Search

Bangladesh, the eighth most populous country in the world with about 153 million people, has recently been applauded as an exceptional health performer. In the first paper in this Series, we present evidence to show that Bangladesh has achieved substantial health advances, but the country's success cannot be captured simplistically because health in Bangladesh has the paradox of steep and sustained reductions in birth rate and mortality alongside continued burdens of morbidity. Exceptional performance might be attributed to a pluralistic health system that has many stakeholders pursuing women-centred, gender-equity-oriented, highly focused health programmes in family planning, immunisation, oral rehydration therapy, maternal and child health, tuberculosis, vitamin A supplementation, and other activities, through the work of widely deployed community health workers reaching all households. Government and non-governmental organisations have pioneered many innovations that have been scaled up nationally. However, these remarkable achievements in equity and coverage are counterbalanced by the persistence of child and maternal malnutrition and the low use of maternity-related services. The Bangladesh paradox shows the net outcome of successful direct health action in both positive and negative social determinants of health--ie, positives such as women's empowerment, widespread education, and mitigation of the effect of natural disasters; and negatives such as low gross domestic product, pervasive poverty, and the persistence of income inequality. Bangladesh offers lessons such as how gender equity can improve health outcomes, how health innovations can be scaled up, and how direct health interventions can partly overcome socioeconomic constraints., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Introduction: The association between infection and growth delay is not well documented in school-age children in developing countries. We conducted a prospective cohort study to examine the association between infectious disease and weight and height gains among Bangladeshi children., Methods: A one-year follow-up study was performed to elucidate the determinants and consequences of physical growth of children under five years of age. The study included 135 households randomly selected from four villages in the Matlab area., Results: The most frequent infections were upper respiratory infections (mean = 4 episodes or 27 days per year) followed by non-dysenteric diarrhoea (mean = 2.3 episodes or 15 days per year) and dysentery (mean = 0.2 episodes or 2 days per year). The number of episodes and their duration decreased significantly with age. Over a 12-month period the mean weight gain was 1.3 kg and the mean increase in height was 2.9 cm. The total number of days when diarrhoea occurred was negatively associated with annual weight gain (regression coefficient beta = -7 g per day, P = 0.02), with adjustment for age, sex, energy and protein intake, and household land ownership. The incidence of diarrhoeal disease was significantly associated with weight gain in intermediate models but only marginally associated with it in the final multivariate model (P = 0.08). Neither the incidence nor the duration of upper respiratory infections was associated with weight gain. Height gain was not significantly associated with the duration or incidence of either category of illness. Diarrhoea was a significant correlate of retarded weight gain among children above preschool age, whereas upper respiratory infections were not., Discussion: Diarrhoeal morbidity slowed growth in children well beyond the weaning age, suggesting that increased attention should be given to the study of the continuous impact of diarrhoea in children aged over 5 years. An understanding of the determinants of growth in school-age children in developing countries would maximize the health and developmental outcomes that are the target of international child survival strategies at younger ages.

From a longitudinal surveillance programme among a rural Bangladesh population of 260,000, the epidemiology and causes of child death (under age 5) over 3 years (1975-1977) were analyzed. The most significant causes of death were diarrhoea (watery and dysentery), tetanus, measles, fever, respiratory disease, drowning, skin disease, and other causes. Of an infant mortality rate of 142.6/1000 live births, neonatal tetanus (37.4/1000), diarrhoea (19.6/1000), and respiratory disease (10.4/1000) were the most significant identifiable causes. Many infant deaths (62.2/1000) were unidentified, taking place during the neonatal (1-28 days) period. The 1-4 year mortality averaged 34.3/1 000. Diarrhoea (15.1/1 000), measles (4.5/1 000), fever (2.9/1 000) and respiratory disease (1.6/1 000) accounted for most 1-4 year deaths. Mortality trends over the past 10 years showed sharp temporary fluctuations in response to 2 disasters but no definitive long-term trend. Most causes of death displayed seasonal fluctuation, and sex differentials were marked with female deaths exceeding male deaths for all ages after the neonatal period. Malnourished children from low socioeconomic status families had higher mortality rates than their better nourished and wealthier counterparts. Overall, the data suggest that the delivery of a few basic health measures (oral hydration and immunization) could result in substantial reduction of under 5 mortality.

To quantitate reduced food intake during diarrhea and to assess possible means of promoting such intake, the 24-hr food and breast milk intakes of 41 children 6 to 35 months divided into three groups were measured. The energy and protein intake of 15 children hospitalized with acute watery diarrhea averaged 75 kcal/kg and 0.96 g/kg, respectively. The energy and protein consumption of another group of 15 children with diarrhea whose mothers received intensive education to promote food intake during hospitalization averaged 60.9 kcal/kg and 0.70 g/kg, respectively. These intake levels were significantly lower than 129.9 kcal/kg and 1.89 g/kg observed among healthy control children. These results suggest that child anorexia may be an important cause of reduced food intake during diarrhea. Anorexia was not overcome with intensive educational efforts. Breast milk was found to be important nutrient source with breast-fed children better protected against reduced intake during diarrhea.

This paper examines the usefulness of various anthropometric classification systems of nutritional status in prognosticating the subsequent risk of mortality among 2019 children aged 13 to 23 months residing in a rural area of Bangladesh. The indices investigated included: weight-for-age; weight-for-height; height-for-age; arm circumference-for-age; arm circumference-for-height; weight quotient; and height quotient. Cross-sectional anthropometry was conducted during October 1975 to January 1976 and the mortality experience of the study children was followed prospectively over 24 months. Results indicated that severely malnourished children, according to all indices, experienced substantially higher mortality risk. Normal, mild, and moderately malnourished children all experienced the same risk. All indices were found to discriminate mortality risk; weight/age and arm circumference/age were strongest and weight/height weakest. For each index, a threshold level was noted below which mortality risk climbed sharply. The discriminating power of anthropometry was enhanced when maternal weight, maternal height, or housing size were included.

The distribution of sucrose-electrolyte oral therapy packets (1 liter) by community-based workers in a rural Bangladesh population of 157,000 was evaluated. A similar population of 134,000 served as a comparison group. The locally-produced packets showed satisfactory chemical composition with a shelf-life of up to 3 months and a cost of U.S. $0.05. After 4 months the workers were distributing an average of 70 packets/1,000 population per month. Most patients used one packet for each episode of diarrhea; 13% of children used two packets, and 15% and 8% of adults used, respectively, two and three packets. The electrolyte composition of the oral fluids prepared by field workers and mothers showed substantial variation, but no hyperconcentrated solutions were noted. A comparison of the hospitalization rate from the two study areas suggested a 29% reduction in hospitalization for diarrhea during the 4 months of distribution.

Prospective field data were employed to examined the effect of child malnutrition on the subsequent risk of diarrhea among preschool children in rural Bangladesh. A total of 2019 children aged 12-23 months were classified according to weight-for-age, weight-for-height, and height-for-age of the Harvard median standard. Over a 24-month prospective period, diarrheal hospitalization rates among the children were matched to the initial anthropometric assessment. No differences in diarrheal hospitalization rates were noted for the children according to initial nutritional status. Another group of 207 children under five years of age were classified according to weight-for-age and their diarrheal attack rate in the field was followed prospectively for one year after nutritional assessment. Again, no differences in field diarrheal attack rates were noted between children of varying nutritional status categories. The nutritional status of the 207 children was then defined as monthly growth velocity (kilogram change in body weight, per cent change of initial body weight, and per cent change in weight-for-age) and the diarrheal attack rate for the subsequent one month period was observed. No differences in attack rates were noted between nutritional groups. The study failed to demonstrate that nutritional status defined by anthropometry was associated with the subsequent risk of diarrheal diseases.