Recently, I was delighted to be asked to participate in a research study involving identifying the best ways of providing calcium to women with very low calcium intakes in Bangladesh. This study is being conducted with Drs. Daniel Roth and Stanley Zlotkin of the Hospital for Sick Children in Toronto who are leading the project.
As part of getting this study started, along with Texas Children’s Hospital and Children’s Nutrition Research Center dietitian Keli Hawthorne, I traveled to Dhaka, the capital of Bangladesh, in early November. While there, we had a chance to spend some time with clinicians and researchers at a place called ICDDR,B the International Center for Diarrheal Disease Research, Bangladesh. This experience was one of the most remarkable educational opportunities I’ve ever had, and I’d like to share some of this experience with you.
First, Bangladesh is a nation that has many seemingly intractable health problems, including monsoon rain seasons leading to a high incidence of a serious disease almost unknown in the United States, called cholera. This illness causes severe diarrhea and dehydration, especially in children that can be fatal. Bangladesh also has a high rate of malnutrition with about 40% of children being malnourished.
Although many hospitals in Bangladesh treat these problems, ICDDR,B is known throughout the world both for providing treatment for diarrheal disease but also for conducting research on infectious diseases and malnutrition. You might wonder why they are focused on research in such a resource-poor setting. The answer is that they need to learn and provide evidence for the best, most cost-effective solutions to health problems and this comes from research, both related to disease causes, prevention and treatment.
The scope of their work in caring for sick patients is truly unbelievable. In the rainy season, they treat about 1,000 patients, mostly children, daily for diarrhea and dehydration. In the dry season, which included the time of our visit, it is about 1/3 that many, but still a huge number. They do so with very limited but well-designed resources focusing on parental care of the children, the use of oral feeding solutions (called ORS, oral rehydration solutions) some of which they designed with the World Health Organization, and the judicious use of antibiotics. They have different areas in their hospital ward for management of short-term rehydration and also those needing longer-term management, which is most common when the diarrhea is accompanied by other problems such as pneumonia or malnutrition.
Anyone trained in pediatrics is experienced in managing these problems, but mostly in the United States we do so with an array of medicines, equipment, and most importantly, follow-up care that are simply not available in Dhaka. Furthermore, it would be extremely rare to care for a 6 month old with diarrhea in Houston who also had a condition called Kwashiorkor, a form of malnutrition with a high rate of death in which the children are swollen (edematous). Yet this combination is common at ICDDR,B.
Although my trip was primarily for a research purpose, I took the opportunity to see and discuss patient care with one of their physicians and scientists, Dr. M. Munirul Islam. Dr. Islam and those who work with him, including Dr. Tahmeed Ahmed, the Head of the Nutrition Program at ICDDR,B, have spent decades developing global guidelines and traveling to other areas of the world to provide training in management of severe diarrhea and malnutrition in resource poor areas.
Spending time discussing both individual patient management and nutritional policies with Dr. Islam was one of the most remarkable educational experiences of my medical career. An amazing individual; compassionate, thoughtful, insightful and eager to teach me how they deal with the difficult situation they face. I explained to him that I help teach classes on malnutrition for Baylor students and doctors who will be working in resource-poor settings and he immediately offered his time and his training material to help me understand their approach in these settings and improve my training materials. The world is a vastly better place for the physicians and scientists at ICDDR,B who provide the best care possible for children who are truly among the world’s poorest.
These doctors are realists, they understand what can and cannot be done to improve the status of some of the world’s poorest children. Yet they are inspiring for the hope and wisdom they bring to developing patient care solutions related to diarrheal diseases and malnutrition, both for individuals and for the world.
It is a privilege to work at a place like Texas Children’s Hospital where resources for managing malnutrition such as intravenously administered nutrition that has protein, fat and micronutrients (called TPN, total parenteral nutrition) are plentiful, and cholera and similar illnesses are rare. But it is also a humbling experience to recognize that real challenges exist in working in settings where TPN, medicines, food and clean water are often lacking. Physicians, such as Drs. Islam and Ahmed at ICDDR,B who dedicate their lives to caring for malnourished children, conducting high quality research, and sharing their experiences through education are folks that I want to spend more time visiting. They have a lot to teach us as do the children of Bangladesh. I encourage readers of this blog to explore the ICDDR.B website and learn about the work they do.