Despite all the progress made by Bangladesh over the last few decades in achieving several of the key health indicators, new disease patterns associated with changed socio-economic trends and demographic shifts are creating new challenges.
Epidemiological transition -- the changing patterns of population age distributions, mortality, fertility, life expectancy, and causes of death -- has brought forward a whole different set of disease and injury risks for the population in Bangladesh. Unless these new health threats are well-explained, understood, and confronted in a timely manner, the health gains and progress made in the past may diminish over time. The country's healthcare delivery system has to be quick and effective in confronting the prevalent health issues that are already knocking on its doors. Bangladesh has not made enough preparations to handle many of these emerging disease conditions that are mostly chronic in nature.
Bangladesh is very quickly urbanising, motorising, and industrialising. How do these macro-level changes in demography, society, and economy and associated changes in living and working change healthcare needs?
Why does it matter if people move frantically from rural to urban areas for making a living? Why is it important to know that people are leaving agriculture and accepting jobs for wages in factories or starting their own businesses? And, how can extensive use of mechanised vehicles plying over a vast and growing network of road, rail, and water network increase health risks? Are healthcare professionals and providers, regulators, and activists in Bangladesh aware of how all these will create new challenges for public health and the healthcare system?
Non-communicable diseases (NCDs) are in fact already responsible for the majority of deaths counted and reported in the Bangladeshi population. Over the period of 2009-2019, Stroke and Ischemic Heart Disease (IHD) maintained the number 1 and 2 top causes of death in Bangladesh. That means no interventions -- an educational, lifestyle change, or medical management -- that have been successfully put in place -- could deter their affliction in a meaningful way. Diabetes and COPD went higher in rank in the list of top causes of death during the same ten years. Also going higher is malignant neoplasm. These statistics show the growing and robust risk and burden of NCDs in Bangladesh. Bangladesh did make good progress in curbing infectious diseases and this has become visible in the mortality ranking. Lower Respiratory Tract Infections (LRTI) and Tuberculosis (TB) went down as leading causes of death during that same decade. The only infectious disease that still remains in the top 5 causes of death in Bangladesh in 2019 is LRTI. All other top causes of death include only NCDs. It is high time to think, plan and act on curbing the incidence, risk, and burden of NCDs.
As millions of people in Bangladesh migrate from rural to urban settings, there is a shift in accompanying health risks. Rural dwellers who migrate to cities have worse cardiovascular outcomes than their non-migrant siblings, a previous research shows. This poor cardiovascular health consequence is partly from a shift from vigorous to less physical activities between rural and urban lifestyles, especially less walking, running, swimming, and bicycling. There is strong research evidence from many countries linking physical inactivity to developing major NCDs (e.g., coronary heart disease, type 2 diabetes, and breast and colon cancers). In addition to this decline in physical activity, urban residents are also exposed to higher concentrations of urban air, water, and soil pollution as well as to high risk for injuries in road traffic crashes and industrial settings. Dhaka has almost no space left for its dwellers to engage in physical activities -- it has turned itself into a very big concrete slum with little green spaces left in isolation for its elite civil servants, defence officials, and foreign diplomats.
Urban living is associated with more time spent in motorised vehicles, consuming less fresh food, and using electronic gadgets for entertainment among others. The disgusting traffic jam of Dhaka costs hours of people's valuable time daily that could be much better spent at work or with family.
Public health practitioners in Bangladesh will face these new and growing challenges of protection, prevention, and promotion of health. Policy and planning decisions taken as early as possible will have long-lasting consequences on population health. Bangladesh has chosen to motorise its all modes of transportation, particularly in its urban centres through motorcycles, cars, or buses, and has chosen not to promote active modes that encourage walking or cycling. These decisions determine levels of physical activity, vehicular emissions, and transportation accident risks, and thus influence incidence rates of NCD and injury for future generations of the urban population.
Soon the majority of Bangladesh's population will live in urban areas and many of these urban dwellers will have limited access to safely managed sanitation services and will lack access to adequate drinking water and all of them will breathe polluted air. Poorly designed urban transport systems and meager law enforcement systems will create a range of other threats including road traffic injuries and violence. The rising prevalence of NCD and the growing incidence of violence and injuries will be key public health concerns in urban Bangladesh. Heart disease, asthma, and diabetes worsen by unhealthy living and working conditions and are associated with obesity and physical inactivity.
Urbanisation and industrialisation have been linked to high rates of depression, anxiety, and other mental health conditions as well.
Unclean, overcrowded, substandard living and working environments, and poor sanitation and waste management escalate the transmission of infectious diseases like TB, dengue, and diarrhoea.
Healthcare professionals and delivery systems both in the private and public sectors and from primary healthcare all the way to tertiary care need to redesign their care delivery models, services, and targets. The evident epidemiological transition shows the healthcare system in Bangladesh must focus on chronic disease prevention and management.
Hasnat M Alamgir is a Professor and Head of Public Health at the State University of Bangladesh. [email protected]
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