Climate change and its impact on health in Bangladesh Climate change affects human health both directly and indirectly. People are exposed This background paper was prepared for a workshop on Climate Change and Health in (temperature, precipitation, sea-level rise and Bangladesh, held on 19–20 November 2007 more frequent extreme events) and indirectly through changes in the quality of water, air and jointly by the World Health Organization food, and changes in ecosystems, agriculture, industry, human settlements and the economy. These direct and indirect exposures can cause death, disability and suffering. Health problems background paper was to facilitate discussion increase vulnerability and reduce the capacity of during workshop by providing latest scientific individuals and groups to adapt to climate assessment on: climate change and health; change. At present the effects of climate change burden and distribution of health impact in Bangladesh related to climate change and progressive increase in all countries and extreme weather events; existing response and human health is multidimensional, as presented schematically in the diagram on page 23. The recently-published Fourth Assessment change effects on human health (IPCC 2007) Report (AR4) of the Intergovernmental Panel on Climate Change (IPCC) states clearly that climate change is contributing to the global • altered the seasonal distribution of sustainable development and includes physical, social and psychological well-being, it is crucial that the health impacts of climate provide the best evidence for the relationship between health and weather or climate factors, but such formal reviews are rare. The *Executive Director, Bangladesh Centre for Advanced evidence published so far indicates that: Regional Health Forum – Volume 12, Number 1, 2008 Figure: Relationship between climate change and human health 2003). The health outcomes included in the seasonality of some allergenic study were chosen on the basis of their known sensitivity to climate variation, predicted quantitative global models (or the feasibility • climate plays an important role in the of constructing them). The following health seasonal pattern or temporal outcomes were included: • cases of Plasmodium falciparum regional and global levels was carried out by morbidity and mortality due to a range of risk factors, including climate change, and to estimate the benefit of interventions to health impacts will be the greatest in low- remove or reduce these risk factors. The study include, in all countries, the urban poor, the estimated to have caused the loss of over elderly and children, traditional societies, 160 000 lives annually. (Campbell-Lendrum subsistence farmers and coastal populations. et al., 2003; Ezzati et al., 2004; McMichael, 2004). The assessment also addressed the level of future burden of climate change that the burden of diarrhoeal diseases in low- could be avoided by stabilizing greenhouse income regions by approximately 2% to 5% Regional Health Forum – Volume 12, Number 1, 2008 domestic product per capita of US$ 6000 or more are assumed to have no additional risk mortality due to diarrhoeal disease primarily following measures be taken to address the expected to rise in East, South and South-East Asia due to projected changes in the • The planning horizon of public health hydrological cycle associated with global coastal water temperature would exacerbate the abundance and/or toxicity of cholera in that focus only on short-term risks will need to be modified. vector-borne viral disease. Several studies spatial, temporal or spatiotemporal pat erns of dengue and climate (Hales et al., 1999; Corwin et al., 2001; Gagnon et al., 2001; Cazelles et al., 2005). The IPCC report also states that approximately one third of the world’s population lives in regions where the climate is suitable for dengue transmission. Malaria is a complex disease to model – all published models have limited parameters for some of the key factors that influence the geographical range and intensity of malaria transmission. Given this limitation, models project that, particularly in Africa, climate change wil be associated with geographical malaria (Plasmodium falciparum) in some regions and with contractions in other regions (Tanser et al., 2003; Thomas et al., 2004; Ebi et al., 2005). Some projections also suggest that some regions will experience a longer season of transmission. Although an increase in the number of months per year of transmission does not directly translate into an increase in malaria burden (Reiter et al., 2004), it would have important implications because the health of populations is an important element of adaptive capacity. prominent if public health systems are not efficient or if new pathogens arise that are everywhere in the world. Recent impacts of resistant to our current methods of disease hurricanes and heat waves have shown that control, leading to falling life expectancies Regional Health Forum – Volume 12, Number 1, 2008 and reduced economic productivity. The total likely to affect all of these conditions. The number of people at risk, the age structure of health effects of a rapidly-changing climate the population and the density of settlements are likely to be overwhelmingly negative, are important variables in any projection of particularly in the poorest communities. • Increasing frequency of heat waves: Bangladesh is vulnerable to outbreaks of infectious, waterborne and other types of diseases (World Bank, 2000). Records show that the incidence of malaria increased from 1556 cases in 1971 to 15 375 in 1981, and 2004 (WHO, 2006). Other diseases such as diarrhoea and dysentery, etc. are also on the rise especial y during the summer months. It has been predicted that the combination of higher temperatures and potential increase in summer precipitation may cause the spread of many infectious diseases [Ministry of about additional stresses like dehydration, especially among children and the elderly. These problems are thought to be closely interlinked with water supply, sanitation and food production. Climate change has already been linked to land degradation, freshwater decline, biodiversity loss and ecosystem • Variable precipitation patterns: decline, and stratospheric ozone depletion. direct or indirect impact on human health as fresh water, thus increasing the risk of diminishing and polluted natural resources. problems, possibly due to climate change and climate variability, will push back its to precipitation patterns – this impacts water, sufficient food, secure shelter and • Malnutrition: Rising temperatures and good social conditions. A changing climate is Regional Health Forum – Volume 12, Number 1, 2008 Table: Incidence of some of the major climate-sensitive diseases occurring during the last few decades in Bangladesh malnutrition. Malnutrition will further increase the vulnerability of those • Vector-borne diseases: Changes in is a regular disease in the major cities • Rising sea levels: These increase the Source: Data modified from WHO, 2006; Director-General, Health (Bangladesh); 1996, 1997; MoEF, and cause many other health-related problems such as cholera, diarrhoea, Overall assessment of the disease burden malnutrition and skin diseases, etc. More than half of the world's Since the country’s independence more than 30 years ago, the Government of Bangladesh institutionalization and strengthening of health and family planning services, with special attention to rural areas, and is committed to the key health-for-all (HFA) and primary health In Bangladesh, millions of people suffer years there has been substantial improvement in the health status of the people. However, mental disorders and dengue, etc. A recent despite these improvements, much still remains study carried out jointly by the BCAS and the to be done. Mortality rates, especially infant National Institute of Preventive and Social and maternal, continue to be unacceptably Medicine (NIPSOM) in 2007 indicated that high. The quality of life of the general population is still very low. Low calorie intake 28 41 273 cases during the period 1988– continues to result in malnutrition, particularly in women and children. Diarrhoeal disease 26 23 092 cases during 1998–1996. Other continues to be the major killer. Communicable and poverty-related diseases that are preventable still dominate the top ten hypertension and kala-azar also affect people of different regions of the country. The following table shows the incidence of some The government is aware of the situation, of the major climate-sensitive diseases and as well as of the major shortcomings that need their trend during the last few decades. to be addressed, such as development of an efficient project management mechanism Regional Health Forum – Volume 12, Number 1, 2008 across the health system; improvement in the chaired by the Prime Minister. At district and logistics of drug supplies and equipment to thana levels, intersectoral coordination health facilities at district and lower levels; committees have been organized, while at improvement in the production and quality of the lowest administrative level (union), human resources; a system to ensure regular intersectoral committees have been formed, maintenance and upkeep of existing health comprehensive plan to improve and ensure Committees have been formed, including an inter-ministerial committee, to integrate/merge the health and family planning departments. Functionally, health and family planning personnel work closely at thana, union and outreach levels, but a dichotomy exists at district and national levels. As a result, greater decentralization of management is The cornerstone of Bangladesh’s national health policy is the Health and Population Sector Strategy (HPSS) which was introduced in decided to formulate a national health policy 1998. The priority of the strategy is to ensure in 1997, for which a health policy committee universal accessibility to and equity in health and five subcommittees were formed. This care, with particular attention to the rural population. The Maternal and Child Health resulted in a change from a “top-down” (MCH) programme receives priority in the planning process for health to a participatory public sector while “reproductive health” has approach involving the stakeholders in the recently become a priority concern. Moreover, health sector. The first product that was government’s financial allocation for health formulated utilizing this approach was the has also improved. Efforts are being made to develop a package of essential services based on the priority needs of clients, to be delivered which is product-oriented and emphasizes on from a static service point, rather than through “outputs” rather than “inputs” is being tried out with WHO’s assistance. Decentralization workers. This will be a major shift in strategy that will require complete reorganization of the existing service structure. Such reorganization is expected to reduce costs and increase epidemiological surveillance and outbreak efficiency as well as meet peoples' demands. Privatization of medical care at the tertiary communicable diseases have been initiated level, on a selective basis, is also being throughout the country. The routine Health considered. The progress being made towards achievement of the health-related Millennium functioning with some limitation, though Development Goals (MDGs) is given below: activities have been undertaken to strengthen Intersectoral cooperation: Intersectoral it. Information support is not yet adequate. committees have been formed at different levels ranging from the national level to the Strengthening of the HMIS through training, use of existing data col ection tools, and cooperation. At national level, for example, establishment of information networks with the nutrition and population councils are Regional Health Forum – Volume 12, Number 1, 2008 emphasized in the intensified action reorganized itself internal y to cope with the involves decentralized planning at thana and union levels. A total of 12 districts (86 thanas) are now covered under the intensified PHC programme. Through intersectoral collaboration and community participation, a joint action handled as a separate, independent entity. plan has been implemented involving 60 000 Individual faculty members and other relevant village health volunteers (one each for 50 people have been trained in HSR, but there is households). The participation of teachers no coordination among researchers. Health and religious leaders is encouraged. The training institutions are yet to include HSR in their curricula. Research culture is just inputs are also utilized to support developing in Bangladesh, hence there is no information, education and communication effective critical mass of researchers to form a networking among researchers and funding Emergency preparedness: Currently, there is no legislation in the country that underpins national and sub-national levels. In the absence of any legislation, the Ministry of issued revised "standing orders for disasters." These “orders” provide guidelines and Health Education Bureau (HEB). In recent instructions to various line departments and years emphasis has been on school health ministries. There are separate “standing orders” education, hospital health education and for different hierarchical levels of the health sector, which include coordination committees; organizations (NGOs). Constraints include contingency plans for manpower deployment, the lack of a national IEC strategy, the low essential medical relief supplies and priority given to health education by health maintaining a database; training in emergency services, underutilization of health education preparedness and response; a communication professional advancement of those working emergency management. A draft "Disaster Management Act" is currently under review. consideration are the inclusion of a health organizations, namely the Bangladesh health policy and strengthening of Institute for Cholera and Diarrhoeal Disease Essential National Health Research (ENHR) Dengue: Dengue was an unfamiliar disease research findings are helpful in making policy in Bangladesh til its outbreak in the summer decisions. Research units have also been of 2000. It started as an acute febrile il ness opened by BMRC in medical colleges. Field in three major cities of Bangladesh (Dhaka, Regional Health Forum – Volume 12, Number 1, 2008 in hospitals). Emphasis is also placed on incidence being in the Dhaka district. People malaria surveillance, preparedness for control of all ages and both sexes are susceptible to dengue. The infection can lead to the fatal dengue shock syndrome (DSS). This vector- bednets. The main constraint is the reduced capacity of the core technical unit for control species of Aedes mosquito. Aedes aegypti of vector-borne diseases to take on activities and Aedes albopictus are peri-domestic mosquitoes that lay eggs in small collections of clean water such as in flower vases and pots. Usually dengue transmission occurs during the rainy season. Bangladesh never experienced a serious epidemic of dengue operations. At least 20 million people in more until 2000. However, scattered studies did than 27 districts are at risk. The estimated indicate sporadic cases over the last few cumulative disease-specific burden is 35 000 cases. Under the project for integrated control of vector-borne diseases, an emergency plan for the control of kala-azar was initiated in DHF cases have been reported in Dhaka and 1994–1995 in 22 thanas of 11 districts other major cities in the country. As of 2004, successful and further expansion is now being reported of which 210 were fatal. The case planned. At least 8000 kala-azar patients fatality rate (CFR) was 1.28%. The Director- have been successfully treated to date. The General, Health Services has taken initiatives major constraint is similar to that faced in the to develop national guidelines by adapting needs. The objective of the guidelines is to Eighteen mil ion people in 12 districts are control transmission of dengue fever and considered to be at risk of filariasis. A revised DHF, reduce morbidity and prevent deaths. strategy for the elimination of filariasis is being pilot-tested in one district. This strategy ivermectin with albendazole yearly for a Plasmodium falciparum to a number of period of three years to the total population antimalarial drugs was increasing and that in relation to 1982 the number of malaria cases had doubled. The government introduced a National Guideline for Treatment of Malaria in 1994, which was revised in 2004. Statistics from 2001 to 2005 show a marked increase in the proportion of Plasmodium falciparum Acute respiratory infection (ARI) accounts for cases every year. WHO declared that malaria about 145 000 (33%) deaths annually among could not be eradicated and subsequently a children less than five years of age (ICDDRB new strategy for malaria control was launched. 1994). Forty to sixty per cent of outdoor visits gradually. It emphasizes disease control attributed to ARI. The programme for the control of ARI continues to be implemented elements (early diagnosis, prompt treatment, recognition of treatment failures and recommended WHO strategies. management of severe and complicated cases Regional Health Forum – Volume 12, Number 1, 2008 be responsible for significant morbidity and mortality, the current strategies have reduced mortality considerably. Multi-sectoral partners are involved in mobilizing the community timely referral. The availability of oral rehydration solution (ORS) has increased through the formation of ORS depots in the community. Constraints include inappropriate use of anthelmintics and anti-diarrhoeals, sector hospital services delivery will be improved through greater autonomy of management, local-level accountability, “cost-recovery”, fee The HPSS (introduced in 1998), which forms the basis for the future national health policy, is based on several key principles: greater orientation to client needs, especially women; improved quality, efficiency and equity of government health services; provision of a expanded private sector role in providing health and population services; and a one- stop shopping via co-location of services. reliance on “cost recovery” for public • unify the bifurcated health and family identified to achieve the above-mentioned Regional Health Forum – Volume 12, Number 1, 2008 • Considering all the relevant climate References Bangladesh Bureau of Statistics (BBS) 2005. Dhaka (Bangladesh): Ministry of Environment and Compendium of Environment Statistics of Bangladesh Confalonieri UB, Menne R, Akhtar KL, Ebi M, Hauengue Bangladesh Health System Profile 2005 [Internet]. New RS, Kovats B, Woodward A, 2007. Human health. In: Delhi (India): WHO, Regional Office for South-East Asia. Climate Change 2007: Impacts, adaptation and vulnerability. Contribution of Working Group II to the Fourth HealthSystemProfile-Bangladesh-Jan2005.pdf. Assessment Report of the Intergovernmental Panel on Climate Change. M.L. Parry, O.F. Canziani, J.P. Palutikof, BCAS and NIPSOM 2007. Climate Change and Health P.J. van der Linden and C.E. Hanson, Eds. Cambridge Impacts. Report prepared for Climate Change Cell. (U.K): Cambridge University Press. p. 391-431. Regional Health Forum – Volume 12, Number 1, 2008 Director General of Health Services (DG-Health) 1999. Ministry of Environment and Forests (MOEF) 2005. Bangladesh Health Bulletin 1997. Ministry of Health and National Adaptation Programmes of Action (NAPA) Study Director General of Health Services (DG-Health) 1998. Bangladesh Health Bulletin 1996. Ministry of Health and Welfare, Government of Bangladesh. Regional Health Forum – Volume 12, Number 1, 2008


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