A Cardiological Sojourn in Bangladesh writes Dr Ian Jeffery from Canberra

28 Apr, 2012 by Priyo Australia

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Associate Professor Atifur Rahman is a cardiologist at the Gold Coast Hospital. A medical graduate from Bangladesh he continues to maintain a close association with the cardiology community in Bangladesh and to be involved in their education programmes. I first met Atifur when I examined him for part of his clinical FRACP exams. Atifur then undertook his advanced training in cardiology at The Canberra Hospital where I was fortunate to be his clinical supervisor.

Recently I was invited to join Atifur to travel to Bangladesh to participate in a series of five cardiology seminars across the country. Our travel was sponsored by Beximco Pharma – one of the largest pharmaceutical manufacturers in Bangladesh. For me, and my wife who also came, it was a wonderful experience as well as a great adventure. My presentation focused on the evidence for varying pharmacologic interventions for the primary prevention of cardiovascular disease and Atifur spoke on recent advances in coronary intervention – “From prevention to intervention.”

The first seminar was in Cox’s Bazaar on the Bay of Bengal adjacent to the border with Myanmar, 150km south of Chittagong. Cox’s Bazaar is famous for having the longest sandy sea beach in the world – a total of 125km ! Atifur did not arrive until the next day so I found myself largely on my own speaking to a group of about 100 mainly general physicians and a few GPs. I was somewhat apprehensive. I need not have been. The audience was friendly and animated. No one cared that my presentation was interrupted by several blackouts and question time in Bangladesh, unlike Australia, often lasted an hour or more with free discussion and friendly banter often only loosely related to the topic presented. What happens if I have an acute infarct tonight in Cox’s Bazaar? I asked. You are rich! they laughed – you would get streptokinase. How about primary angioplasty? No chance. Only available in Dhaka. No flights tonight and 15 hours by road – you would die before you reached there! What if I was not rich? – it seemed probably just aspirin and heparin. The meeting finished with lucky door prizes which included mobile phones and a microwave oven. This pattern of free flowing discussion following our presentations persisted with all our meetings. Medicine is however changing rapidly in Bangladesh and since our visit primary angioplasty is now available in a private hospital in Chittagong.

Day three saw us on the road to Chittagong – a four to five hour drive to cover 150km along a narrow road with one lane each way .Green and tropical initially but dry and dusty close to Chittagong with a dramatic increase in the number of villages and people. We arrived at the hotel at 3pm for a quick meal before a visit to the beautiful Foy’s Lake then return to the hotel at 6:30 to start the seminar at 7:30pm. It finished at midnight! This time the audience was mostly cardiologists with the discussion just as lively. Next morning an early flight to Dhaka.

Dhaka is the capital of Bangladesh, with a population of 12 million it is one of the most densely populated cities in the world. It is renowned for its mosques, producing the world’s finest muslin and for 400,000 cycle rickshaws on the road each day.Traffic in Dhaka generally travels at a snail’s pace. Cars weave around one another, the rickshaws and pedestrians with rules seemingly based on chaos theory. Surprisingly we rarely saw an accident and certainly nothing serious. In Dhaka we visited a private hospital with facilities much the same as we have in Australia – two cardiac catheter suites, a cardiac surgical unit and a highly skilled and very busy team. Not much primary angioplasty because the traffic in Dhaka means most patients take one to two hours to reach the hospital, perhaps thirty minutes to be assessed and, out of hours, it takes the cardiologist another one to two hours to arrive – the traffic is much the same at all hours of the night and day! Facilities in the government hospitals, for the majority of the populace, are very limited but interventional cardiology is available in some. The government system is stressed by the enormous workload.

In Dhaka we also visited the manufacturing plant of Beximco. It was fascinating. My wife, a pharmacist, knows about these things and was very impressed. The plant produces seventy percent of the drugs for Bangladesh and also exports to the Middle East, Europe the US and perhaps soon to Australia. That night we spent a wonderful evening with Atifur and his extended family. All the delights of Bangladesh cuisine were laid on and we were encouraged to try every dish. Just when we advised our hosts we were in danger of bursting distinctive Bangladeshi sweetmeats made from milk products were produced and could not be resisted! Retired to bed, exhausted, well after midnight. The following day Atif’s family took us to a modern shopping centre in the heart of Dhaka were we purchased silk and very fine muslin saris. They were wonderful hosts.

The meeting in Dhaka was to about six hundred cardiologists and cardiac surgeons. Several speakers and once again we were made very welcome. During lunch I sat beside a cardiac surgeon. As one would expect the majority of his work was congenital and rheumatic valvular heart disease rather than CABG. I pointed out the most common valve operation in Canberra was for calcific aortic stenosis in the elderley. At his government hospital they were only allocated twenty aortic prosthetic valves per year but clearly needed many more. How do you decide who gets one of the valves I asked? Clearly it was with great difficulty and family influence often played a part. Most people needing prosthetic valves were managed medically. He personally did over three hundred open heart operations a year which seemed to me a heavy workload.

We left the meeting late in the afternoon to join the overnight ferry to travel from Dhaka through the Bangladesh delta to Barisal on the Bay of Bengal. The port in Dhaka was packed with people joining thirty or so ferries travelling all over the country – water transport being the most convenient, affordable and fastest way for people and goods to travel It was a scene straight from “Lord Jim”. Our ferry had two decks – a large open deck and, above it a deck of small cabins. Those on the open deck slept on rugs but we cabin people had (firm) foam mattresses. Vendors selling food joined the ferry but, perhaps fortunately for us, one of our physician colleagues arrived with an enormous selection of food for all of us to graze on. Standing on the deck that night watching the lights of villages glide past was an unforgettable experience even for our Bangladesh colleagues many of whom had never previously made this journey.

The two final meetings were in Barisal and Khulna – two rural towns, but large by Australian standards. We were in full swing by this time and the meetings were informal, great fun and I had a wonderful oppourtunity to meet and exchange experiences with our fellow physicians. In Barisal we also visited the Sher-e-Bangla Medical College where Atif had been an undergraduate. This area is adjacent to the Sundarbans, a national park where Bengal tigers still roam. Alas there was not enough time to visit. Crossing the Bangladesh delta from east to west by car and car ferry was a little hair raising especially being attacked by mosquitos despite my best efforts with clothing and insect repellant. I depended on my doxycycline. We Flew to Dhaka late at night after the Khulna meeting to return to Australia the next day on a flight leaving near midnight. After a splendid meal with our hosts on the evening of our departure we made it to our flight with seconds to spare after being caught in another Dhaka traffic jam for an hour within sight of the airport. I settled into my seat on the plane, had my first glass of wine for two weeks and the next thing I remember the hostess was telling me to put my seat upright to land in Singapore. My wife won’t tell me if I snored!

I learnt a great deal in Bangladesh. It is clear that with the digital dissemination of medical knowledge all physicians have much the same breadth and depth of medical knowledge. In Bangladesh they realize that as their public health colleagues reduce deaths from infectious diseases and as inroads are made into maternal and infant mortality, cardiovascular deaths as a part of the total will rise sharply and risk factors should be addressed now. Their “can do” attitude to the management of cardiac disease despite the financial limitations is inspiring. I also learnt that all physicians in all countries regard ourselves as part of the same “tribe” which is reflected in their warmth and hospitality to one another.

As the Bangladesh economy expands – as it is rapidly doing – health facilities will improve exponentially. We thought this would probably take a generation. That seems a long time to us but in the scheme of history it is just the blink of an eye.

Dr Ian Jeffery.
Cardiologist
The Canberra Hospital .

Myself with Atif and Kerry