Injury and the Bangladeshi Child
When Shaikat's mother went off to cook in the kitchen that afternoon, she was confident that her 19-month-old son was safe with his grandmother in the courtyard. Not realising that the child had been left under her care, the old lady, however, had been paying little attention. Shaikat wandered out of the house unnoticed. Twenty minutes later, when the family panicked and rushed out looking for him, they discovered Shaikat's body floating on the surface of a pond less than 30 metres away from the house.
Residents of a village in Sherpur district, four hours from Dhaka, the family was unfortunate — it had to cope with a senseless loss of a loved one and the hopes the infant represented. What makes Shaikat's death even more striking is the fact that he was hardly alone. He was but one among the 83 or so children in Bangladesh who would have died that day due to accident and injury. Drowning would have accounted for 46 of those deaths.
Bangladesh, says a health and injury study released earlier this year, is in the midst of a "previously unrecognised epidemic of child injury deaths". The largest community-based injury survey ever conducted in the developing world, the Bangladesh Health and Injury Study (BHIS) covered 171,000 households and more than 800,000 people. The results are so startling that it is important not only to consider them, but also to try and understand why something this grave, which affects so many young and innocent lives, has not even been flagged as an issue of public health.
Getting Hurt
Injury, it turns out, is the leading cause of death among Bangladesh's children over one year of age, accounting for 38 percent of all deaths in the 1-17 age group. More than 30,000 children annually succumb to accidents and injury. More than a million suffer from non-fatal injuries, which translates into 2,600 children getting injured daily. Of those hurt annually, 13,000 are permanently disabled. The statistics have left many shocked, including Bangladesh's Health Minister, Khandaker Mosharraf Hossain, who said he was stunned to hear the BHIS findings.
The results are shocking due to both the enormity of the problem and the fact that injury has never been considered a serious issue in public discourse. While the belated recognition of injuries as a leading cause of death and disability among children marks a transition in child health concerns that is characteristic to many developing countries, it also reveals the loose linkage between communities and the national health system. Additionally, it raises disturbing questions about whether the 'donor-driven' nature of public health strategy and development discourse has diverted national attention from an area so instinctively important.
These life-threatening injuries may occur due to a diverse set of reasons at different stages of a child's life. While drowning is the single-largest killer in the early childhood years, road traffic accidents take the lead in later years when a child is more mobile. Other causes leading to death or disability include burns, falls, cuts, snake and animal bites, and poisoning, besides intentional injuries related to suicide attempts. The biggest tragedy, perhaps, is that most of these injuries, which kill and maim, are both predictable and preventable.
But prevention of injury becomes complex because the subject is intertwined in a maze of political, social, cultural and economic issues — from entrenched patriarchy that relegates child supervision as the sole responsibility of the mother to her economic compulsions and workload which make such supervision less feasible; from the influx of modernity which has brought with it accompanying new-world hazards such as traffic accidents and electrocution to a 'vaccine lobby' which would not like the focus of health interventions to shift away from diseases. Furthermore, there is the absence of safety norms which increases the likelihood of injuries, as well as lack of health infrastructure to immediately respond to accidents that happen. The dynamics of child injuries prevention is truly multi-faceted.
The hidden mountain
If there is anything as astounding as the scale of child injuries in Bangladesh, it is the fact that the phenomenon had not been 'discovered' till now. With no numbers in hand, and hardly any injury prevention programme in place, the matter was not even a peripheral priority for the government, development agencies or ngos. Admits Dr Md Abdur Rahman Khan, Director General of Health Services, "Injury was never recognised as a health issue and we always thought it was a law and order concern." Morten Giersing, representative of UNICEF in Bangladesh who pushed the BHIS study, puts it simply, "Injuries as an issue got overlooked."
Interestingly enough, it was not only the national level planners who neglected injuries. One would have expected district health offices and local communities, which see the problem up close, to be more concerned. Says a researcher for BHIS, "In our interactions, health officials would either deny the existence of injury deaths or would argue that little could be done to prevent it." The survey found that in the communities, there was "a lack of awareness regarding the level of risks for child injury". Most of those questioned blamed injury among children on external forces beyond their control.
What explains this glaring oversight of child injuries both as a public health priority and in popular perception? Some analysts point to the epidemiological transition underway in Bangladesh which has highlighted the role of injuries. "We have seen successful health and immunisation campaigns that have reduced mortality occurring due to infections and diseases. This has resulted in the relative increase in mortality due to injuries," says Dr A K M Fazlur Rahman, executive director of the Centre of Injury Prevention and Research, Bangladesh (CIPRB), who has pioneered injury studies in the country. A study in the delta region of Matlab by the ICDDR, a centre involved with population and health research, confirms the point made by Dr Rahman. Despite little change in the absolute number of drowning cases, the proportion of deaths among children between 1and 4 due to drowning increased from 9 percent in 1983 to 53 percent in 2003. This dramatic shift is attributed to the decline of deaths due to other reasons. Says Giersing of Unicef, "As we conquer the mountain of vaccine-preventable diseases, we can see another mountain behind it, the mountain of injuries." While diseases and infections were indeed responsible for a large proportion of child deaths and deserved attention, the question the analogy raises is why was the mountain of injuries not noticed at all, either in the first place or while combating diseases and infections?
For one, there clearly existed a knowledge gap about the extent of injuries as a leading cause of child deaths. This was because of the inadequate coverage of the rural communities by the national health system, as well as poor information transfer. While mortality data, collected at the household and community level during periodic census, provides a reasonably accurate picture of the number of child deaths, figures regarding the cause of death are obtained from the health information systems. Many kinds of childhood deaths, particularly those that are immediate such as drowning, are not reported at the nearby hospitals or health centres. Additionally, the practice of registering births and deaths has not yet taken firm root in villages, thus leaving a gap in the data.
Some put the blame on donor-driven policies, so critical in determining the health discourse of Bangladesh, which has led to the neglect of injuries on a nationwide level. This discourse, while focusing on the 'mountain' of diseases, did not take into account specific community problems such as drowning in a heavily populated deltaic country. The shifting of focus to the prevention and cure of disease may indeed have diluted traditional injury prevention practices by targeting and prioritising a different set of health problems, even if important in themselves. For instance, an old method to keep track of young children was to tie bells around their waist, clearly revealing that communities in the past were aware of the need to guard against a child going too far from the doorway towards dangerous water bodies in the neighbourhood. Such practices have now faded in the villages. Admits a senior Unicef official, "A process of de-learning might have taken place."
Dr M. Amjad Hossain, head of the orthopaedic and trauma department at the Dhaka Medical College and Hospital (DMCH), has no doubt that the neglect of injuries as a public concern is closely linked to a political and development system that has become utterly dependent on donor governments and agencies. Dr Hossain sees the injuries brought to his trauma unit as the end result of this failure of Bangladeshi government and development sector. He says sardonically, "Child injury is a huge crisis but it seems we will wake up to reality only after international funding agencies tell us about the problem."
Dr Hossain should derive some satisfaction that his society is slowly but surely waking up to the challenge of accidents and injuries. Scholars, civil servants, activists in local communities, NGOs and, yes, international agencies are beginning to look at the arena which kills more Bangladeshi children than any other. The discovery of this lost and unseen 'mountain of injuries', for its part, has been a remarkable story in itself. Unicef's Giersing, who had earlier been involved in an injury study in Vietnam, was aware of the dangers and extent of injury related childhood death and disability in the developing world. The key to understanding and action, however, was to gather data. For his part, Dr Fazlur Rahman had done a research on injuries in the district of Sherpur back in 1995 and believed that a national survey would throw up interesting figures. The ICCDR study in Matlab, meanwhile, had already indicated a trend towards injuries emerging as a leading cause of childhood deaths. With the development agencies on board, the government was responsive as well, and a collaborative effort finally led to the Bangladesh Health and Injury Survey. The hidden mountain had appeared back on the horizon.
Water, water..
Bangladesh is blessed with water, and also with floods which bring fertility to the land even while devastating sections of the population. It should come as no surprise why drowning is the leading cause of death among children. Almost 17,000 children between 1-17 years of age die of drowning every year. A further break-up of data suggests that drowning is the single largest killer in the 1-4 and the 5-9 age brackets, with other causes taking the lead during adolescence.
What is surprising, however, is that most children do not drown during floods or in the rivers. Instead, they fall into neighbourhood ponds and ditches, which are filled with water as a result of the high water table in most parts of the country. Although incidents do increase during the rainy months, the presence of these 'harmless' water bodies makes drowning a perennial danger in rural Bangladesh. "Adults perceive knee level water to be safe, not realising that a child needs merely six inches of water to drown," notes Shams El Arifeen, a research epidemiologist at the ICCDR.
Besides the dangerous proximity to ponds and lakes, it is weak supervision that makes children vulnerable. "Most incidents of drowning happen during the day when mothers are busy cooking in the house. They may either leave the children alone or with slightly older siblings who themselves are not mature enough to be protective," says Arifeen. Even while others may lend a hand, it is the mother who is considered to have the ultimate responsibility for a child's protection. When she is busy, the child is inevitably exposed to danger.
General perceptions regarding drowning are also instructive. The injury study in Matlab reveals that for district health officials, drowning simply did not exist as a cause of death while among mothers, it ranked as the fourth leading cause of death in the village. Apart from accepting injuries with a sense of fatalism, the communities were also found to be superstitious. In order to prevent drowning, the villagers would, the Matlab study reports, "have the kobiraj (spiritual healer) bless the ponds and make sacrifices to the goddess of water Gongima" This superstition is stretched to dangerous levels when parents of a drowned child are excluded from efforts to revive the child. Explaining popular perception, the mother of a child who nearly drowned said, "A child will die if the mother touches him/her even if there is a sign of life still left."
While the extent of drowning deaths itself presents a formidable challenge, activists and scholars agree that beliefs and perceptions related to the phenomenon must be tackled before anything else. This means conveying the message that drowning is not n:'natural' and in fact, preventable. "We already have health workers at the ward, union as well as the sub-division level who are in touch with families to facilitate the immunisation programme. This group is the key to making villagers aware of the risk of drowning and the need to be careful," says Dr Md Firoz Miah, civil surgeon of the Sherpur district. Dr Miah and others suggest that community discussions in the wake of a drowning death are crucial for awareness and prevention.
A successful prevention strategy would need to include several components. "To ensure supervision, the traditional practice of tying bells around the child's waist must be revived and encouraged. This would help parents to keep a track of their child," says Dr Fazlur Rahman, who also runs the only injury prevention and safe community programme in Bangladesh. It is also important to encourage shared responsibility between both parents and to tap into the extended family structure and community links in villages to look after young children. The burden of supervision must not be allowed to rest solely on the mother.
While some suggest fencing off ponds and ditches around homes to make them inaccessible for children, such a proposal may not be popular or practical where access to water is important. "There are other ways to reduce the risk. We can fill in the ditches during rainy months and also have door barriers to prevent the child's movement outside the home without supervision," says Zahurul Haq, a primary school teacher in Sadar subdivision in Sherpur.
While infants may wander into neighbourhood ponds, older children tend to drown in slightly distant water bodies. Despite the fact that children after the age of four or five can be taught to swim, drowning continues to be the leading killer in the 5-9 age group. Children who have managed to pick up swimming skills by then do not die but there are many others who cannot swim. In fact, it is reported that only 18-20 percent of five year old children can swim, a figure that increases to 50 percent by the time they reach the age of 10. BHIS argues forcefully that swimming needs to be encouraged to prevent drowning deaths among older children.
The ills of modernity
Lying on a bed in a Dhaka hospital, Shumi, a six-year old, presents a disturbing sight. Hit by a taxi while running across the road, the young girl has multiple fractures in her leg and around the hips. Shumi, however, is lucky. She is alive and will recover, unlike many other children her age involved in accidents. Road traffic accidents have emerged as the second leading cause of fatal injury among children between 1-17 in Bangladesh, with close to 3,400 dying annually. These accidents also curse 1,400 children with permanent disability every year.
A consequence of rapid urbanisation, extension of road networks in rural areas, poor enforcement of safety regulations, an absence of footpaths and lack of road safety awareness among children, road accidents have now gained recognition as a major health concern. Says Dr Md Siraj-ul-Islam, Director of the National Institute of Trauma and Orthopaedic Rehabilitation (NITOR) in Dhaka: "Reckless driving, children playing on the road, shops constructed on the highway, rash road crossing — all these factors have come together to exacerbate the number of accidents. In all this, it is the pedestrians and the rural people, particularly children, who suffer the most."
Road accidents, while a major cause of death among children between 5 and 9, become the leading cause of fatal injury in the 9-14 age group. That is the age when the children emerge from their houses unsupervised. The gender composition of the victims is also revealing. With most girls staying inside homes after their early childhood, it is the boys who are most vulnerable. Considering that the society in Bangladesh, like other developing countries, is still in the initial phases of vehicular ownership, traffic accidents can only be expected to increase in the days ahead.
The fact that expansion of the road network has not been accompanied by road-safety awareness is gradually being recognised as a major concern. "Target school curricula, teach children how to cross roads properly and make parents aware that vehicular traffic could be dangerous," suggests a district health activist. Additionally, enforcing traffic rules vigilantly, clearly demarcating pedestrian footpaths and strictly regulating driving license distribution could also contribute to making roads safer.
Burns are a major cause of non-fatal injury besides causing a limited number of deaths. BHIS reports that burns injure over 170,000 children each year, and make 3,400 permanently disabled. One child on average dies every day in Bangladesh from burns. Most of the serious and severe burns in infants and young children occur inside the house, with over half of these happening in the kitchen.
The rapid expansion of electrification in the country is producing an expected but unintended consequence in the form of electrocution deaths. Electric burns also now constitute 20 percent of all the child cases reported at the Burns and Plastic Surgery Unit in the DMCH. "These burns occur when children get exposed to non insulated wires, say while flying kites or climbing trees, and when they may be playing with electric switches located near ground level in homes," says A J M Salek, professor at the Burn Unit of the DMCH.
Besides these causes of death, falls and cuts, long considered trivial and inconsequential, have also emerged as numerically significant causes of serious non-fatal injuries. Falls, in fact, are among the leading causes of permanent disability among children. Intentional injuries, primarily suicides, rather than accidents are reported to be among the leading causes of death in later adolescence. An overview of the diverse set of factors that have made Bangladeshi children increasingly vulnerable to death and disability clearly reveals the need to recognise the complexity of this rediscovered crisis of child injuries.
The injury battle
If Bangladesh wants to reduce its child mortality, it will clearly have to combat injuries on a war-footing. The battle has to include four major inter-related components — awareness, prevention, response and rehabilitation.
When it comes to generating awareness and recognition of the injury calamity, it is important that the message not get lost in the maze of 'development communications'. After all, rural communities in Bangladesh are being targeted by a barrage of messages, from family planning to immunisation campaigns, and attention span is at a premium. As one communications expert warns, "Injury prevention must not become another buzzword. Instead, if we are talking about behaviour change, we must focus on inter-personal communication and talk to villagers in small groups."
The key to evolving prevention strategies is building an attitude and mindset of 'carefulness' among parents and guardians. Like all developing societies, Bangladesh's rural world is going through metamorphosis in which age-old traditions and values are being buffeted by new ideas and means. It is understandable when communities lose simple, traditional techniques such as the bell tied around the infant's waist. "We must inculcate a culture of safe behaviour coupled with simple but effective measures that will work, for instance, parents supervising young children, general understanding of traffic hazards among all age groups, and keeping children at a distance from fire," says Dr Fazlur Rahman of CIPRB.
Despite the best efforts, however, injuries are bound to keep occurring, though hopefully over time in lower numbers. What is also needed, therefore, is an effective response strategy to provide immediate remedy. "There is a golden window of 3-6 hours after an injury. If a patient can be given professional medical assistance during this period, prospects of recovery brighten," explains Dr Siraj-ul-Islam of NITOR. The Dhaka government is reported to be planning to build several trauma centers along the country's highways to provide immediate relief to victims of accidents as well as those in the adjoining rural areas. While the step is welcome, it is clear that an extensive health infrastructure, in close proximity to every village, will not materialise immediately. The BHIS report, for its part, recommends that villagers, particularly older children, be trained in first aid treatment, which could provide immediate relief and response at least till the injured reach the hospital.
Can Bangladesh sensitively deal with and help rehabilitate the 13,000 children who become permanently disabled due to injuries every year? "No. Not with the present government apathy and social attitudes regarding disability," says an emphatic Dr Nafeesur Rahman, director of the National Forum of Organisations working with the Disabled (NFOWD). "Here, once you are disabled, you lose everything -social status, position in the family, economic opportunities and even your name. You begin to get referred to by the name of your injury – Shujon, who may be blind, would only be called andha," says Dr Rahman. With only four percent of the total number of disabled children attending primary school in Bangladesh, the challenges that the new 13,000 annual entrants to this 'club' face becomes clear. It is also crucial that the larger society jettison prejudiced notions of the disabled, and the government build inclusive institutions.
Reviving the instinct
While awareness about the child injury crisis present in Bangladesh is spreading, there are clear obstacles on the way – from vested interests that have a stake in existing health priorities to senior medical professionals who are reluctant to do a course correction.
The discovery that it is not diseases and infections but injuries that are the leading cause of child deaths is not music to the ears of one sector – the vaccine industry. As an official confides, "They would like to sell more vaccine but from the perspective of the health system, any additional investment there would only yield diminishing returns as the cause of mortality is already shifting elsewhere." The vaccine lobby is extremely powerful globally, with the money as well as political network to determine health priorities at donor headquarters as well as in distant governments. It would try to retain focus on vaccine preventable disease and ensure status quo vis-à-vis present health priorities. There is also a level of resistance among leading medical practitioners in Dhaka to recognise injury as a major health concern. To be kind, one can say that this attitude stems from ignorance rather than a subliminal leaning towards an approach that would rather maintain the focus on infections and diseases and their treatment.
But there is hope – younger doctors in Dhaka hospitals seem overwhelmingly aware of the drastic nature of the data on injuries. This is because they are present in the trauma and emergency units, seeing for themselves the scale of injuries. The inclusion of injury in several of its key plans and programmes reflects the positive attitude of Bangladesh's Ministry of Health. Meanwhile, Dr Fazlur Rahman's pioneering safe community programme in Sherpur, where drowning deaths have been reduced significantly, proves that injuries can to a large extent be prevented even in low-income communities. All these events, seemingly unconnected, show that there is progress at each level – from growing awareness to policy intervention to prevention – and all of this has happened in a relative short period of five years.
The 'unseen mountain' is now clearly visible, and with the large number of children dying or being disabled from injuries, it does not present a pretty picture. While the earlier mountain of diseases was vaccine preventable, the present one clearly requires a more complex and integrated approach – from making a traditional people recognise the a traditional problem with a new dimension, as well as devising strategies to prevent it. Indeed, the challenge in Bangladesh is to revive the society's instinctive urge to protect its young from injury such as drowning, an instinct that has been dulled or diverted with other health priorities taking precedence, and also by new injury-causing sources in the form of highway accidents or electrocution. As Bangladesh moves to reduce its volume of childhood injury deaths, other Southasian countries would do well to ask themselves whether they have a hidden mountain left to deal with.