Malaria in Bangladesh
Background
The disease and area chosen for the purpose of this paper are ‘Malaria in Bangladesh’. Malaria is a serious public health concern in Bangladesh, with the Chittagong Hill Tracts being particularly endemic, impacting 13 of the country's 64 districts (Reid et al., 2012). Bangladesh is home to malaria, a feverish condition that can be fatal and is mostly spread by Anopheles mosquitoes, the malaria parasite's vector (Emeto et al., 2020). It is one of ten Asian countries where malaria is endemic (Haque et al., 2010) . The risk of malaria infection was higher in males than in females. The observed greater risk of malaria in women with higher temperatures may be attributed to the gender-specific social, cultural, and occupational norms in these primarily tribal areas, which, in contrast to the rest of the nation, have distinct matriarchal civilizations. Jhum (slash and burn) farming, which has been determined to be a risk factor for malaria transmission, is carried out by women in these indigenous communities therefore they have higher rates due to their active participation in agricultural and forest work activities where they are exposed to the vector for an elongated period of time. Additionally, women who get up early to complete housework run a higher risk of getting bitten by mosquitoes when engaging in indoor and domestic activities. When women begin their household activities even earlier, this exposure risk may increase in the summertime (Emeto et al., 2020).
Children of age 0-14yrs were more vulnerable than individuals 15-49 and ≥50 years of age because they have yet to acquire the required immunity to protect themselves from the disease. Certain ethnic groups like Tipura Tonchonga were high at risk as well. Residents within this community may be closer to swamps and agricultural fields, resulting in a higher local mosquito density resulting in higher malaria exposure (Haque et al., 2011).
Ecological factors contributing to malaria are temperature, humidity, water availability, and rainfall. Malaria is generally seasonal in Bangladesh, with the peak incidence happening from April to October during the rainy season. Temperature has a significant impact on mosquito development, survival, reproduction, activity, and the extrinsic incubation rate, making it an integral element in malaria transmission (Ahmed et al., 2013). In the Chittagong Hill Tracts of Bangladesh, rainfall and temperature have a substantial and positive correlation with malaria incidence. The substantial correlation between environmental temperature and the presence of malaria may be due to the great temperature susceptivity of the Anopheles mosquito and the Plasmodium parasite. The extrinsic incubation period is shortened by increased temperature, which also intensifies the rate of mosquito bites while accelerating parasite reproduction. This causes the rate of malaria parasite transmission from an infected individual to a healthy individual to escalate and speed up. The correlation between rainfall and the incidence of malaria was shown to be positive, which could be ascribed to the rain producing more ideal breeding grounds (Emeto et al., 2020). In and out-migration, which is frequent in the CHT region, can be linked to malaria transmission. Many of the stable hotspots share a border with India or Myanmar. The highest and most steep areas southeast of the CHTs are where the stable hotspots are located; these areas have dense forests and multiple streams passing through them. Vicinity to water bodies and forests is a recognized risk factor for malaria in CHTs (Noé et al., 2018)
Other factors relating to malaria incidence in Bangladesh are age, sex, education, ethnicity, occupation, altitude, number of bed nets, household density, malaria control activities, population movement, socio-economic indicators, and housing structures. Certain occupations, such as jhum cultivation which is a form of shifting cultivation where ethnic tribal groups grow crops on remote, steep hillsides and daily labour, as well as living near the forest, are linked to greater rates of infection. Males are at increased risk due to their activity in agriculture and spending more time outside near swamps, as previously noted (Ahmed et al., 2013)
Abiotic factors are temperature, humidity, altitude, and rainfall. Followed by biotic factors which are human beings and population movement. Lastly, cultural factors are sex, education, ethnicity, occupation, socio-economic indicators, and housing structures.
Local perspective
Bangladesh has a healthcare system that serves both rural and urban areas. There are 3,976 public healthcare facilities and 975 privately owned hospitals and clinics. The healthcare system in Bangladesh is extremely scattered. As a result, for-profit enterprises, non-governmental organizations (NGOs), the national government, and international welfare organizations help regulate it (Siddiqui & Khandaker, 2007). Due to the lack of healthcare facilities, a significant proportion of community members, particularly those from lower socioeconomic groups, resort to traditional healers for assistance regarding their medical issues. They go to specialists for bio-medical treatment after traditional treatments failed. Surprisingly if the biomedical treatment did not work for them, they turned back to the traditional healers. Traditional healing methods are firmly embedded in Bangladesh's cultural history and are a vital element of the people's culture. Traditional medicines based on locally available ingredients, cultural customs, and religious ceremonies, along with Ayurvedic and Unani systems based on the scientific use of pharmacological procedures and technology, are the most commonly practiced healing techniques in Bangladesh. Traditional healing practises are most commonly used in rural areas where access to biomedical health services is limited, nonetheless, it still holds their value in cities due to reflection of their results of working in rural areas. In rural areas, there are two types of traditional healing systems: religious healing and non-religious healing. Some examples of religious healing are kalami, bhandai and Spiritual healing and examples of non-religious healing are sorcery, kabiraji and home medicine (Haque et al., 2018)
The healers of the rural communities are called tribal medicine practitioners (TMP) who use eleven medicinal plants for curing malaria. Leaves, roots, barks, seeds, fruits, and flowers were among the plant parts used. The leaves were the most commonly used plant component. TMPs for malaria treatment prevented any kind of sophisticated preparations. Fruits and seeds were eaten on its own or mixed with water. In most instances, it was recommended to drink the juice prepared from squeezed plant parts or take pills manufactured from plant paste orally. It was also advised to consume plant components with black pepper or rice. TMPs from the Garo tribe recommended taking a paste made from Rauwolfia serpentina roots and black peppers to treat malaria. TMPs from the Murong tribe suggested mixing juice made from Amaranthus spinosus roots with powdered rice and water. Most of the mixes were taken orally. The Murong tribe's TMPs recommended boiling Mussaenda corymbosa leaves in water and then sponging and bathing the malaria-afflicted individual in it. The Bawm tribe's TMPs suggested the malaria patient to shower with the leaf infusion of the same plant, subsequently massaging the patient's body with the mixture for a bit. Another method of treatment was to take three powdered Caesalpinia nuga seeds mixed with water once. The Chak TMPs believed that a single dose of the Caesalpinia nuga seeds was enough to cure malaria, regardless of its intensity or length. (Rahmatullah et al., 2012)
Narrative Interpretive Perspectives
Case One
The first case revolves around a sufferer's experience with malaria. The patient receiving care is a 12-year-old Bangladeshi female. The patient presented to the medical facility with fever episodes in the prior week (Starzengruber et al., 2010). Some of her symptoms included chills, abdominal pains, headache, fatigue and dizziness. The patient received treatment for quartan malaria. However, the patient relapsed and was back after 49 days with internment fever and symptoms consistent with malaria. An alternative assessment resulted in diagnosing the patient with malaria leading to successful treatment.
The type of illness narrative presented is a restitution narrative; this is because the narrative focuses on achieving a diagnosis that can facilitate patient recovery. In addition, the case is presented in a linear form, explaining the patient's state, symptoms and how they received care that helped them recover. The primary character in the narrative is the patient. The narration does not expand on the interaction between the patient and her medical caregivers. Any interaction is only for assessing the patient and establishing a diagnosis. The nature of the interaction is purely professional.
The narrator highlights the importance of differential diagnosis in their story. The presenter focuses on patient symptoms and the process of achieving a diagnosis. The narrator does not mention the patient's emotional state or coping strategies. The central theme is positioning the discussion from a scientific perspective. The narrator does not use any metaphors and only applies scientific terminology.
Case Two
The second narrative involves a witness of the sufferer's experience. The narrator is a mother who highlights that her three-year-old daughter is suffering from malaria. The patient's symptom that was highlighted was that she could not eat and the sign for the mother was that the child was too sickly (Médecins Sans Frontières, 2014). The patient lived in a village, and health workers had to travel across vast distances to provide the patient with care. The international organization, MSF, is responsible for locating the patient and providing them with care.
The type of illness narrative presented in the case is a restitution narrative. The patient's mother linearly tells the story, beginning with highlighting her daughter's symptoms. The narration proceeds to state that the patient received malaria drugs from health workers and the care she received. The narration ends with the patient recovering due to care from health officials. The characters in the narrative are the patient's mother, the three-year-old patient, and MSF healthcare workers.
The interaction between the characters is cordial as the mother feels grateful for the care her daughter is receiving. The central theme in the narrative is how a patient in disparate locations within Bangladesh are receiving the care they need. A metaphor that is used in the narration is the patient's mother saying she feels relief and safety; this indicates the distress she was in when there was no hope that her daughter would receive care.
A commonality between these two narratives is that both are restitution narratives. They both present a patient who was suffering from malaria and received the required care and recovered from their infection. A difference between the two narratives is that one is scientifically focused. The first case highlights the signs and symptoms in detail and uses scientific terminology to arrive at a diagnosis. I have gained insight from the narratives that differential diagnosis is important, especially in situations where healthcare institutions have limited resources.
Critical Medical Perspective
A critical understanding of the factors worsening malaria in Bangladesh requires establishing connections between the country's social group and the larger human societies and how those influence behaviour, emotion, and attitude. Using critical health anthropology (CHA) requires identifying cultural connections to health and the conditions that led to the development of current conditions (Singer et al., 2020). In addition, it is also necessary to assess the power structures that contribute to inequality in the healthcare system. This presentation aims to use CHA and determine the political and economic factors contributing to disparities worsening malaria in Bangladesh.
The first factor that has contributed to the disparity that worsens the state of malaria in Bangladesh is inequality. A dominant factor that shapes global health is the inequality that exists between rich and developing countries. Lesser developed countries face disease burdens that are the consequence of growing inequality (Singer et al., 2020). Bangladesh is a developing country and, as such, has populations within a country suffering from extreme poverty. These conditions make it easy for malaria to paralyze vulnerable populations within Bangladesh. In addition, there is also a growing wealth inequality between countries, meaning richer countries will afford better healthcare for their citizens.
Research has established a connection between malaria, social inequality and poverty ( Ren.,2019). Malaria burdens the poorest countries in the world. Within these countries, the populations affected the most are children, women, and other vulnerable groups; this is reflective of the two illness narratives selected as both consist of female victims, and one has a mother seeking care for her daughter. Malaria is a double-edged sword because it also affects the economic contributions of affected individuals and families, further dragging them into poverty.
A potential solution to ending healthcare disparity is to eliminate structures and institutions that perpetuate the privilege of a few at the exclusion of others. Bangladesh needs to raise the standards of living for all its citizens. However, the existing economic system of capitalism will still contribute to some disparities in care as the rich within the country will have ready access to healthcare facilities and staff.
Economic policy is the second factor contributing to malaria healthcare disparity. Specifically, the world bank has a structural adjustment policy that negatively affects developing countries such as Bangladesh. The World Bank is an important developmental partner for Bangladesh and provides the country with billions of dollars worth of funding. However, World Bank funding comes with strings attached, and the institution requires Bangladesh to implement certain policies to guarantee future funding. Some of these policies require the privatization of social and healthcare programs (Singer et al., 2020).
The problem with the privatization of healthcare in Bangladesh is that it primarily affects the access the poor have to healthcare services. Consequently, hospital admission is expensive for malaria patients, and drugs are often beyond the reach of low-income citizens (Rahman, 2019). As a result, a gap emerges, and those who cannot afford medication to treat malaria either for themselves or their families can end up losing their lives. In developing countries, private institutions and NGOs such as Médecins Sans Frontières (MSF) can send out personnel and medication to villages in Bangladesh without a charge.
However, NGOs cannot effectively fill this gap, and the government needs to take charge and create policies that can improve medical outcomes. Privatization has limited benefits in improving healthcare in Bangladesh. It is essential to utilize the public sector in mobilizing resources to combat malaria ( Rahman.,2019).
The third factor contributing to the disparity in Bangladesh is the lack of access to health insurance. National insurance is a social change effort to eliminate healthcare disparities (Singer et al.,2020). Healthcare insurance would cover hospital expenses for patients suffering from malaria. The institutionalization of malaria health insurance would contribute to one of the most important interventions against malaria, case management. Case management involves diagnosing and treating patients with malaria and is a crucial step in controlling the spread of malaria. These interventions aim to ensure that malaria transmission is reduced to a level that is not a constant health problem in Bangladesh. Bangladesh lacks healthcare insurance, especially in areas plagued by constant malaria outbreaks.
The lack of coverage means that some patients will not be accurately diagnosed, and others do not get the required care and medication they require, leading to death. A universal healthcare plan would go a long way in addressing the health disparities mentioned above (Singer et al., 2020). Notably, it would significantly reduce the cost of healthcare for malaria. However, the government of Bangladesh is aware of the importance of coverage and has committed to achieving full coverage by 2032. As a result, the government is grappling with policy decisions necessary to improve services and quality while expanding coverage.
The factors of inequality, policy, and access to health insurance reflect the social determinants of health. Poverty, local conditions, and malnutrition are some of the causal factors related to health in the group (Singer et al.,2020). Using the same principle on Bangladesh reflects that the area is among the poorest in the world, meaning poverty contributes to the spread and persistence of malaria. The local conditions in Bangladesh promote the presence of mosquitoes which spread malaria. Therefore, the local conditions are unconducive for the elimination of the disease. From a malnutrition perspective, lack of access to a healthy diet weakens the immune system of citizens.
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