Report on visit to Dhaka Medical College Hospital, Dhaka, Bangladesh, February to April 2014
funded by an ABN Travel Bursary
Dr Fahmida Amin Chowdhury, Neurology SpR, London, UK
I took an OOPE from my Neurology Training Programme in order to work in Dhaka, Bangladesh. I
wished to improve my clinical experience of tropical neurological diseases, but also hoped to
contribute back some of my own knowledge and skills, both to clinical cases and through teaching.
Bangladesh is situated in the tropics between India and Burma, and is one of the most densely
populated countries in the world with an area the same size as England but a rapidly growing
population of more than 160 million. There is a very wide rich/poor divide and this is unfortunately
also reflected in the health care system. There are a large number of hospitals in the capital city
Dhaka, primarily in the private sector, but the majority of the population are not able to benefit
from these and are dependent on government services, which are poorly funded. In addition, health
awareness is poor. I was based in the Department of Neurology at Dhaka Medical College Hospital
(DMCH) which is a large General Hospital run by the Government, under the supervision of Professor
Mansur Habib, Head of the Dept. It was a valuable experience and I was made to feel very welcome
by Professor Mansur and his colleagues. The neurology department at DMCH also has three
Associate Professors, one Assistant Professor and two Junior Consultants, along with a number of
post-graduate neurology trainees. All of them are general Neurologists.
During my visit, I took part in clinical work (inpatient care, outpatient clinics and also helped out in
the neurophysiology laboratory) and was also involved in teaching postgraduate doctors (mainly on
neurological history taking, examination and communication skills, and on Epilepsy related topics). I
also presented some of my PhD work on 'Endophenotypes in Epilepsy' at the National Neurology
Conference.
The neurology ward at DMCH has 12 female beds and 24 male beds in the form of open bays with six
patients in each, with little privacy. All nursing care apart from administration of medication is
provided by the patients' families. Most neurological patients present acutely to medical wards, but
there are also planned admissions twice weekly to the neurology ward from referrals seen on other
wards and from outpatient clinics. I saw many cases of neurological diseases seen commonly in the
UK such as stroke (approximately half the inpatients at anytime), Parkinson's disease, motor
neurone disease, refractory epilepsy, myasthenia gravis but there were also many cases seen less
commonly in UK, related to infections, particularly TB and various encephalitis, and post-infective
syndromes (eg SSPE). I also saw an interesting case of organophosphate poisoning which has
cholinergic effects and was treated with atropine. There seemed to be a disproportionate number of
cases of axonal GBS, presumably related to campylobacter infections and also of young onset MND,
presumably linked to a yet unidentified environmental factor. I did not see any cases of malaria,
which mostly occurs in the south east of Bangladesh in Chittagong Hill Tract area.
Neuroinflammatory disease is also less commonly seen in Bangladesh.
There are 4 x weekly ward rounds by Professors/ Associate Professors and daily referral rounds.
Although beds and services of doctors are provided free of charge, and there are some basic
medications available free of charge at DMC, due to limited funds, patients are still required to pay
for most tests and treatments. The cost of a CT scan is around £20, MRI is around £60 and
neurophysiological testing is around £10. Some patients are unable to afford these. Most CSF does
not get tested for microbiology and virology as this is too expensive. Additionally, in some cases
investigations cannot be carried out due to lack of facilities (equipment/ expertise) for carrying out
those tests in Bangladesh (for example genetic testing/ specific antibody testing/ complex muscle
biopsy tests). As a result doctors treatment tends to be empirical, based on the most likely diagnosis,
and doctors have to rely on using clinical skills of history and examination, and need to be less
dependant on complex/ expensive investigations to make a diagnosis. There are no
neuroradiologists at DMC and scans may be misreported so neurologists tend to review their own
scans. In terms of availability of common neurological drugs (within the government sector), basic
drugs such as phenobaribitone, anti-TB drugs, paracetamol and some antibiotics are provided free
of charge (while stocks last!) but patients are required to buy all other medications. Steroids are
readily available and generally affordable, IVIg is available but generally unaffordable, and there
were no facilities for plasma exchange. L-dopa is available and affordable, whereas dopamine
agonists are available but usually not affordable. Thrombolysis has just become available for the
first time in Bangladesh in one of the private hospitals.
Each week, the department has three speciality clinics for Epilepsy, Stroke and Headache along with
two more 'general' Outdoor Clinics. An admission card to a clinic costs 10Tk (about 10p) but again
patients have to pay for all their tests and most drugs. Clinics take place in large rooms with multiple
doctors and patients in a single room which restricts examination and patient confidentiality. Huge
numbers of patients were seen in each clinic (eg in the outdoor clinics I was involved with there
were around 100 patients, mainly new patients, with 4 doctors running the clinic). Amitriptylline was
the most common drug used for migraine and almost all patients with epilepsy were taking
phenobarbitone, phenytoin, carbamazepine and sodium valproate, due to other newer anti-epileptic
drugs being unaffordable. Of note, there seemed to be a high proportion of patients with nonepileptic attacks (diagnoses based on history only since there are no Videotelemetry facilities).
I was impressed with the formal postgraduate teaching programme within the department with 3x
weekly lectures, which over a period of months covers a wide range of neurological topics and is
delivered mainly by Professorial level staff. There is also substantial case based teaching during
Consultant Ward Rounds.
I believe this was a worthwhile experience for me and am grateful to the Association of British
Neurologists for their support through my travel grant. Firstly the range of cases was immense.
Some of these were neurological conditions common in the UK for which I hope my clinical
contribution was helpful; others were more unusual 'tropical' cases which were a useful learning
experience for me. My hosts were extremely welcoming and I learnt from them how to treat
patients in a situation where resources are very limited, specifically, how to rely on clinical acumen
rather than expensive/specialised tests. This visit was a good taster for me and I plan to return in
future, to offer specialist knowledge and contribute to the teaching programme.