CHAMPS Sites - News
Exploratory Site Visits
June 10, 2016
Reducing under 5 mortality: Visiting Bangladesh
Assessments for potential CHAMPS sites are happening in many places throughout Africa and Southeast Asia. Ultimate site selection depends on a number of factors, including high childhood mortality rates, research capacity, and data-to-action capabilities, i.e., public health engagement and community acceptability. It is – and will continue to be – important to find ways to work effectively in areas of high fragility, in order to ensure the research is impacting places with the highest causes of preventable childhood mortality.
With these things in mind, guiding our journey, I recently traveled to Bangladesh – first to urban Dhaka and then to more rural Faridpur – with other members of the CHAMPS team, which includes the Emory Global Health Institute and the International Association for National Public Health Institutes (IANPHI). The purpose of our visit was to meet with in-country partners and assess how we might work together to eventually gain a clearer understanding of the causes of under-five child mortality. Our partners in Bangladesh include the well-known research organization icddr,b and a medical university known as BSMMU, both of which work closely with rural hospitals and clinics in the Baliakandi upazila (or district) of Faridpur, situated in west-central Bangladesh.
Every single meeting we had, whether with hospital administrators or researchers, included tea and a tour. Taking time for tea, which included hot tea and snacks – usually including a sweet, was a lovely way for everyone to get to know one another and made us feel quite welcome. Every tour of facilities we embarked on was filled with enormous pride in both the facilities and the people who ran them. A mutual respect between everyone working in both public health and practical medicine was palpable.
While no national child health card has been implemented in Bangladesh (though they do track immunizations), CHAMPS is investigating establishing health cards that follow the children in an effort to track health outcomes, morbidity and mortality and add value to the participating communities.
Because many deaths happen outside the medical establishment, one potential approach for identifying cases may be through a call center where residents could call and speak with a physician or other clinicians with any health questions and would also be encouraged to call in cases of severe illnesses and deaths. Adolescents were identified as potential resources for reporting as many have access to cell phones and they are thought to have more time available to make such calls.
As part of a protocol we want to help establish there, one of the procedures that will give us a better picture of the causes of death is called MITS which stands for minimally invasive tissue sampling. MITS is a mechanism to obtain specimens post –mortem in a way that minimizes trauma to the body and thus minimizes disruption to the burial process.
The cultural norm in Bangladesh is to bury dead in just a few hours after death (6-8 hours) which presents a considerable challenge in obtaining accurate assessments in cause of death. Moreover the cultural belief is that the body can continue to experience pain after death, thus eliminating the possibility of full autopsies.
Our partners already have some limited experience collecting MITS in the general community through a pilot study conducted at one of the hospitals in the catchment area we are targeting in Baliakandi and are in the process of obtaining a fatwah (legal opinion or ruling issued by an Islamic scholar) to support MITS. The fatwah is expected to help tremendously with community acceptance. Extensive outreach among community members via respected members of each community is planned to ensure that familiarity with these procedures and services before anyone ever encounters a request for participation.
The research teams we met with were smart, kind and fully invested intellectually and emotionally in helping the local communities improve important outcomes like child and family health. Saiful Islam, one of the gifted iccdr,b social scientists who is investigating MITS acceptability in Bangladeshi communities, helped explain MITS to families to gain consent for previous procedures. Of the 15 families originally approached for MITS, five families consented.
“We might have been able to collect more but, in some cases, I was crying too hard along with the family… [to make the request],” Dr. Saiful added.
Bangladesh has already made great strides in improving public health by reducing population growth along with other investments in health and education. Further reducing under 5 mortality will be important progress in strengthening their population for a vibrant future.