Saving Lives of Children and Newborns in Bangladesh
Dr Abdul Hanif (Tablu)
A male baby was born in a village. While the family was distributing sweets among relatives to welcome the newcomer a day after his birth, the baby suddenly developed severe abdominal distension and his condition rapidly deteriorated. Unfortunately, the baby had died before he was taken to the hospital. In contrary, another one-day-old baby developed similar symptoms in a city and the baby was immediately admitted into a renowned hospital, diagnosed as a case of imperforate anus and cured surgically.
An eight-year-old girl suddenly developed severe abdominal pain and began vomiting. She was admitted into a hospital and diagnosed as a case of intestinal perforation. She was saved by a major surgery. Many more cases of cleft lip, hernia, undescended testes, ano-rectal malformation, hypospedias, appendicitis, intestinal obstruction etc. are successfully treated by Pediatric Surgeons who provide these types of services to the children in Bangladesh.
Pediatric Surgery is one of the specialized branches of surgery that was developed in America in early twentieth century. Dr. William E. Ladd (1880-1967), a general surgeon and Gynecologist, devoted himself for the treatment of surgically ill children after observing the extreme sufferings and lack of treatment facilities of thousands of crippled and burnt children in a major ship accident at Halifax Harbor on 6 December, 1917. After that he worked hard to establish Pediatric Surgery as a separate discipline by recruiting fresh resident physicians in Boston Children's Hospital of Harvard Medical School. He was able to prove the importance of trained pediatric surgeons for children, because the development, growth and structure of children are different from adults. Later on, Pediatric Surgery was developed as a separate specialized unit in Europe and Asia. In India and Pakistan, Pediatric Surgery started its journey from late sixties.
In Bangladesh the endeavor began when Dhaka Shishu (Children) Hospital (DSH) was established in 1973 with a view to developing a comprehensive health care system for the pediatric population of a war torn country. The medical department of this hospital under the direction of our National Professor M. R. Khan flourished rapidly. He soon felt the necessity for a surgical wing and requested Dr. A. F. M. Masood, who was a consultant of orthopedic surgery in the Guy's Hospital, London at that time to come back and serve the children in Bangladesh. Prof. A. F. M. Masood responded to the call from his homeland and in 1981 returned to establish the first Pediatric Surgery unit in DSH. When Bangladesh Institute of Child Health (BICH) was commissioned in 1983, a department was created and Prof. Q. Q. Zaman joined as associate professor of Surgery.
A motion that was set continued unabated and the first generation of pediatric surgeons began to be trained in DSH & BICH. To provide them with essential academic qualification, a five year MS course in Pediatric Surgery was initiated under Dhaka University in 1985. By then Prof. Sajjadur Rahman joined as associate professor of Pediatric Surgery Bangabandhu Sheikh Mujib Medical University (BSMMU). With his active initiative and persuasion, Government gradually created 51 different academic and training posts of professors, associate professors, assistant professors, assistant registrars in BSSMU (then IPGMR) and in eight government owned old medical colleges namely Dhaka Medical College, Sir Salimullah Medical College, Mymensingh Medical College, Chittagong Medical College, Sylhet Medical College, Rajshahi Medical College, Barisal Medical College and Rangpur Medical College. Through this the newly trained pediatric surgeons were able to render their surgical services to the children of the country.
There are about 50 million children under 14 years. As per United Nations' CRC (Convention on the Rights of the Child), if we consider the age limit of children under 18 years, then the number of children is 90 million. According to BDHS 2007, under five mortality rate is 65 per 1000 live births. More than 50 percent of under-five death numbering 120,000 deaths took place during the first 28 days, the neonatal period. The risk of mortality is greatest during the first day after birth, because this is the time when 25 to 45 percent of neonatal death occurs. For the newborn, the greatest health risks are posed by severe infection (including pneumonia, sepsis and diarrhea), asphyxia and preterm birth. Mortality due to these medical causes is gradually decreasing but death due to birth injuries and congenital anomalies are alarmingly increasing which has become fourth leading cause of neonatal deaths. Many of these deaths are preventable. Most of these congenital anomalies are surgically curable and more than 85 to 90 percent of these neonates are surviving with limited facilities in only few hospitals of the country, while two decades ago more than 80 per cent died when there was no pediatric surgical unit in most of the medical college hospitals of Bangladesh. Thus after establishing pediatric surgical unit pediatric surgeons are contributing gradually in the reduction of neonatal mortalities and as a whole child mortalities.
Currently there are only about 120 pediatric surgeons in Bangladesh to provide surgical services to children. It means there is only one pediatric surgeon or one surgeon per 7.5 lakh (.75million) children under 18 years age. Out of 17 Government owned medical colleges, only 8 government medical colleges mentioned above have separate Pediatric Surgery department and more than 38 private medical colleges have no such department. In these medical colleges general surgeons are treating surgically ill children but most of them have no training in Pediatric Surgery. On the other hand many newly trained pediatric surgeons cannot provide their specialized services due to lack of adequate posts.
Moreover, in 2002, Bangladesh Medical and Dental Council (BMDC) included Pediatric Surgery in MBBS course curriculum. As a result, undergraduate medical students are now able to gain theoretical as well as practical knowledge about common pediatric surgical problems. This knowledge helps them in great extent when they treat and refer surgically ill children in villages and small towns after completion of MBBS course. But, this learning facility is available only in 8 government medical colleges. Hence, rest of the undergraduate students in government and non-government medical colleges are deprived of this specialized learning opportunity by pediatric surgeons. So, it is necessary to develop infrastructure including more posts in both public and private medical colleges for teaching purposes along with service provisions.
Government has already taken some initiatives. Postgraduate M.S. course has been started in Dhaka Medical College, Mymensingh Medical College, Chittagong Medical College and M. A. G Osmani Medical College, Sylhet from 2002 apart from BICH and BSMMU. Each year about 30 surgeons get admitted in this programme. The government hospitals in our country immediately require more posts as well as new units like Neonatal Surgery, Pediatric Surgical Oncology, Pediatric Urology, Pediatric Orthopedics & Pediatric Neurosurgery as further branches of Pediatric Surgery to give
better services to the children of the country. It is also essential to open Pediatric Surgery department in new government and non-government medical colleges. Further, it is required to equip the departments with necessary surgical equipments, functional lab facility and efficient manpower. Hundreds of babies are born every month with various complicated diseases and congenital anomalies, many of which are curable. The UNICEF & World Health Organization (WHO) should extend their support and include Pediatric Surgery in their activities to reduce neonatal as well as child mortality rate.
There is good news that with the initiatives of Association of Pediatric Surgeons of Bangladesh (APSB), after 16 long years government has recently created posts of associate and assistant professors, registrar and assistant registrars in each of the five new government medical colleges (Comilla, Dinajpur, Bogura, Khulna, and Faridpur & Shahid Suhrawardy Medical College). Government has also created three professorial posts and some associate and assistant professorial posts in eight government medical colleges (mentioned above) along with the post of registrars, which results in a total of approximately 54 posts. However, these numbers are not adequate for serving millions of children in Bangladesh. There is still need to develop more expertise in this sector by training more doctors to be pediatric surgeons as well as ensuring infrastructure development so that their valuable services could be efficiently used.
Last but not the least, establishing a National Children Hospital in the public sector is essential for the total development of pediatric education & services both in medicine & surgery - what we should have established long ago. Better late than never.
(The writer is a Joint Secretary, Association of Pediatric Surgeons of Bangladesh & Assistant Professor, Department of Pediatric Surgery, Dhaka Medical College.)