medical College; Rangpur Medical College; Sher-e-Bangla Medical