Fighting Diarrheal Diseases/Cholera in Bangladesh
-------------------------------------------------
Evaluation Oral Re-hydration Therapy Communication Campaign (ORTCC)
fighting the Cholera and other Diarrheal Diseases in Bangladesh
Evaluation of the largest Communication Campaign in the history of
Bangladesh
In the last decade, thousands of people, mainly children used to die
from diarrheal diseases in Bangladesh (approx. 300,000/year), as it
is one of the most densely populated countries (over 864 people/sq.
kilometer) in the world with yearly massive flood and poor sanita-
tion.
With the efforts from different concerned agencies, the situation has
now markedly improved. The people became increasingly conscious about
safe drinking and sanitary habits. The most remarkable achievement is
almost all of them now understand the effect of diarrheal disease and
the requirement of extra fluid to replenish the lack of fluid in the
body of a diarrhea patient. Although, mentioning "Cholera" is forbid-
den by the government health authorities, along with the shigellosis
it has been predicted as the common cause of diarrhea in Bangladesh.
We are still poor, but we have been able to constitute a nationwide
system, the CDD, which is capable of dealing with any emergency
situation regarding diarrheal diseases. One might be happy to know
that in last devastating flush flood in the south-western Bangladesh
(September-October, 2000, when I was engaged in the area as the Medi-
cal Officer of MSF-Holland), out of approx. 100,000 diarrheal pa-
tients, only a few were detected severely dehydrated and the number
of death was non-significant frustrating many international agencies
that came there to set up Diarrhea Treatment Centers (DTC) and to see
thousands of helpless people! Local doctors and paramedics - with ap-
plication of their locally evolved participatory methods - proved
highly effective and low-expensed.
I think all of you know that Bangladesh has the maximum number of
NGVDOs working in the grass root levels in various fields including
the health. In one stage, MSF-Holland was waiting loosely until the
flood water receded (instead of starting mobile OPDs to treat the
thousands distressed in emergency peak periods, even after proposed
by the local staffs repeatedly!) and preferred to chlorinate the
tube-wells with bleaching powder flown from Europe with the expatri-
ate in very high cost, who had almost no knowledge of indigenous
health seeking behaviours, no knowledge of trends of the local dis-
eases and almost totally failed to achieve and initiate the vital
participatory approach, which resulted in their total isolation from
the people in emergency in the field of disaster.
Another important thing - please do not confuse the well advertised
role of International Center for Diarrheal Diseases Research, Bangla-
desh. The latter one is only involved in a hospital in the capital
city of Dhaka and in two or three project sites. Its main role is the
research. But the great service for diarrhea for more than 120 mil-
lions of people have been almost solely planned and delivered by Con-
trol of Diarrheal Disease, Directorate of Health, Ministry of Health
and Family Welfare, Government of Bangladesh in collaboration with
mainly UNICEF.
(Synopsis from "Evaluation of Oral Re-hydration Therapy Communication
Campaign", the evaluation of the largest communication campaign in
Bangladesh conducted by Associates for Family Health Research (AFHR),
a reputed health and Family Planning research firm of Bangladesh. Dr.
Shamim ul Moula was the Principal Investigator and main author of the
study report. The study has been funded by UNICEF, BCO and Royal
Netherlands Government. The outcome of the study is now the basis of
Control of the Diarrheal Disease in Bangladesh).
* This synopsis exposed on the Internet is strictly for non-
commercial purpose and for the benefit of the diarrhoeal disease pa-
tients. I shall be happy if any quarter engaged in the public health
field will benefit from the experiences and findings.
--
National Control of Diarrhoeal Diseases (CDD) programme, Government
of Bangladesh and UNICEF, Bangladesh had been engaged in Oral Rehy-
dration Therapy Communication Campaign (ORTCC) to increase ORT use in
diarrhoeal diseases by the caretakers of children under five years of
age in the country. The campaign started in October 1996. CDD program
and UNICEF, BCO have initiated this study to evaluate the outcome of
the ORTCC to get a comprehensive feedback from the caretakers to spe-
cifically look into the degree of behavior change in diarrhoeal dis-
eases management imparted to them.
The fieldwork of the study has been conducted among the primary re-
spondents or caretakers (mothers mainly-over 16,000 in number),
Health Workers, Primary school teachers and Students as the secondary
respondents. For a qualitative assessment, in-depth interviews were
held with the program managers and Focus Group Discussions (FGD) were
conducted with Health Workers (Health Assistants) and Primary School
Teachers.
Study Findings
From the caretaker interview
Knowledge and perception
* Caretakers' knowledge of all the three golden rules has substan-
tially increased to 46.4 percent in the evaluation from 4.9 percent
in that of the baseline for ORTCC. Knowledge about the rule 1 (give
extra fluids), rule 2 (continue normal feeding including breast milk)
and 3 (referral) were increased to 98.8, 58.9, and 79.3 percents in
the evaluation respectively from those of the 37.4, 12.3 and 56.7
percents respectively in the baseline of ORTCC.
* The most important disseminators of knowledge about the three
"golden rules" have been found as the Health Assistants (60.2%), TV
and Radio (52.7%), Government service outlets (29.2%), Village Doc-
tors (26.0%), NGO workers and their facilities (16.6%), MBBS doctors
(9.2%), and Pharmacy/Drug sellers (8.8%).
* Caretakers' knowledge on diarrhoeal drinks had been found in the
evaluation as ORS (packet saline) of 89.7 percent followed by Molas-
ses Salt Solution (LGS-labon gur sharbat) of 73.8 percent . Other im-
portant fluids for diarrhoea known by the caretakers in home remedy
of diarrhoeal diseases were Green Coconut water of 51.7 percent,
boiled rice water or "Bhater Mar" (49.6%), husked rice water or
"Chirar Pani" about 38.7 percent. Knowledge in plain water was found
to be 16.7 percent.
* The most important sources of knowledge of the fluids for the diar-
rhoeal diseases are the Health Assistants (59.0 percent) and Radio/TV
(50.9 percent nationally of which the urban's share is greater as
87.4 percent) as found in the evaluation. Government Hospitals and
other outlets have accounted for 27.8 percent and Village doctors for
24.4 percent as found in the evaluation. NGOs and their associates
contributed for only 16.9 percent in the issue. The MBBS doctors are
accounted for 8.8 percent as the sources.
* About 75.4 percent of the caretakers in evaluation informed of the
perception of giving extra fluids to the diarrhoea patients in con-
trast to that of the 37.4 percent in the baseline study for ORTCC.
About 12.4 percent caretakers had the knowledge of continuing normal
quantity fluid in the diarrhoeal episodes of their children as found
in the evaluation.
* In evaluation, nationally 67.8 percent of the caretakers have the
knowledge of practicing normal or grater quantities of food during
the diarrhoeal episodes of their children in contrast to 12.3 percent
normal feeding in the baseline study of ORTCC.
* Nationally, about 65.5 percent of the respondent caretakers have
been breast-feeding their children during the time of the study.
* Nationally, about 80.8 percent of the respondent caretakers have
the correct knowledge of breast-feeding their children during diar-
rhoeal episodes.
* Nationally in evaluation, about 85.1 percent of the respondents
have the knowledge of referral in frequent watery loose motion in
contrast to 62.6 percent in the baseline study for ORTCC. About 83.3
percent of the respondents in evaluation have the knowledge of refer-
ral in patient's conditions of not getting better.
* Repeated vomiting is accounted for 37.4 percent in evaluation in
contrast to 27.4 percent in baseline study for ORTCC. Almost all
other percentages regarding to the referral knowledge have increased.
* About 73.9 percent caretakers have got knowledge about correct
preparation of ORS (packet saline) found in evaluation in contrast to
that of about 38.3 percent in the baseline study of ORTCC.
* Nationally in evaluation, about 36.0 percent caretakers have the
knowledge of the adverse effects with in-appropriate volume of water
in ORS preparation.
* About 41.4 percent of the respondents know the ineffectiveness of
the ORS solution prepared with the volume of water less than 500 ml.
Among them, 18.1 percent respondents knew the correct most informa-
tion i.e. " intensity of the loose motion is increased ".
* Most important sources of the knowledge regarding the adverse ef-
fects with the lesser volume water in packet saline preparation are
the Health Assistants (44.8 percent), TV and Radio (43.5 percent),
Government hospitals and other service outlets (22.4 percent) as
found in the evaluation.
* Nationally in evaluation, 52.9 percent of the respondents have been
found knowledgeable of the correct preservation time of the prepared
ORS of 12 hours in contrast to 19.3 percent of the baseline for
ORTCC.
Prevalence
* Nationally, two week and 24 hours prevalence of diarrhoeal disease
has been found as 9.0 and 4.1 respectively in the evaluation.
Practice
* Nationally, about 57.0 percent of the caretakers had been treating
or consulting for the diarrhoeal episodes of their patients.
* Nationally, Village Doctors (42.5%), Drug Sellers (22.3%), Govern-
ment hospitals and other service outlets (16.6%) and Health Assis-
tants (15.8%) are the major groups found to contribute in treatment
and consultation for the diarrhoea patients as described by the care-
takers in evaluation.
* Nationally, NGOs contribution in the issue is 3.6 percent, among
which, 1.7 percent is accounted for the rural.
* Nationally, about 52.9 percent of the respondents used medications
in the diarrhoeal episodes of their patients.
* In evaluation, it has been revealed that 95.5 percent caretakers
reported frequent watery stool and 61.1 percent observed their pa-
tients as not getting better. About 42.6 percent caretakers reported
of fever, whereas 33.8 percent informed of insufficient ingestion of
food and fluid by the patients.
* In evaluation, 59.3 percent of the caretakers provided increased
quantity of fluids to their patient in diarrhoeal episodes. In the
urban, the trend is higher as 71.1 percent in contrast to 56.4 per-
cent in the in the rural in the evaluation study.
* Nationally, in evaluation, about 71.6 percent of the respondents
have been found to practice normal or higher amount of food including
breast milk in the diarrhoeal episodes of their children.
* In evaluation, nationally 25.9 percent caretakers attempted feeding
of their children in the diarrhoeal episodes 8 times or more in a
day, 17.2 percent did it 5 times a day, 16.5 percent and 15.4 percent
did it for 4 and 6 times respectively in a day. Nationally 0.3 per-
cent did not give any food to their children in diarrhoea whereas 0.8
percent and 3.2 percent of the respondents did it for one and two
times a day respectively.
* In evaluation, nationally 53.9 percent of the respondents used
packet saline (ORS) as the diarrhoeal fluid, which is the highest
amongst its kind. Other frequently used fluids are Molasses Salt So-
lution (Labon Gur or Chini Sharbat) of 46.1 percent, Plain water
(53.0%), boiled rice water or "Bhater Mar" (27.5%)), husked rice wa-
ter or "Chirar Pani" (24.7%) and Green coconut water (22.7%).
* Nationally, in evaluation, Health Assistants are accounted for 48.9
percent as the source of recommendations of diarrhoeal fluids fol-
lowed by Radio/TV (30.4%). Health Assistants are major in the rural
area (54.6%). Village Doctors have been revealed as an important
source for the fluid knowledge (25.7% nationally). Government hospi-
tals and other outlets accounted for 24.3 percent nationally. MBBS
doctors are accounted for 7.7 as the source nationally.
* NGO clinic/NGO workers have been accounted for 10.1 percent nation-
ally as the source of knowledge; it is 12.8 percent in the urban and
9.4 percent in the rural areas as described by the caretakers in
evaluation study.
* Nationally, 81.6 percent caretakers used brand saline of SMC (OR-
Saline). Other commercial brands used were only 4.1 percent. Govern-
ment brands accounted for 14.2 percent.
* On observation by the AFHR Field Investigators, nationally 87.0
percent of the caretakers have used entire contents of ORS packet
while preparing packet saline. About 89.7 percent respondent caretak-
ers nationally dissolved the entire ORS packet content in the water
with higher proportion in urban areas (94.5%).
* Nationally, 65.5 percent of the caretakers have been observed to
use appropriate volume of water for the preparation of ORS solution.
* Nationally, 58.9 percent of the caretakers have been observed pre-
paring ORS solution correctly.
N.B. Any question regarding the study will be welcomed. Other inter-
esting features of the study can be sent through afro-
nets@usa.healthnet.org if anybody is interested.
Please contact:
Dr. S. M. Shamim ul Moula
N.B. Any question regarding the study will be welcomed. Other inter-
esting features of the study can be sent to you directly if anybody
is interested.
Showing posts with label Bangladesh. Show all posts
Showing posts with label Bangladesh. Show all posts
Saturday, July 26, 2008
Tuesday, July 22, 2008
A Report on ICDDRB Anomalies in recruitment, failings in research publications Analysis
A Report on ICDDRB
Anomalies in recruitment, failings in research publications
Analysis , by Morshed Ali Khan , 24-July-2006
[Blog]
‘Within the last decade over 100 major research protocols were funded by ICDDR,B but not a single report on these researches was published or made public. Neither was the management able to show any breakthrough in combating diarrhoeal diseases.... It is the only institution in the country that has the legal mandate for movement of biological materials in and out of the country.’ Daily Star, the leading daily of Bangladesh published an investigative report on this. A rejoinder from the authority was also published later with a reply from Morshed Ali Khan, the reporter. Here is the report alongwith rejoinder and the reply.
The only international centre of its kind in developing countries, the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) is fast losing its reputation due to alleged anomalies in management, recruitment and researches.
Within the last decade over 100 major research protocols were funded by ICDDR,B but not a single report on these researches was published or made public. Neither was the management able to show any breakthrough in combating diarrhoeal diseases.
Although ICDDR,B's two hospitals and its diagnostic facilities in Dhaka and at Matlab in Chandpur district are well reputed in the country, annually treating over 130,000 patients suffering from diarrhoeal diseases, its contribution towards researches and studies remains unknown, at least to Bangladesh.
With 'discriminative and anomalous' decisions made at the top level, ICDDR,B is now alleged to have become a one-man show with its executive director deciding over controversial recruitment and alleged unethical researches.
Resentment among ICDDR,B's Bangladeshi scientists, experts and employees run high with allegations of discrepancies in salaries and recruitment, and discrimination in fund allocations for research works of Bangladeshi scientists.
Although ICDDR,B is owned and largely funded by the Bangladesh government, since its inception no Bangladeshi has ever been considered for the post of its director. Currently 20 foreigners with top grade international salaries and facilities work for the centre.
The management of ICDDR,B however remains defiant to its ordinance when it comes to the payment of Bangladeshi workforce. Although the ordinance clearly states in section 14 (2) that salaries for non-international level positions should be comparable to the salaries paid by the United Nations organisations in the country, the Bangladeshi workforce of ICDDR,B does not even receive 50 percent of the UN salary structure.
"We cannot afford to pay the local staff as per the ordinance, we have to run the centre first," said David A Sack, executive director of ICDDR,B, who has been serving for seven years.
Sources alleged that the management overtly gives priority to foreign scientists over the local ones who submit proposals for research. They said Bangladeshi scientists are often subjected to long delays in processing their papers for funds.
"When a local scientist does his research work, he is paid from the fund available for the particular project, but a foreign scientist continues the same work with a top grade fixed salary, made available from a special fund," said a source.
With a fund of US $19 million in 2005, ICDDR,B, since its inception 28 years ago, has spent over $300 million to run the centre. The bulk of the fund is provided by the Government of Bangladesh with almost a million dollar in cash annually, and with assets and exemptions from taxes, duties and rates for the centre and its 2000 personnel. Other major donors are Switzerland, the Netherlands, UK, USA, Sweden, Canada and Japan.
Recently, two recruitment in ICDDR,B for the posts of director of human resources and the finance director, with top international tax free salaries (around US $8,000 a month) and facilities, created more resentments among its staff. The recruitment were carried out violating the charter under which ICDDR,B is supposed to run. Sources said prior to the appointments no advertisement was published in the mass media to ensure wide participation. Sources also said quite a few eyebrows were raised throughout the office when an external auditor of ICDDR,B, belonging to a foreign audit firm engaged in auditing the centre's finances, was given the position of the finance director of ICDDR,B with a top international salary. The auditor's independence and neutrality was instantly assumed to be compromised when he was offered the job during an external audit of the centre. The auditor immediately went back to his country of origin, resigned from the auditor's post and returned to join ICDDR,B as the head of its finance department.
The director of human resources, also a foreign national, was previously working for an international school in Dhaka as its head of 'after school extracurricular activities'. Allegedly she is a family friend of Professor Sack, and the position she was given requires a highly skilled person with relevant qualifications.
Professor David A Sack said he does not think the recruitment are in violation of any norm or 'a conflict of interest'.
"He was an external auditor and he knows the centre, and he totally disassociated himself from the other firm. He is very skilled, very qualified and he knows his job," said Sack.
ICDDR,B has a 16-member board of trustees where Bangladesh as the host is the only country represented by three members. By virtue of a decision made by the erstwhile president of the country, late Ziaur Rahman, the health secretary and the secretary to the Economic Relations Division become members of the board of trustees automatically. The Ministry of Health selects the third member, with relevant qualifications and expertise. The current Bangladeshi members are Secretary to the Ministry of Health AKM Zafar Ullah Khan, Secretary to the Economic Relations Division Mohammad Ismail Zabihullah and for the first time ever Secretary General of the Bangladesh Medical Association (BMA) Dr AZM Zahid Hossain.
The trustees meet twice a year supposedly to take some of the vital decisions on recruitment, researches and important other issues. The chair of the board is Prof Terence H Hull from Australia while the member secretary is Prof David A Sack.
ICDDR,B sources said the role of the trustees during meetings remains 'totally insignificant', where all decisions made by Prof Sack are silently accepted and approved.
"Most of the members are very busy executives both in Bangladesh and abroad, who hardly have time to scrutinise facts and figures, so they trust the executive director working directly in the field," said a top-level source.
Sources said the silence of Bangladeshi board members is usually managed by hefty honorariums, foreign trips and lucrative consultancies. A former health secretary to the Ministry of Health was offered the post of an 'adviser', a completely new position, with a top international salary. He joined the post a day after his retirement, raising questions as to how sincerely he served Bangladesh's interest while in the office.
Despite repeated attempts over a period of several days, the secretary of health and the secretary general of BMA could not be reached.
But, Secretary to the Economic Relations Division Mohammad Ismail Zabihullah said Bangladeshi board members are never consulted before any recruitment.
"I have heard about some anomalies in the centre and we would like to convene an urgent meeting to discuss the issues," he said.
The ICDDR,B ordinance clearly says that the board of trustees must approve the appointments of all top level personnel in the centre. David A Sack however said he usually takes approvals of the members over the telephone.
The executive director denied the allegations saying, "I hope that is not true [that he runs a one-man show], these [members] are experienced people and we have a majority of people [members] coming from developing countries."
Over the last 28 years, the centre has conducted eight 'candidate vaccine trials' on lakhs of people at Matlab in Chandpur but mysteriously failed to produce a single report on the trials.
Officials who were serving at the time of 1985 vaccine trials on the people of Matlab alleged that the trials were run without the consent of the people on whom the experiment was conducted. Following the allegation of 'unethical research' the government then formed a task force to look into the matter. The report of the task force was never made public.
According to Sack, the cholera vaccine trial conducted in 1985 in Matlab was 'quite successful'. After 20 years, the same vaccine tried on the people of Matlab, has been patented by a Swedish company, and licensed and marketed in Europe, he said.
"It's too expensive to make it available in Bangladesh, but now WHO is making recommendations for use of the same vaccine in Bangladesh. We are working to develop a formulation which would be inexpensive for the people to use here, I am afraid that might take years," Sack said.
According to the ICDDR,B Ordinance 1978, the centre is to undertake and promote study, research and dissemination of knowledge in diarrhoeal diseases and directly related subjects with a view to developing improved methods of healthcare. The centre is to provide facilities for training to Bangladeshi and other nationals in collaboration with international institutions.
Although the executive director denied it, recently ICDDR,B in a clear violation of its charter, decided to hand over its training division to a top NGO, whose expertise in training personnel in the field of diarrhoeal diseases is not known.
"We are working with BRAC in their school of public health, the students of the school come to ICDDR,B for the second half of the school year for training, it is not true that we are handing our training division over to anyone," Sack claimed.
But the dean of BRAC's school of public health, also Deputy Executive Director A Mushtaque R Chowdhury told The Daily Star that talks are underway to hand over the international training division of ICDDR,B to BRAC.
"We have long experience in public health related work and we are preparing to take over the training division of ICDDR,B," Chowdhury said.
There are two distinct components of training -- diagnostic and clinical. For the former extensive laboratory work is necessary, and for the latter a well functioning hospital is needed. BRAC does not have either of the two. How can BRAC impart training is a question that experts familiar with ICDDR, B's work are asking.
ICDDR,B was set up by an ordinance in 1978, giving it immunity from local taxes, rates and duties. The ordinance offers a wide range of privileges for its foreign employees including exemption from income tax and privilege of duty free import of all personal and household items. The chairman, trustees, director, officers and employees of ICDDR,B are also immune from any legal proceedings with respect to acts performed by them in their official capacity. It is the only institution in the country that has the legal mandate for movement of biological materials in and out of the country.
June 16, 2006
Rejoinder and the Reply
1. After living in Dhaka for nearly 13 of the last 29 years, I have deep regard for the people who work at the International Centre for Diarrhoel Diseases, Bangladesh (ICDDR,B), its Board of Trustees, and the people who are helped by our hospital. I generally have high regard for the press of Bangladesh as well. Thus, I was extremely disappointed by the article by Mr Morshed Ali Khan in The Daily Star regarding the ICDDR,B (16 June, 2006). As Executive Director of the Centre, I can say that the allegations contained in this article were unfounded and untrue. One wonders how an esteemed newspaper like The Daily Star could print such an article without first checking its facts. That the article appeared during the first day of the semi- annual meeting of our international board of Trustees, and at a time the Board is planning to begin searching for the next Executive Director is a curious coincidence. In fact, the centre is a highly respected international research institute whose results are known throughout the world and whose efforts locally save the lives of thousands in Bangladesh each year.
2. An obvious error in article states that "within the last decade over 100 major research protocols were funded by ICDDR,B but not a single report on these researches was published or made public." This statement is obviously false given the thousands of scientific papers that have been published by scientists at the Centre. This could easily have been understood if the writer had taken the time to visit any medical library or even consulted the internet. The Daily Star regularly uses information from our quarterly bulletin in its newspaper, and several articles from The Daily Star have praised the work of the Centre. My office has an entire file containing many articles from The Daily Star reporting on the findings from the ICDDR,B. Even last week, two articles written by the Bangladeshi scientists at the Centre were published in two of the most prestigious international journals -- the New England Journal of Medicine, and the Proceedings of the National Academy of Sciences. Each of these articles was accompanied by an editorial highlighting the importance of the findings. In addition, the Centre publicizes important new findings quickly through a quarterly bulletin for medical professionals (the Health and Science Bulletin) and to grass roots workers through newsletters (Shayasta Sanglap). In addition, dissemination seminars are held regularly including the ASCON and ASCODD conferences, and the scientists from ICDDR, B participate regularly in seminars and symposia in other institutions. Lack of publications and dissemination is hardly an issue.
3. These publications have an impact all over the world. The development of methods for treating diarrhoel diseases, including oral rehydration solution. Has saved the lives of over 40 million children all over the world during the last two decades. Other research efforts toward helping children pneumonia, reducing deaths in newborns, and mothers, and assisting the government in their family planning programmes are well known. These contributions were recognized by the first ever Gates Award for Global Health in 2001 and by the Independence Day Award in 2005.
4. The writer attempted to distort the work of the Centre to create the impressions that Bangladeshi scientists were somehow disadvantaged. In fact a majority of the scientists at ICDDR,B are from Bangladesh. They regularly develop projects and publish their results. As a result of their productivity and their contribution to health research, many of the Bangladeshi scientists have now been promoted to the international level.
5. The article also does a disservice to the more than 2000 staff members of the Centre both in Dhaka, Matlab, and other areas of Bangladesh who are literally working night and day to help the poor people of Bangladesh. Last year more then 110,000 patients sought care from our Dhaka Cholera Hospital, about 20,000 of whom had a life- threatening diarrhoel disease. The lives of these mothers, fathers and children were saved through the efforts of our hospital staff.
6. Recruitment of all staff at the Centre is totally fair and open. For staff at the highest international levels, the international Board of Trustees must approve these selections and they take this responsibility seriously. The board has an established and transparent process for the selection. As an international institution, the ICDDR,B attempts to recruit the best and brightest individuals from around the world -- including Bangladesh and including one of the Division Directors who is from Bangladesh. Recruitment for all local positions is also through a totally transparent process. We seek to find the women and men who are best qualified to fill the job.
7. Among the allegations, the writer says that the there have been no reports from 1985 cholera vaccine field trial in Matlab. In fact, more than 40 publications have been published in international journals. The vaccine was found to be totally safe and based on the experience in Matlab; it was later evaluated in other countries, most recently in Mozambique where its effectiveness was again reconfirmed. Due to the knowledge gained in Matlab and these other countries, the vaccine is now licensed in Europe and many countries and the World health Organization now recommends its use for persons who are vulnerable to cholera epidemics. One of the Centre's activities now is to develop a formulation of the vaccine to be practical and inexpensive so that it can be made available to people in this country who choose to take it. It is important to note that all studies at the ICDDR,B involving humans are approved by our Ethical Review Committee including the 1985 study. This committee is composed primarily of Bangladeshi people outside the Centre who also take their responsibility very seriously.
8. I especially object to the photo of the students who are shown working in the immunology laboratory of the Centre. At present, 27 M.Sc. students from different universities in Bangladesh are working diligently toward their degree, and they are using the facilities of the ICDDR, B to help them achieve this goal. The scientists at the ICDDR,B coordinate with faculty supervisors at these universities to facilitate the training experience of these students. The caption under the photo belittles the efforts of these students who are contributing to the scientific output from Bangladesh while at the same time, preparing for a future career in health research.
9. In summary, the article by Mr. Khan was most unfortunate. The fact that the Daily Star chose to print the article with so many obvious misstatements was doubly unfortunate. The ICDDR,B is the only such international health research institute in a developing country. Other international centres have headquarters in Geneva or New York, but we are proud to claim that the headquarters for this international centre is in Dhaka. Under the direction of a distinguished international Board of Trustees, we work for the people of Bangladesh in partnership with the ministry, provide opportunities for Bangladeshi health professionals, and build the knowledge for life saving solutions that benefit poor people all over the world.
The Reply:
We generally do not publish full text of such big rejoinders, especially when they fail to respond to points we have raised. We are doing so to show before the public how David A Sack's rejoinder avoids answering the main questions we have raised. We address his rejoinder in detail and provide our response below.
In paragraphs 1, 2 and 3 David A Sack details international publications of ICDDR,B's research works but fails to elaborate as to how Bangladeshi medical science and especially medical practitioners have benefited from those. His rejoinder mentions some international publications but does not mention how these research works were made available to Bangladeshi people or professionals. He refers to some The Daily Star articles that referred to ICDDR,B works or events but this cannot be taken as substitute for research publication that were made available internationally, but not, to our knowledge, nationally.
In paragraph 4 and 5 Sack says that majority of scientists in the centre are Bangladeshi and that they are not disadvantaged. He fails to answer our question about salary discrepancies of Bangladeshi staff in violation of the ICDDR,B Ordinance. There is also no response from Sack about Bangladeshi scientists receiving research grants from project fund only, while foreign scientists receiving the grants from a special fund. Instead, he tries to play on emotion by saying how thousands of Bangladeshi workers are working day and night. This is precisely our point. When Bangladeshis are working so hard, day and night, then why pay them a discriminatory salary?
In Paragraph 6, the Executive Director makes general comments about the openness in recruitment policy. In our report we made two specific allegations. Firstly, appointment of the Human Resources Director, who was head of after school extracurricular activities at an international school prior to joining the post. Secondly, we raised questions about the appointment of former auditor of the centre as a Finance Director. This is clearly a case of conflict of interest. Questions naturally arise when an auditor is offered a job in the same organisation whose financial propriety he is supposed to be investigating.
The Executive Director clearly avoids answering these two specific issues.
In Paragraph 7 he mentions about the cholera vaccine, experiment of which was conducted in Matlab, being available in Mozambique and many other countries. This is precisely the point we made in our article. The vaccine for which our people were experimented upon, is now licensed in Europe and sold in many other countries except ours. We did not even know about these experimental developments. Is it fair that Bangladeshi people should not benefit from a medicine, in the discovery of which we were experimented upon?
In conclusion we reiterate the fact that we made allegations or discrepancies in salaries, discrepancies in fund allocation for research, recruitment and management but Sack has failed to address any of the questions raised.
A Mushtaque Chowdhury's letter and reply
We also received a letter from A Mushtaque R Chowdhury, Dean of James P Grant School of Public Health, who denied having told The Daily Star correspondent that BRAC was planning to take over the International Training Division of the ICDDR,B. He said that he was misunderstood by the correspondent. The BRAC School of Public Health is a joint collaboration between BRAC and ICDDR,B. At the moment the BRAC school students spend half of the time at ICDDR,B utilising their facilities including the library, classrooms, laboratories, filed sites and more importantly the researchers most of whom also teach at the school.
Our reply: We are further investigating this point, and reserve our response at this point.
Terrence H Hull's letter and our reply
Terrence H Hull, the Chair Board of Trustees, ICDDR,B in a letter claims, "The Board is responsible for reviewing senior appointments made at ICDDR,B and can affirm that there are no anomalies in the appointment procedures or selections as asserted by our article. Those assertions contained neither evidence nor attribution to a source that could have possibly had any knowledge of the matter..."
Our reply: Like Sack, Terrence H Hull also gives a general reply and does not answer the point we raised about two specific senior level appointments, which should have been reviewed by the Board of Trustees. We specifically ask Hull, "did the Board review the appointment of the Human Resources Director? What qualified a former instructor of after school program of an international school to qualify for such a senior post? As for the director finance, doesn't the Chair of the Trustee Board find anything curious in the appointment of an auditor during an audit, as its finance director?"
Our readers would be well served and we may even stand corrected if the Chair of the Board of Trustees is so kind enough to let us know how the Board discharged responsibilities in appointing these two directors. For the sake of transparency and accountability, we will welcome any information by the Chair other than affirmation that "....that there are no anomalies in the appointment procedures or selections as asserted by our article."
Anomalies in recruitment, failings in research publications
Analysis , by Morshed Ali Khan , 24-July-2006
[Blog]
‘Within the last decade over 100 major research protocols were funded by ICDDR,B but not a single report on these researches was published or made public. Neither was the management able to show any breakthrough in combating diarrhoeal diseases.... It is the only institution in the country that has the legal mandate for movement of biological materials in and out of the country.’ Daily Star, the leading daily of Bangladesh published an investigative report on this. A rejoinder from the authority was also published later with a reply from Morshed Ali Khan, the reporter. Here is the report alongwith rejoinder and the reply.
The only international centre of its kind in developing countries, the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) is fast losing its reputation due to alleged anomalies in management, recruitment and researches.
Within the last decade over 100 major research protocols were funded by ICDDR,B but not a single report on these researches was published or made public. Neither was the management able to show any breakthrough in combating diarrhoeal diseases.
Although ICDDR,B's two hospitals and its diagnostic facilities in Dhaka and at Matlab in Chandpur district are well reputed in the country, annually treating over 130,000 patients suffering from diarrhoeal diseases, its contribution towards researches and studies remains unknown, at least to Bangladesh.
With 'discriminative and anomalous' decisions made at the top level, ICDDR,B is now alleged to have become a one-man show with its executive director deciding over controversial recruitment and alleged unethical researches.
Resentment among ICDDR,B's Bangladeshi scientists, experts and employees run high with allegations of discrepancies in salaries and recruitment, and discrimination in fund allocations for research works of Bangladeshi scientists.
Although ICDDR,B is owned and largely funded by the Bangladesh government, since its inception no Bangladeshi has ever been considered for the post of its director. Currently 20 foreigners with top grade international salaries and facilities work for the centre.
The management of ICDDR,B however remains defiant to its ordinance when it comes to the payment of Bangladeshi workforce. Although the ordinance clearly states in section 14 (2) that salaries for non-international level positions should be comparable to the salaries paid by the United Nations organisations in the country, the Bangladeshi workforce of ICDDR,B does not even receive 50 percent of the UN salary structure.
"We cannot afford to pay the local staff as per the ordinance, we have to run the centre first," said David A Sack, executive director of ICDDR,B, who has been serving for seven years.
Sources alleged that the management overtly gives priority to foreign scientists over the local ones who submit proposals for research. They said Bangladeshi scientists are often subjected to long delays in processing their papers for funds.
"When a local scientist does his research work, he is paid from the fund available for the particular project, but a foreign scientist continues the same work with a top grade fixed salary, made available from a special fund," said a source.
With a fund of US $19 million in 2005, ICDDR,B, since its inception 28 years ago, has spent over $300 million to run the centre. The bulk of the fund is provided by the Government of Bangladesh with almost a million dollar in cash annually, and with assets and exemptions from taxes, duties and rates for the centre and its 2000 personnel. Other major donors are Switzerland, the Netherlands, UK, USA, Sweden, Canada and Japan.
Recently, two recruitment in ICDDR,B for the posts of director of human resources and the finance director, with top international tax free salaries (around US $8,000 a month) and facilities, created more resentments among its staff. The recruitment were carried out violating the charter under which ICDDR,B is supposed to run. Sources said prior to the appointments no advertisement was published in the mass media to ensure wide participation. Sources also said quite a few eyebrows were raised throughout the office when an external auditor of ICDDR,B, belonging to a foreign audit firm engaged in auditing the centre's finances, was given the position of the finance director of ICDDR,B with a top international salary. The auditor's independence and neutrality was instantly assumed to be compromised when he was offered the job during an external audit of the centre. The auditor immediately went back to his country of origin, resigned from the auditor's post and returned to join ICDDR,B as the head of its finance department.
The director of human resources, also a foreign national, was previously working for an international school in Dhaka as its head of 'after school extracurricular activities'. Allegedly she is a family friend of Professor Sack, and the position she was given requires a highly skilled person with relevant qualifications.
Professor David A Sack said he does not think the recruitment are in violation of any norm or 'a conflict of interest'.
"He was an external auditor and he knows the centre, and he totally disassociated himself from the other firm. He is very skilled, very qualified and he knows his job," said Sack.
ICDDR,B has a 16-member board of trustees where Bangladesh as the host is the only country represented by three members. By virtue of a decision made by the erstwhile president of the country, late Ziaur Rahman, the health secretary and the secretary to the Economic Relations Division become members of the board of trustees automatically. The Ministry of Health selects the third member, with relevant qualifications and expertise. The current Bangladeshi members are Secretary to the Ministry of Health AKM Zafar Ullah Khan, Secretary to the Economic Relations Division Mohammad Ismail Zabihullah and for the first time ever Secretary General of the Bangladesh Medical Association (BMA) Dr AZM Zahid Hossain.
The trustees meet twice a year supposedly to take some of the vital decisions on recruitment, researches and important other issues. The chair of the board is Prof Terence H Hull from Australia while the member secretary is Prof David A Sack.
ICDDR,B sources said the role of the trustees during meetings remains 'totally insignificant', where all decisions made by Prof Sack are silently accepted and approved.
"Most of the members are very busy executives both in Bangladesh and abroad, who hardly have time to scrutinise facts and figures, so they trust the executive director working directly in the field," said a top-level source.
Sources said the silence of Bangladeshi board members is usually managed by hefty honorariums, foreign trips and lucrative consultancies. A former health secretary to the Ministry of Health was offered the post of an 'adviser', a completely new position, with a top international salary. He joined the post a day after his retirement, raising questions as to how sincerely he served Bangladesh's interest while in the office.
Despite repeated attempts over a period of several days, the secretary of health and the secretary general of BMA could not be reached.
But, Secretary to the Economic Relations Division Mohammad Ismail Zabihullah said Bangladeshi board members are never consulted before any recruitment.
"I have heard about some anomalies in the centre and we would like to convene an urgent meeting to discuss the issues," he said.
The ICDDR,B ordinance clearly says that the board of trustees must approve the appointments of all top level personnel in the centre. David A Sack however said he usually takes approvals of the members over the telephone.
The executive director denied the allegations saying, "I hope that is not true [that he runs a one-man show], these [members] are experienced people and we have a majority of people [members] coming from developing countries."
Over the last 28 years, the centre has conducted eight 'candidate vaccine trials' on lakhs of people at Matlab in Chandpur but mysteriously failed to produce a single report on the trials.
Officials who were serving at the time of 1985 vaccine trials on the people of Matlab alleged that the trials were run without the consent of the people on whom the experiment was conducted. Following the allegation of 'unethical research' the government then formed a task force to look into the matter. The report of the task force was never made public.
According to Sack, the cholera vaccine trial conducted in 1985 in Matlab was 'quite successful'. After 20 years, the same vaccine tried on the people of Matlab, has been patented by a Swedish company, and licensed and marketed in Europe, he said.
"It's too expensive to make it available in Bangladesh, but now WHO is making recommendations for use of the same vaccine in Bangladesh. We are working to develop a formulation which would be inexpensive for the people to use here, I am afraid that might take years," Sack said.
According to the ICDDR,B Ordinance 1978, the centre is to undertake and promote study, research and dissemination of knowledge in diarrhoeal diseases and directly related subjects with a view to developing improved methods of healthcare. The centre is to provide facilities for training to Bangladeshi and other nationals in collaboration with international institutions.
Although the executive director denied it, recently ICDDR,B in a clear violation of its charter, decided to hand over its training division to a top NGO, whose expertise in training personnel in the field of diarrhoeal diseases is not known.
"We are working with BRAC in their school of public health, the students of the school come to ICDDR,B for the second half of the school year for training, it is not true that we are handing our training division over to anyone," Sack claimed.
But the dean of BRAC's school of public health, also Deputy Executive Director A Mushtaque R Chowdhury told The Daily Star that talks are underway to hand over the international training division of ICDDR,B to BRAC.
"We have long experience in public health related work and we are preparing to take over the training division of ICDDR,B," Chowdhury said.
There are two distinct components of training -- diagnostic and clinical. For the former extensive laboratory work is necessary, and for the latter a well functioning hospital is needed. BRAC does not have either of the two. How can BRAC impart training is a question that experts familiar with ICDDR, B's work are asking.
ICDDR,B was set up by an ordinance in 1978, giving it immunity from local taxes, rates and duties. The ordinance offers a wide range of privileges for its foreign employees including exemption from income tax and privilege of duty free import of all personal and household items. The chairman, trustees, director, officers and employees of ICDDR,B are also immune from any legal proceedings with respect to acts performed by them in their official capacity. It is the only institution in the country that has the legal mandate for movement of biological materials in and out of the country.
June 16, 2006
Rejoinder and the Reply
1. After living in Dhaka for nearly 13 of the last 29 years, I have deep regard for the people who work at the International Centre for Diarrhoel Diseases, Bangladesh (ICDDR,B), its Board of Trustees, and the people who are helped by our hospital. I generally have high regard for the press of Bangladesh as well. Thus, I was extremely disappointed by the article by Mr Morshed Ali Khan in The Daily Star regarding the ICDDR,B (16 June, 2006). As Executive Director of the Centre, I can say that the allegations contained in this article were unfounded and untrue. One wonders how an esteemed newspaper like The Daily Star could print such an article without first checking its facts. That the article appeared during the first day of the semi- annual meeting of our international board of Trustees, and at a time the Board is planning to begin searching for the next Executive Director is a curious coincidence. In fact, the centre is a highly respected international research institute whose results are known throughout the world and whose efforts locally save the lives of thousands in Bangladesh each year.
2. An obvious error in article states that "within the last decade over 100 major research protocols were funded by ICDDR,B but not a single report on these researches was published or made public." This statement is obviously false given the thousands of scientific papers that have been published by scientists at the Centre. This could easily have been understood if the writer had taken the time to visit any medical library or even consulted the internet. The Daily Star regularly uses information from our quarterly bulletin in its newspaper, and several articles from The Daily Star have praised the work of the Centre. My office has an entire file containing many articles from The Daily Star reporting on the findings from the ICDDR,B. Even last week, two articles written by the Bangladeshi scientists at the Centre were published in two of the most prestigious international journals -- the New England Journal of Medicine, and the Proceedings of the National Academy of Sciences. Each of these articles was accompanied by an editorial highlighting the importance of the findings. In addition, the Centre publicizes important new findings quickly through a quarterly bulletin for medical professionals (the Health and Science Bulletin) and to grass roots workers through newsletters (Shayasta Sanglap). In addition, dissemination seminars are held regularly including the ASCON and ASCODD conferences, and the scientists from ICDDR, B participate regularly in seminars and symposia in other institutions. Lack of publications and dissemination is hardly an issue.
3. These publications have an impact all over the world. The development of methods for treating diarrhoel diseases, including oral rehydration solution. Has saved the lives of over 40 million children all over the world during the last two decades. Other research efforts toward helping children pneumonia, reducing deaths in newborns, and mothers, and assisting the government in their family planning programmes are well known. These contributions were recognized by the first ever Gates Award for Global Health in 2001 and by the Independence Day Award in 2005.
4. The writer attempted to distort the work of the Centre to create the impressions that Bangladeshi scientists were somehow disadvantaged. In fact a majority of the scientists at ICDDR,B are from Bangladesh. They regularly develop projects and publish their results. As a result of their productivity and their contribution to health research, many of the Bangladeshi scientists have now been promoted to the international level.
5. The article also does a disservice to the more than 2000 staff members of the Centre both in Dhaka, Matlab, and other areas of Bangladesh who are literally working night and day to help the poor people of Bangladesh. Last year more then 110,000 patients sought care from our Dhaka Cholera Hospital, about 20,000 of whom had a life- threatening diarrhoel disease. The lives of these mothers, fathers and children were saved through the efforts of our hospital staff.
6. Recruitment of all staff at the Centre is totally fair and open. For staff at the highest international levels, the international Board of Trustees must approve these selections and they take this responsibility seriously. The board has an established and transparent process for the selection. As an international institution, the ICDDR,B attempts to recruit the best and brightest individuals from around the world -- including Bangladesh and including one of the Division Directors who is from Bangladesh. Recruitment for all local positions is also through a totally transparent process. We seek to find the women and men who are best qualified to fill the job.
7. Among the allegations, the writer says that the there have been no reports from 1985 cholera vaccine field trial in Matlab. In fact, more than 40 publications have been published in international journals. The vaccine was found to be totally safe and based on the experience in Matlab; it was later evaluated in other countries, most recently in Mozambique where its effectiveness was again reconfirmed. Due to the knowledge gained in Matlab and these other countries, the vaccine is now licensed in Europe and many countries and the World health Organization now recommends its use for persons who are vulnerable to cholera epidemics. One of the Centre's activities now is to develop a formulation of the vaccine to be practical and inexpensive so that it can be made available to people in this country who choose to take it. It is important to note that all studies at the ICDDR,B involving humans are approved by our Ethical Review Committee including the 1985 study. This committee is composed primarily of Bangladeshi people outside the Centre who also take their responsibility very seriously.
8. I especially object to the photo of the students who are shown working in the immunology laboratory of the Centre. At present, 27 M.Sc. students from different universities in Bangladesh are working diligently toward their degree, and they are using the facilities of the ICDDR, B to help them achieve this goal. The scientists at the ICDDR,B coordinate with faculty supervisors at these universities to facilitate the training experience of these students. The caption under the photo belittles the efforts of these students who are contributing to the scientific output from Bangladesh while at the same time, preparing for a future career in health research.
9. In summary, the article by Mr. Khan was most unfortunate. The fact that the Daily Star chose to print the article with so many obvious misstatements was doubly unfortunate. The ICDDR,B is the only such international health research institute in a developing country. Other international centres have headquarters in Geneva or New York, but we are proud to claim that the headquarters for this international centre is in Dhaka. Under the direction of a distinguished international Board of Trustees, we work for the people of Bangladesh in partnership with the ministry, provide opportunities for Bangladeshi health professionals, and build the knowledge for life saving solutions that benefit poor people all over the world.
The Reply:
We generally do not publish full text of such big rejoinders, especially when they fail to respond to points we have raised. We are doing so to show before the public how David A Sack's rejoinder avoids answering the main questions we have raised. We address his rejoinder in detail and provide our response below.
In paragraphs 1, 2 and 3 David A Sack details international publications of ICDDR,B's research works but fails to elaborate as to how Bangladeshi medical science and especially medical practitioners have benefited from those. His rejoinder mentions some international publications but does not mention how these research works were made available to Bangladeshi people or professionals. He refers to some The Daily Star articles that referred to ICDDR,B works or events but this cannot be taken as substitute for research publication that were made available internationally, but not, to our knowledge, nationally.
In paragraph 4 and 5 Sack says that majority of scientists in the centre are Bangladeshi and that they are not disadvantaged. He fails to answer our question about salary discrepancies of Bangladeshi staff in violation of the ICDDR,B Ordinance. There is also no response from Sack about Bangladeshi scientists receiving research grants from project fund only, while foreign scientists receiving the grants from a special fund. Instead, he tries to play on emotion by saying how thousands of Bangladeshi workers are working day and night. This is precisely our point. When Bangladeshis are working so hard, day and night, then why pay them a discriminatory salary?
In Paragraph 6, the Executive Director makes general comments about the openness in recruitment policy. In our report we made two specific allegations. Firstly, appointment of the Human Resources Director, who was head of after school extracurricular activities at an international school prior to joining the post. Secondly, we raised questions about the appointment of former auditor of the centre as a Finance Director. This is clearly a case of conflict of interest. Questions naturally arise when an auditor is offered a job in the same organisation whose financial propriety he is supposed to be investigating.
The Executive Director clearly avoids answering these two specific issues.
In Paragraph 7 he mentions about the cholera vaccine, experiment of which was conducted in Matlab, being available in Mozambique and many other countries. This is precisely the point we made in our article. The vaccine for which our people were experimented upon, is now licensed in Europe and sold in many other countries except ours. We did not even know about these experimental developments. Is it fair that Bangladeshi people should not benefit from a medicine, in the discovery of which we were experimented upon?
In conclusion we reiterate the fact that we made allegations or discrepancies in salaries, discrepancies in fund allocation for research, recruitment and management but Sack has failed to address any of the questions raised.
A Mushtaque Chowdhury's letter and reply
We also received a letter from A Mushtaque R Chowdhury, Dean of James P Grant School of Public Health, who denied having told The Daily Star correspondent that BRAC was planning to take over the International Training Division of the ICDDR,B. He said that he was misunderstood by the correspondent. The BRAC School of Public Health is a joint collaboration between BRAC and ICDDR,B. At the moment the BRAC school students spend half of the time at ICDDR,B utilising their facilities including the library, classrooms, laboratories, filed sites and more importantly the researchers most of whom also teach at the school.
Our reply: We are further investigating this point, and reserve our response at this point.
Terrence H Hull's letter and our reply
Terrence H Hull, the Chair Board of Trustees, ICDDR,B in a letter claims, "The Board is responsible for reviewing senior appointments made at ICDDR,B and can affirm that there are no anomalies in the appointment procedures or selections as asserted by our article. Those assertions contained neither evidence nor attribution to a source that could have possibly had any knowledge of the matter..."
Our reply: Like Sack, Terrence H Hull also gives a general reply and does not answer the point we raised about two specific senior level appointments, which should have been reviewed by the Board of Trustees. We specifically ask Hull, "did the Board review the appointment of the Human Resources Director? What qualified a former instructor of after school program of an international school to qualify for such a senior post? As for the director finance, doesn't the Chair of the Trustee Board find anything curious in the appointment of an auditor during an audit, as its finance director?"
Our readers would be well served and we may even stand corrected if the Chair of the Board of Trustees is so kind enough to let us know how the Board discharged responsibilities in appointing these two directors. For the sake of transparency and accountability, we will welcome any information by the Chair other than affirmation that "....that there are no anomalies in the appointment procedures or selections as asserted by our article."
Monitoring the disease trends, health care behavior and quality of care of an Adolescent Health Initiative (ARHI) by NGO in rural Bangladesh
Brief description of your proposed Master thesis: Dr. S. M. Shamim ul Moula
Monitoring the disease trends, health care behavior and quality of care of an Adolescent Health Initiative (ARHI) by NGO in rural Bangladesh
A. Introduction:
“Solidarity”, a local NGO of Kurigram District, Bangladesh has been implementing a project titled “Adolescent Reproductive Health Initiative (ARHI)” sponsored by Save the Children Fund UK and EC/UNFPA since August 2000. “Solidarity” contracted Chiinamukul Bangladesh (-CB1, the partner of Terre Des Hommes, Lausanne, Switzerland, a leading NGO of northern Bangladesh with HQ in Kurigram, working mainly on Health and Nutrition intensively in the community and institutional levels since 1975) for clinical and technical components of the project mainly for service delivery as CB has been operating considerable number of institutional and satellite service delivery centers (clinics) equipped with manpower and logistics since deades.
As per the contract, CB has been engaged in the project for i) management of male and female adolescents suffering from reproductive diseases ii) relevant expert level counseling for reproductive health anomalies referred by ““Solidarity”” from the community where “Solidarity” has been working for mainly community mobilization and awareness development component for the mentioned project.
CB commissioned the service in its Kurigram Mother and Child Health Center (KMCHC) and maintained relevant records for each adolescent patient with monthly reporting to “Solidarity” in the context.
Ideas and traces about health care behavior of adolescents in reproductive disease, reproductive disease trends in adolescent in (northern) Bangladesh, monitoring the quality of the treatment offered in context of Bangladesh, evaluating the outcome and impact for the management with follow up elements (that contained in the CB operating component of the project of ARHI sponsored by Save The Children UK) can be a mater of interest for a researcher in Reproductive Health.
The outcomes with the lessons learnts of the mentioned research can contribute significantly in the future interventions (more specifically to the monitoring and evaluation components of those) to manage the adolescent reproductive ailments in Bangladesh
B. Research Question
i) Psycho-social: How, when and why the adolescents seek health care in Reproductive Diseases (RD) in the rural context of Bangladesh? What is their health care behavior? What is their idea about “forbidden” RD in their conservative society, where people usually hesitate or discouraged to speak about
“sexuality” or reproductive health care and that is much truer for the adolescents, as in general their “talk” in the issue regarded as a punishable offence! What are the major constraints to seek health care for adolescent RD in the community? Are they started to open themselves to have proper managements for their reproductive anomalies? Do they have enough knowledge in the issue? What is (are) their source of “sexual” or reproductive knowledge what they contain? What is their experience in the society after being exposed to the (CB) hospital for RD? What is their own perception of the endeavors made by the NGOs to open them, acknowledge them and aware them in the Adolescent Reproductive issue? Did that do any “good” to them? Are they satisfied with the management offered in CB clinics for RD and what are their expectations? What is their satisfaction level in CB management of their reproductive ailments? And many more..................
ii) Medico-social: What was/is the adolescent RD trends in (northern) Bangladesh? How it is dealt/managed in the community usually in the rural Bangladesh and what management CB offered for them for the particular disease? What is the quality of care of CB offered services in comparison to the standardized management for the particular RD? How was/is the quality of care in the community component by “Solidarity” for adolescent RD? What was the service providers’ satisfaction level by managing adolescents for their RD?
What is service providers’ perception about the adolescent service seekers for their offered services? Did the service seekers think that a considerable percentage of adolescent service seekers have some type of “psycho-somatic” problems rather than any typical disease? And many more…………
iii) Monitoring , evaluation and impact analysis:
Was there any baseline or follow-up prior to the intervention?
Was the quality of service to the adolescents for their RD by CB and “Solidarity” monitored? If yes, then how? Was it internal or external? What were the tools and mechanisms for that and how effective those were? Who were involved with that monitoring process? What was their quality for the task? Review and rate the methodology of the conducted monitoring if any. Analysis of the conducted monitoring procedures if any.
If no, then what was/is the impact of that on the intervention?
Compilation of the appropriate tools for monitoring for the CB/”Solidarity” project those could fit with the intervention.
Was there any evaluation for the project? What type, internal or external? Midterm or final?
If yes, what were the tools? ? Review and rate the methodology of the evaluation if any.
If no, how it could be designed? What methodology would be better and effective?
Impact analysis in the community and among the service seekers (adolescents) and service providers (CB and “Soliderity”).
C. General Objective
To have knowledge to design effective adolescent reproductive health interventions in Bangladesh (specially in rural context), to explore and generate most effective tools for essential monitoring and evaluation of such projects for expected successes.
To track the adolescent reproductive and general health care behavior in (this part of) Bangladesh to design appropriate intervention program in future to address adolescent reproductive health ailments. To assess the outcome of the awareness building program among the adolescents and its impact in the community for use in the future for designing successful project/intervention. To assess the effectiveness, success and constraints of an ARHI project in the community and evaluation and monitoring of particular cases in an ARHI project to see the quality of care offered in comparison to the standard practice in Bangladesh with tracking the follow up process. Also the adolescent Reproductive Disease trend will be monitored and assessed for future use in the program designing and service seekers and providers’ satisfaction in the context will be documented for same reason.
Specific Objective
i) To see the Adolescent Reproductive Disease trends in (the part) of Bangladesh
ii) To monitor and evaluate the quality of care made available for Adolescent Reproductive Disease or anomalies in the “Solidarity”/CB ARHI project
iii) To track the health care behavior of the adolescents for their Reproductive Health anomalies
iv) To document the service seekers and providers satisfactions for the offered services in the ARHI
v) Investigating monitoring and evaluation processes and associated tools.
v) To see the impact of the ARHI in the community and the outcome of the awareness building process by the project
D. Literature Review minimum 1/2 page at least 5 article related with your subject
(Apa, I could not manage it till date, can any body help?)
E. Research Methodology
i) Study Design
The study will consist of a number of sub studies and those will be conducted through a number of surveys as follows:
a) Monitoring cases of adolescent reproductive diseases in CB KMCHC:
Cases that are recorded in the CB Kurigram Mother and Child Care Center register will be tracked, analyzed for quality of care offered and for the understanding of disease trends.
b) Monitoring particular cases of adolescent reproductive diseases in CB KMCHC:
A number of cases from CB Kurigram Mother and Child Care Center register will be tracked and analyzed for quality of care offered including that of the diagnosis, prescription and other advises.
c) Tracking adolescent reproductive service seekers KAP and comparison with a “control group”:
At least 30 adolescent patients will be identified from CB Kurigram Mother and Child Care Center register and will be interviewed for their health seeking behavior. They will also be checked for their satisfaction in the care offered by CB and ““Solidarity”” and they will be investigated for their perception of social impact for their health care seeking for reproductive anomalies. They will be carefully screened for their own feelings in the issue of seeking health care for reproductive health by the adolescents (themselves) that are normally “forbidden” in the society. Careful examination of their conceptual changes will be investigated changes. Endeavor will be made for tracking their KAP level and to compare it with a “control group”.
d) Tracking the service providers’ satisfaction and “lessons learnt:
For this, a total number of 10 service providers will be interviewed. Among them, 5 from each of the 2 groups, namely clinical service providers and non-clinical service providers for their perception of the adolescent health anomalies and their attitudes, social impacts and their satisfaction in rendering the service to adolescents. Endeavor will also be made for track their “lesson learnt” for providing the reproductive health services to the adolescents.
e) Tracking the social impacts/reaction in the community for the adolescent reproductive health initiative:
For the component, a total of 10 social elite will be interviewed to track their response to ARHI.
f) Examining the records for exploring monitoring and evaluation elements if any:
Interviews with “Solidarity” and CB officials, reviewing data and documents available.
g) Observation: Observation/case study.
ii) Study Population
Number of adolescents served by the project
iii) Place of Study
Place of the study will be in the district of Kurigram, Bangladesh where NGO “Solidarity” and CB have been engaged in the EC/UNFPA sponsored Adolescent Reproductive Health Initiative (ARHI) through Save the Children Fund, UK.
iv) Sampling techniques for the surveys:
a) Monitoring cases of adolescent reproductive diseases in CB KMCHC:
All the cases recorded in CB Kurigram Mother and Child Care Center register will be taken as sample.
b) Monitoring particular cases of adolescent reproductive diseases in CB KMCHC:
Systematic Random Sampling technique will be adopted for drawing the samples from each disease category for analyzing for quality of care offered including that of the diagnosis, prescription and other advises.
c) Tracking adolescent reproductive service seekers KAP and comparison with a “control group”:
Systematic Random Sampling technique will be adopted for drawing at least 30 Samples from CB Kurigram Mother and Child Care Center register for interviewing for their health seeking behavior.
d) Tracking the service providers’ satisfaction and “lessons learnt/recommendations:
Purposive sampling technique will be adopted for to draw a total number of 10 samples among the service providers for interviewing. Among them, 5 from each of the 2 groups, namely clinical service providers
(CB) and non-clinical service providers (“Solidarity”).
e) Tracking the social impacts/reaction in the community for the adolescent reproductive health initiative:
For the component, purposive sampling technique will be adopted to draw a total sample of 10 among social elite for interviewing to track their response to ARHI.
v) Sample size:
In fact, this composite study contains a number of studies containing different number of samples as follows:
Study Sample category Proposed number for interviewing
Monitoring disease trends Adolescent reproductive patient All patients recorded in CB
Monitoring quality of care Adolescent reproductive patient 15 (5 patients in each respondent category for 3 diseases)
Service seekers KAP i) Adolescent reproductive patient in CB
ii) Adolescents of “control group” i) 30ii) 30
Service Providers’ perception/interview i) Clinicians of CB
ii) Non clinical service providers from “Solidarity” 10 (CB-5+”Solidarity”-5)
Perception of social elites on ARHI Local elites 10
vi) Analysis plan/presentation of findings
Survey data of the study will be analyzed keeping in view the need and direction of the study objectives. Analytical Strategies will be chosen in such a way so that all possible requirements needed to address each objective in an optimum position can be met.
Separate analyses will be carried out for all sub studies in the study. These analysis have been carried out with the help of uni-variate and bi-variate tables, and if necessary with graphic presentation.
F. Outcome of the research study:
Useful secondary data will be revealed for future use to design and implement similar project.
Useful monitoring and evaluation tools can be generated for use in future projects of similar nature.
Constraints/limitations for similar projects/interventions can be assessed.
Idea about cost, logistics and technical inputs for the similar projects can be perceived.
Expertise can be developed in similar project.
Future research questions can be drawn out.
G. Conclusion
As the study has been designed with effective knowledge of research, it has got the better scope for success. If it is successfully implemented, it will serve the purpose of the researcher yielding the different objective oriented outcomes for a noble academic purpose.
The study can reveal the utmost need for a appropriate monitoring and evaluation system for a (reproductive) health project for its final success and can unveil the problems those can be en countered in absence of such a appropriate M&E system.
Monitoring the disease trends, health care behavior and quality of care of an Adolescent Health Initiative (ARHI) by NGO in rural Bangladesh
A. Introduction:
“Solidarity”, a local NGO of Kurigram District, Bangladesh has been implementing a project titled “Adolescent Reproductive Health Initiative (ARHI)” sponsored by Save the Children Fund UK and EC/UNFPA since August 2000. “Solidarity” contracted Chiinamukul Bangladesh (-CB1, the partner of Terre Des Hommes, Lausanne, Switzerland, a leading NGO of northern Bangladesh with HQ in Kurigram, working mainly on Health and Nutrition intensively in the community and institutional levels since 1975) for clinical and technical components of the project mainly for service delivery as CB has been operating considerable number of institutional and satellite service delivery centers (clinics) equipped with manpower and logistics since deades.
As per the contract, CB has been engaged in the project for i) management of male and female adolescents suffering from reproductive diseases ii) relevant expert level counseling for reproductive health anomalies referred by ““Solidarity”” from the community where “Solidarity” has been working for mainly community mobilization and awareness development component for the mentioned project.
CB commissioned the service in its Kurigram Mother and Child Health Center (KMCHC) and maintained relevant records for each adolescent patient with monthly reporting to “Solidarity” in the context.
Ideas and traces about health care behavior of adolescents in reproductive disease, reproductive disease trends in adolescent in (northern) Bangladesh, monitoring the quality of the treatment offered in context of Bangladesh, evaluating the outcome and impact for the management with follow up elements (that contained in the CB operating component of the project of ARHI sponsored by Save The Children UK) can be a mater of interest for a researcher in Reproductive Health.
The outcomes with the lessons learnts of the mentioned research can contribute significantly in the future interventions (more specifically to the monitoring and evaluation components of those) to manage the adolescent reproductive ailments in Bangladesh
B. Research Question
i) Psycho-social: How, when and why the adolescents seek health care in Reproductive Diseases (RD) in the rural context of Bangladesh? What is their health care behavior? What is their idea about “forbidden” RD in their conservative society, where people usually hesitate or discouraged to speak about
“sexuality” or reproductive health care and that is much truer for the adolescents, as in general their “talk” in the issue regarded as a punishable offence! What are the major constraints to seek health care for adolescent RD in the community? Are they started to open themselves to have proper managements for their reproductive anomalies? Do they have enough knowledge in the issue? What is (are) their source of “sexual” or reproductive knowledge what they contain? What is their experience in the society after being exposed to the (CB) hospital for RD? What is their own perception of the endeavors made by the NGOs to open them, acknowledge them and aware them in the Adolescent Reproductive issue? Did that do any “good” to them? Are they satisfied with the management offered in CB clinics for RD and what are their expectations? What is their satisfaction level in CB management of their reproductive ailments? And many more..................
ii) Medico-social: What was/is the adolescent RD trends in (northern) Bangladesh? How it is dealt/managed in the community usually in the rural Bangladesh and what management CB offered for them for the particular disease? What is the quality of care of CB offered services in comparison to the standardized management for the particular RD? How was/is the quality of care in the community component by “Solidarity” for adolescent RD? What was the service providers’ satisfaction level by managing adolescents for their RD?
What is service providers’ perception about the adolescent service seekers for their offered services? Did the service seekers think that a considerable percentage of adolescent service seekers have some type of “psycho-somatic” problems rather than any typical disease? And many more…………
iii) Monitoring , evaluation and impact analysis:
Was there any baseline or follow-up prior to the intervention?
Was the quality of service to the adolescents for their RD by CB and “Solidarity” monitored? If yes, then how? Was it internal or external? What were the tools and mechanisms for that and how effective those were? Who were involved with that monitoring process? What was their quality for the task? Review and rate the methodology of the conducted monitoring if any. Analysis of the conducted monitoring procedures if any.
If no, then what was/is the impact of that on the intervention?
Compilation of the appropriate tools for monitoring for the CB/”Solidarity” project those could fit with the intervention.
Was there any evaluation for the project? What type, internal or external? Midterm or final?
If yes, what were the tools? ? Review and rate the methodology of the evaluation if any.
If no, how it could be designed? What methodology would be better and effective?
Impact analysis in the community and among the service seekers (adolescents) and service providers (CB and “Soliderity”).
C. General Objective
To have knowledge to design effective adolescent reproductive health interventions in Bangladesh (specially in rural context), to explore and generate most effective tools for essential monitoring and evaluation of such projects for expected successes.
To track the adolescent reproductive and general health care behavior in (this part of) Bangladesh to design appropriate intervention program in future to address adolescent reproductive health ailments. To assess the outcome of the awareness building program among the adolescents and its impact in the community for use in the future for designing successful project/intervention. To assess the effectiveness, success and constraints of an ARHI project in the community and evaluation and monitoring of particular cases in an ARHI project to see the quality of care offered in comparison to the standard practice in Bangladesh with tracking the follow up process. Also the adolescent Reproductive Disease trend will be monitored and assessed for future use in the program designing and service seekers and providers’ satisfaction in the context will be documented for same reason.
Specific Objective
i) To see the Adolescent Reproductive Disease trends in (the part) of Bangladesh
ii) To monitor and evaluate the quality of care made available for Adolescent Reproductive Disease or anomalies in the “Solidarity”/CB ARHI project
iii) To track the health care behavior of the adolescents for their Reproductive Health anomalies
iv) To document the service seekers and providers satisfactions for the offered services in the ARHI
v) Investigating monitoring and evaluation processes and associated tools.
v) To see the impact of the ARHI in the community and the outcome of the awareness building process by the project
D. Literature Review minimum 1/2 page at least 5 article related with your subject
(Apa, I could not manage it till date, can any body help?)
E. Research Methodology
i) Study Design
The study will consist of a number of sub studies and those will be conducted through a number of surveys as follows:
a) Monitoring cases of adolescent reproductive diseases in CB KMCHC:
Cases that are recorded in the CB Kurigram Mother and Child Care Center register will be tracked, analyzed for quality of care offered and for the understanding of disease trends.
b) Monitoring particular cases of adolescent reproductive diseases in CB KMCHC:
A number of cases from CB Kurigram Mother and Child Care Center register will be tracked and analyzed for quality of care offered including that of the diagnosis, prescription and other advises.
c) Tracking adolescent reproductive service seekers KAP and comparison with a “control group”:
At least 30 adolescent patients will be identified from CB Kurigram Mother and Child Care Center register and will be interviewed for their health seeking behavior. They will also be checked for their satisfaction in the care offered by CB and ““Solidarity”” and they will be investigated for their perception of social impact for their health care seeking for reproductive anomalies. They will be carefully screened for their own feelings in the issue of seeking health care for reproductive health by the adolescents (themselves) that are normally “forbidden” in the society. Careful examination of their conceptual changes will be investigated changes. Endeavor will be made for tracking their KAP level and to compare it with a “control group”.
d) Tracking the service providers’ satisfaction and “lessons learnt:
For this, a total number of 10 service providers will be interviewed. Among them, 5 from each of the 2 groups, namely clinical service providers and non-clinical service providers for their perception of the adolescent health anomalies and their attitudes, social impacts and their satisfaction in rendering the service to adolescents. Endeavor will also be made for track their “lesson learnt” for providing the reproductive health services to the adolescents.
e) Tracking the social impacts/reaction in the community for the adolescent reproductive health initiative:
For the component, a total of 10 social elite will be interviewed to track their response to ARHI.
f) Examining the records for exploring monitoring and evaluation elements if any:
Interviews with “Solidarity” and CB officials, reviewing data and documents available.
g) Observation: Observation/case study.
ii) Study Population
Number of adolescents served by the project
iii) Place of Study
Place of the study will be in the district of Kurigram, Bangladesh where NGO “Solidarity” and CB have been engaged in the EC/UNFPA sponsored Adolescent Reproductive Health Initiative (ARHI) through Save the Children Fund, UK.
iv) Sampling techniques for the surveys:
a) Monitoring cases of adolescent reproductive diseases in CB KMCHC:
All the cases recorded in CB Kurigram Mother and Child Care Center register will be taken as sample.
b) Monitoring particular cases of adolescent reproductive diseases in CB KMCHC:
Systematic Random Sampling technique will be adopted for drawing the samples from each disease category for analyzing for quality of care offered including that of the diagnosis, prescription and other advises.
c) Tracking adolescent reproductive service seekers KAP and comparison with a “control group”:
Systematic Random Sampling technique will be adopted for drawing at least 30 Samples from CB Kurigram Mother and Child Care Center register for interviewing for their health seeking behavior.
d) Tracking the service providers’ satisfaction and “lessons learnt/recommendations:
Purposive sampling technique will be adopted for to draw a total number of 10 samples among the service providers for interviewing. Among them, 5 from each of the 2 groups, namely clinical service providers
(CB) and non-clinical service providers (“Solidarity”).
e) Tracking the social impacts/reaction in the community for the adolescent reproductive health initiative:
For the component, purposive sampling technique will be adopted to draw a total sample of 10 among social elite for interviewing to track their response to ARHI.
v) Sample size:
In fact, this composite study contains a number of studies containing different number of samples as follows:
Study Sample category Proposed number for interviewing
Monitoring disease trends Adolescent reproductive patient All patients recorded in CB
Monitoring quality of care Adolescent reproductive patient 15 (5 patients in each respondent category for 3 diseases)
Service seekers KAP i) Adolescent reproductive patient in CB
ii) Adolescents of “control group” i) 30ii) 30
Service Providers’ perception/interview i) Clinicians of CB
ii) Non clinical service providers from “Solidarity” 10 (CB-5+”Solidarity”-5)
Perception of social elites on ARHI Local elites 10
vi) Analysis plan/presentation of findings
Survey data of the study will be analyzed keeping in view the need and direction of the study objectives. Analytical Strategies will be chosen in such a way so that all possible requirements needed to address each objective in an optimum position can be met.
Separate analyses will be carried out for all sub studies in the study. These analysis have been carried out with the help of uni-variate and bi-variate tables, and if necessary with graphic presentation.
F. Outcome of the research study:
Useful secondary data will be revealed for future use to design and implement similar project.
Useful monitoring and evaluation tools can be generated for use in future projects of similar nature.
Constraints/limitations for similar projects/interventions can be assessed.
Idea about cost, logistics and technical inputs for the similar projects can be perceived.
Expertise can be developed in similar project.
Future research questions can be drawn out.
G. Conclusion
As the study has been designed with effective knowledge of research, it has got the better scope for success. If it is successfully implemented, it will serve the purpose of the researcher yielding the different objective oriented outcomes for a noble academic purpose.
The study can reveal the utmost need for a appropriate monitoring and evaluation system for a (reproductive) health project for its final success and can unveil the problems those can be en countered in absence of such a appropriate M&E system.
PROJECT PTOPOSAL: PILOTING ON COMMUNITY BASED PARTICIPATORY DRUG DE-ADDICTION AND HIV HARM REDUCTION PROGRAM
PILOTING ON COMMUNITY BASED PARTICIPATORY DRUG
DE-ADDICTION AND HIV HARM REDUCTION PROGRAM
CAPTER-1: INTRODUCTION
A. History:
As with other South Asian nations Bangladesh has a long history of illicit drug use, particularly of opium and cannabis. Before 1948, Bangladesh was a part of an undivided India and therefore much of its history mirrors eastern India, particularly Bengal. From the time of British colonisation until 1984 it was possible to purchase opium from government controlled vendors (Ray 1998). Cannabis has been widely used in Bangladesh society for many years and was often not perceived as a drug of abuse (Kabir 1998). In the late 1970s consumption of opium was strictly restricted and the scheme of compulsory registration identified about 1,600 chronic opium addicts (Spencer and Navaratnam 1981). Since 1987 production of cannabis has been banned and most is now smuggled across the Indian border (Hossain 2000). Until the mid 1980s the drugs of use, among the young, were cannabis, local wine and prescribed tablets (Mandrax and Prodrom). Heroin, generally called brown sugar, did not appear until the mid to late 1980s. It had low potency and became the drug of choice (Ray 1998) among the lower socio-economic sector and some students (Kabir 1998). In 1991, the majority of drug users in treatment indicated heroin as their drug of choice, followed by pethidine. At this time the level of education and affluence tended to influence drug-taking practices; 15% of the poor injected compared to 42% of the more affluent (Gibney 1999). At the same time as heroin addiction increased, a shortage in supplies emerged as a result of law enforcement activities. As a result drug users turned to the pharmaceutical buprenorphine from India (Habib 2000, Hossaine 2000). The emerging popularity of buprenorphine (commonly know as Tidegesic) stems from its cheapness, availability, longevity of effect and as a result of some pharmacies promoting the drug as a way of treating heroin addiction (Kabir 1998). By the mid 1990s individuals dependent on buprenorphine started to appear in treatment centres (Ray 1998).
B. Current situation:
Bangladesh is surrounded by one of the largest drug producing regions in the world. While it is not a significant producer of narcotics, opium cultivation near the Myanmar border, albeit small, has been detected in some districts. In 1999, 90 acres of poppy fields were destroyed by the army (Narcotics 2001, Henry 1999) and 28 kilograms of heroin and 2.3 metric tons of cannabis were seized. The drug Phensidyl (a cough syrup containing codeine) has become increasingly popular among drug users. In 2000, 140,000 bottles were seized by law enforcement officials (International 2000). Phensidyl is readily available and remains the most visible illicit drug: it requires no prescription and is easily accessed by many illegal traders in various parts of the country (Habib 2001).
In 1996, a Rapid Situation Assessment (RSA) of the drug use in three major cities (Dhaka, Rajshahi and Chittagong) was conducted; 1,750 participants were selected at random. The results of this survey reported the most commonly used drugs in descending order were cannabis, cough syrup (codeine based), sedatives and heroin. For those surveyed in treatment centres the most commonly used drugs in descending order were heroin, codeine, cough syrup, buprenorphine, cannabis and sedatives (Ray 1998). Among all the participants the life time use of selected drugs show cannabis at 25.8%; cough syrup at 11.3% with heroin and buprenorphine, 2.9% and 0.5% respectively (Ray 1998). However, a recent study in Dhaka showed buprenorphine as the most commonly used drug among users (70%) (Mallick and Gomes 2000). It is widely agreed among experts that there is increasing evidence of the widespread use and availability of illicit drugs (Ahmed 1999; Habib 2001; Ray 1998; Hossain and Ahmed 1999; Malibubur 1999).
In the northern part of the country, drug use, including injecting, has been reported in the cities of Coxes Bazar, Chittagong, Jessore, Khuna, Rajshahi and Chapainawabganj and drug use is common in several areas of the capital, Dhaka (Jenkins 1999a; Begg 1999). While drug use is mainly confined to the urban centres it has also been reported in several rural areas and villages (Ray 1998; Jenkins 1999a).
In 1998, a study was undertaken to assess the vulnerability of an estimated 200,000 street children (aged between 5- 14 years) living in the metropolitan area of Dhaka.
While the study found many of the children were the victims of exploitation, harassment and abuse (including sexual) it also found that some were addicted to injectable drugs and other substances. Awareness on HIV/AIDS issues was reported to be poor among this group (Milky 1999).
C. Drug taking practices and risk factors:
While the most popular routes for taking drugs is reported as ingesting or inhalation (Malibubur 1999) injecting does appear to be gaining popularity (Hossaine and Ahmed 1999). The injecting of drugs is believed to have commenced in 1990 (Hossaine 2000) and data recorded in treatment centres reports an increase in the rate of injecting from 6% in 1993 to 17% in 1995 (Ray 1998). The time frame from using different types of drugs before switching over to injectables ranges from six to fifteen years (Jenkins 1999a; Mallick and Gomes 2000). In 1996, a study in Rajshahi reported the injecting of sedatives as widespread (78%), followed by buprenorphine (21%) (Habib 2001). The behavioural surveillance study of 1998-99 showed that for those who injected, the drug of choice was buprenorphine which was frequently mixed in a cocktail of substances including diazepam, promethazine hydrochloride and chlorpheniramine. A recent study also reported that 29% of participants injected a cocktail of drugs (Hussaine, 2000; Mallick and Gomes 2000). Heroin was used by only 2% of participants, and was usually dissolved in lemon juice before injecting (Hussaine, 2000). One study shows that 90% of all injectors had once smoked heroin (Begg 1999).
Reports of drawing up blood in the syringe in order to dilute the drug and front or back loading (moving the drug from one syringe to another) occurs, even though in small numbers (<10%) (Jenkins 2001, Mallick and Gomes 2000). In 2000, a study in Dhaka reported the average number of injections per day was two and the sites of injecting varied; 26% injected into the vein, 56% into muscle and the rest (18%) used both the vein and the muscle (Mallick and Gomes 2000). Another earlier study reported that 59% always injected into the vein (Jenkins 1999b).
In the city of Rajshani most IDUs used the services of a professional injector in an adda: an adda is a place where IDUs gather to inject and where the drugs and the professional injector can be found. While the same practice is likely to occur in Dhaka it is not as common (Hussaine 2000; Jenkins 1999b) It has been suggested the professional injectors are able to maintain business through a good supply of drugs, connections to wholesalers and by providing the injecting services. In 1999, in Rajshani an estimated 50 adda injectors operated and there were an estimated 94 addas in the city. These facilities are often located in disused buildings and lane ways but some also operate in hotel rooms (Hossaine 2000). For a small additional cost, people can ask to be injected at their homes. In one study it was reported up to 90 persons a day used a single adda injector, often for multiple injections. Being an adda injector was not exclusively the domain of men as several women had also become involved (Jenkins 1999a).
Reports suggest an adda injector will use the same needle for 20-50 people and that it is not unusual for it to be used for 2-3 days. (SHEAS, 1996). Studies in the late 1990s reported widespread sharing of needles among all IDUs (60% - 90%) and that professional injectors did not sterilise their needles and syringes (Hossaine 2000; Begg 1999; Ashaful 1999). The sharing of injecting equipment has also been documented among street children (Gibney 1999). Among professional injectors it has been observed that a needle is only changed when it becomes blunt and glass syringes are rarely changed or discarded (Hossaine 2000). New needles add an expense that few poor IDUs can afford thus explaining the reasons for the widespread sharing (Jenkins 1999a) and why some people have been known to use syringes rejected by hospitals (SHEAS 1996). It costs an average of three Taka (US$0.05) to buy a disposable syringe and needle. There are regulations in place requiring a prescription to buy such equipment but this is often ignored. It is not difficult to find a needle and syringe in most parts of the country (P.S. Mallick personal communication 2001). Cleaning of needles by those who shared their needles is nearly always inadequate. Some methods included using cotton or paper to clean the needle or using distilled water (Mallick and Gomes 2000). Some IDUs used saliva to clean their needles believing this would destroy any poisons found in the blood (SHEAS 1996).
The establishment of needle and syringe programs (NSP) from May 1998 has shown some behavioural changes. Results from a recent study between two surveys show the overall sharing of needles in Dhaka appears to have been reduced from 93% to 75% of people ever sharing in the last week. In Rajshahi the reduction is from 96% to 55% (Jenkins 2001). The government recognises that NSP clearly impacts on the proportion of injections shared (Government of Bangladesh 2001).
D. Prevalence and profile:
The number of drug users has been estimated to be between 100,000 to 1.7 million (Ray 1998; Rhaman 2000; Narcotics 2001; WHO 2001). In the early 1990s it was estimated that there were 100,000 heroin users in the country but this figure is likely to have lessened as buprenorphine has become the favoured drug (Hossaine 2000). It has been estimated there could be 20,000 to 25,000 IDUs in the country (Hossaine 2000; Jenkins 1999a; Wodak 2001). In the capital Dhaka, reports suggest there are 7,650 injectors and at least 11,000 heroin users (Begg 1999). In northern Bangladesh there are an estimated 12,000 to 15,000 injectors, most of whom are found in the cities of Rajshahi and Chapainwabganj (Jenkins 1999b). However, these figures are disputed by others: a Rapid Situation Assessment (RSA) in 2000 found there was no more than 2,000 IDUs in Rajshahi and 1,000 IDUs in Chapainawabgonj (Mallick and Rabbani 2000).
The majority of drug users, and those who inject, are reported to be male with less than 2.5% females (Government of Bangladesh 2001; Hossaine 2000; Begg 1999). The number of female drug users could be greater but reaching out to this sector of the community is difficult when most are very hesitant to identify themselves as IDUs (Begg 1999). One outreach program in Dhaka has contact with about 40 female IDUs most of whom are also sex workers (Begg and Nizam 1999). In one southern city a survey found 14% of street female sex workers injected drugs and in the brothels 6% stated they were IDUs. Among male IDUs a high proportion paid for sex. A survey in various cities has shown that half to three-quarters of male injectors paid for sex and close to one in ten bought sex from men or transvestites; less than 25% used a condom the last time they paid for sex (MAP 2001).
In 1986, HIV was first detected in a foreign drug trafficker and in 1989 the first case of HIV in a citizen of Bangladesh was recorded (Gibney 1999; Hussaine 2000). While the HIV prevalence levels have remained relatively low there has been a sizeable increase since 1989 (Gibney 1999). As of December 2000 the total number of HIV/AIDS cases was 157 (127 males, 30 females). Between December 1999 and December 2000 the number of identified HIV infections was 31 cases, the highest number in a single year. A breakdown of the transmission route is not available but it is likely the majority are sexually acquired (Department of Virology 2001). In 1999 an estimated 7,500 adults and children lived with HIV infection (UNAIDS 2000) but in 2000 this increased to 13,000 (WHO 2001). It has been calculated that the annual number of AIDS cases was 1,100 in 2000 which will rise to 1,700 by 2005 (WHO 2001). A sero-surveillance of 1998-1999 reported that among IDUs coming into detoxification centres, 2.5% were found to be HIV positive and among the 880 surveyed the rate of needle and syringe sharing was about 90% (Hussaine 2000).
A follow up survey for the second national expanded HIV surveillance in mid 2000 reported that of the 418 participants from a central NSP, 6 people (1.4%) were found to be HIV positive (Government of Bangladesh 2001). The low levels of HIV infection in the two rounds of surveillance have yet to be fully explained considering widespread sharing of needles was still occurring. Studies have shown that Hepatitis C can be found in 25% of IDUs: this was associated with the sharing of needles and the longer duration of drug injecting (Shirin 2000). Surveys conducted on IDUs have shown a wide age range (15 to 70 years) with the average age being 30 to 35 years (Mallick and Gomes 2000; Hossaine 2000, Hussaine 2000). Many have poor education and unskilled occupations, a substantial number are married, and the majority had previously been to jail, mostly for drug offences (Begg 1999; Jenkin 1999b; Hussaine 2000; Habib 2000) A recent study found most family members were aware of the users drug using behaviour (Habib 2001). Use of commercial sex workers, particularly among the unmarried, was fairly common and the use of condoms was generally very low; condoms are rarely a consideration and are seen as mainly for family planning (SHEAS 1996; Jenkins 1999b; Malibubur 1999; Ashaful 1999; Hussaine 2000; Mallick and Gomes 2000). Many sex workers were aware of colleagues having sex with drug users without condoms (Gibney 1999). A 1997 study showed 21% of IDUs donated their blood and many did so as a way to raise money (Jenkins 1999a). This is clearly a problem when none of the blood banks test the blood for HIV (Begg, 1999).
E. Government responses to illicit drug problems:
In the Narcotics Control Act, 1990, there is provision for the establishment of narcotic addiction treatment centres and when it is deemed treatment is necessary the person is directed to a competent physician or a treatment centre (Ray 1998). However, detoxification and rehabilitation programs are scarce in the country and few drug users have the resources to attend them. As occurs in most countries of the world recidivism is high for those receiving treatment. A 1998-99 study showed 90% of the participants who had made attempts to stop drug use had failed (Hussaine, 2000). It has been suggested that the drug prohibition laws enacted under the Narcotics Act of 1990 are not an effective strategy for harm reduction (Habib 2000). The government does not view drug addiction as a high priority issue and it is seen as a self-created problem (Hossain and Ahmed 1999). If a person is found in possession of heroin, cocaine and coca derivatives, and the quantity does not exceed 25 grams, imprisonment will not be less than two years and not exceed 10 years. If the quantity exceeds 25 grams the penalty can be the death sentence or life imprisonment. For possession of pethidine, morphine or tetrahyrocannabinol, if the quantity does not exceed 10 grams, imprisonment will be no less than two years and no more than 10 years. If the quantity exceeds this amount the penalty is a death sentence or life imprisonment. There are various A class narcotics which is where buprenorphine is likely to be classified. Being in possession of this drug is also likely to incur a severe penalty. The penalty is an imprisonment of not less than two years and no more than 15 years: the possession amount is not specified (Rahman 1990). There is usually no provision for arrested drug users to be sent to drug treatment centre. The only option appears to be prison (P.S Mallick, personal communication 2001).
The Department of Narcotics Control has recently initiated a community level of coordination to streamline the activities of the non-governmental organizations (NGOs) to strengthen existing and future drug prevention activities in the country (Ahmed 2001). There are four government de-addiction centres in the country with a total of 55 beds (Ray 1998).
The traditional approach to treating drug users is in the psychiatric units of hospitals. The shortage of beds results in few being able to receive treatment. Other problems include physicians being discouraged from offering their services to treatment centres because they can lose their seniority if they are not properly released by the Ministry of Health and placed under the Department of Narcotic Control (Hossain and Ahmed 1999).
The two models of treatment are the ashram model, run by non-medical social activists, and the medical hospital model run by medical professionals. Most drug users are serviced by government health care facilities and at the Dhaka centre people stay for four weeks. There is only one program designed to cater for female drug users (Hossain and Ahmed 1999) Only one government- run detoxification centre exists in Dhaka, which has 40 beds and charges a nominal fee (Begg 1999). Many drug users have tried various ways to stop their drug use and a study shows 68% had been in prison at least once. However, even here drug injecting occurs (Jenkins 2001).
F. Government response to drug use and HIV:
The government is aware of the link between HIV/AIDS and drug use as has been shown in the two sero-surveillance surveys. It has been acknowledge NSP can play a role in reducing the amount of needle sharing and impact upon HIV transmission.
However, there are reports of IDUs being arrested for carrying syringes and needles even though no ‘paraphernalia laws’ exist (Begg 1999; Hussaine 2000). Substitution therapy is currently not available. Information about HIV/AIDS which directly targets drug users is reported to be unavailable.
G. National AIDS policy:
The Ministry of Health and Family Welfare produced a National HIV/AIDS Policy which received approval by the cabinet in 1998. In the policy there is a special focus on IDU and approval of harm reduction as a useful strategy. However, the Ministry of Home Affairs, whose focus includes narcotic laws, does not approve of harm reduction believing such a policy cannot supersede the law of the land. As a result of these contradictions serious threats from the Narcotics Department and police have emerged with this policy. In recent times the Narcotics Department has indicated they acknowledge the existence of NSP and at this stage have tended to ignore the operations of such programs.
H. Non-government responses to drug use and HIV:
In 1999, the SHAKTI project CARE-Bangladesh (NGO) operated seven drop in centres in Dhaka, which are open six hours per day, six days per week and offer needles and basic primary health care for drug users (Begg 1999). A NSP has been set up at a professional injector site in Rajshahi, reaching approximately 10-20% of the local IDUs. In 1999, SHAKTI was estimated to have access to 3,500 IDUs; peer educators distributed two new syringes and six needles every other day, per person at their drop in centres (Jenkins 2001). About 90,000 needles and syringes per month are exchanged at the DIC with a reported high return (>80%) (Wodak 2001). As there is no incinerator in Bangladesh, there has been no other option for NGOs but to burn collected needles and syringes at the drop in centres in the open air (Begg 1999). CARE-Bangladesh also has programs in Rajshahi and in early 2001 they set up a program in Chapai Nawabgonj which reaches 200 IDUs. In this latest project they have trained five adda educators who are current drug users. Their role is to educate other IDUs and professional drug injectors on STD/HIV issues and to exchange old needles and syringes for new ones (CARE-Bangladesh 2001). It has been reported there are nine NGOs focused on drug demand reduction with a total of 190 beds between them for in-patient treatment (Ray 1998).
Estimated number of drug users : 100,000 - 1.7 million
Estimated number of IDUs : 20,000 - 25,000
Drugs used : cannabis, cough syrup, buprenorphine, sedatives, heroin, codeine
Drugs injected : sedatives, buprenorphine, heroin, drug cocktails
Estimated number of HIV infection : 2.5% of IDUs in detoxification centres among IDUs are HIV +
J. Life, the proposing NGO:
Like-mindedness and the urge to achieve a common goal aided by knowledge, skill and experience is that has given birth to NGO life. It is an organization committed to all out development of the society and its approach to development is a people oriented one. Life believes in an integrated approach, which included both humans and materials aspects of development. For any development effort to be meaningful it must integrated both human material components of development organically. In other words, our scope of activity encompasses the whole gamut of development issues obtaining in Bangladesh.
Our motto is to build self-confidence and capabilities in human races by development critical consciousness in them or other words, humanize them. We do not believe in relief or loan as an end in itself. Hence we are for building adequate human infrastructure as a prerequisite for introducing material imputes within any community. For the task, empowerment of community and person is the most desired intervention by “Safe Life”. Also community based solution is the dream as that will be the utmost sustainable development of a community or the person. Participatory methodology of development is the most important technique in which “Safe life” believes. The primary beneficiaries of the “Safe Life” development approaches are the most vulnerable sections of the rural and urban population especially the landless poor, children and women groups. It is a national organizational its jurisdiction of activities spread all over the country.
Life is a non-profit, voluntary non-Government organization working for the uplift of the people in Bangladesh since decades. Life’s main objective is to uplift the social condition of the poorest of the poor living mostly in rural areas as well as in the urban centers of Bangladesh. As because poverty is responsible from the social and natural environment conditioning the lives of the people Life include in its activities and ambitions program for developing the natural and social environment around the people habits. Achieving household food security, to ensure fundamental rights for the population accepted and ratified by the UN and Bangladesh constitution, structural poverty alleviation, community actions to stop drug abuse, harm reduction of the drug abuse, detoxification and rehabilitation of the drug abusers, health and nutrition including the issues relating HIV/AIDS, environmental protection and regeneration, improvement in women's status, increasing people's participation in the public institution, increasing people's capacity to gain and exercise democratic and human rights etc. are among the important mottos of the NGO Life.
In recent years, along with other interventions, Life is working on the drug abusers to refrain them from abusing drugs through mainly community based participatory awareness raising, advocacy and other holistic approaches. However, from the experiences of Life it is now evident that only the awareness program is not sufficient to restrict the massive damage of the community and persons made by the drug abuse and the dimension of the drug related program has be widened by establishing drug abuse detoxification and rehabilitation centers to intervene the already addict population, to save their lives and to stop any more propagation of the addiction by them.
I. OBJECTIVES:
The objectives of the program are as follows:
1. To establish a fellowship of recovering addicts living in a healthy atmosphere, helping fellow addicts and their families recover from addiction.
2. To disseminate knowledge of basic facts about drug abuse, addiction, the Twelve Steps Program of Narcotics Anonymous and the recovery process.
3. To provide an environment in which addicts review their lifestyle, develop healthy attitudes, demonstrate sobriety and form good habits in daily life and work.
4. To provide an environment in which addicts acquire sufficient skill training, education and other preparatory knowledge that will lead to constructive and gainful employment.
5. To enable recovering addicts to make a full and active positive contribution to family and society, living a happy drug free and crime free life, who are constructively and gainfully employed, motivating others to stay off drugs or to get off drugs. Special emphasis is on high-risk youngsters of the nearby slums.
6. To provide drug prevention, motivational and training assistance for young drug addicts and high-risk youngsters, especially those from poor and/or dysfunctional families.
7. To create awareness and educating the people about the ill effects of alcoholism and substance abuse on the individual, family and the society at large.
8. To evolve culture-specific models for the prevention of the alcoholism and substance and the treatment and rehabilitation of addicts.
9. To provide for the whole range of community based services for the identification, motivation, counseling, de-addiction, after care and rehabilitation of addicts.
10. To promote collective initiatives and self help endeavors among individuals and groups vulnerable to addiction are found at risk.
11. To establish appropriate linkage between Government interventions and voluntary efforts in the field of prohibition and substance abuse prevention.
12. To increase community participation and public co-operation in the reduction of demand for dependence-producing substances. Creating Awareness
J. Activities:
Life’s target group will be the poor and young addicts of the local area but people come for treatment from all over Bangladesh. Those who come to Life pay according to the family means; as a result many of those who come for assistance pay little or nothing. The activities of Life will cover all aspects of drug addiction treatment and after care rehabilitation for male addicts, including prevention and awareness activities. These activities can be grouped into the following main forms of service provision:
(i) Identification of addicts.
(ii) Awareness building
(iii) Motivational counseling
(iv) Preventive education
(v) Screening of abuses-addicts
(vi) Detoxification / De-addiction
(vii) Formation of Self Help Groups
(viii) Vocational rehabilitation
(ix) After care and re integration into the social main stream.
Program components:
I. Production and Dissemination of Educative and Publicity Material
a) Posters/Flash Cards/Flannel Charts/Flip Charts
b) Pamphlets/Brochures/Leaflets
c) Hoardings/Panels/Banners
d) Booklets/Periodicals etc.
II. Community Participation Programs
a) Corner meetings/Workshops/Conferences
b) Essay/Debate/Slogans/Drama/One Act Play Competitions
c) Pantomime Shows/Street Plays/Folk Media, etc.
III. Training Camps for Voluntary Workers
IV. Any Other Activity for Awareness building programme against drug/alcoholism
V. Residential Treatment/ Rehabilitation:
The principles of Narcotics Anonymous 12 Step Program form the basis of this program of treatment and rehabilitation/habilitation. The importance of structure, work production, exercise, prayer and relaxation is acknowledged and these are all essential elements in this holistic program.
VI. Awareness, Prevention, Demand and Harm Reduction:
This is comprised of:
i) A series of meetings that all Life residents participate in on a daily basis.
ii) The Children's Program that is focused on removing 'at-risk' children from potential drug abuse situations.
iii) An important educational service for addicts, their families and the general community.
iv) Aftercare and Halfway House with Skill Training and Income Generation: This incorporates a range of post rehabilitation meetings and also a strong support network (Life based) to assist with the continued recovery of the addict. Additionally the aftercare service provides participants with the option to obtain skill training and to contribute to the income generation of the program.
VII. Community Outreach Project: With the program, Life will operate community based participatory detoxification and de-addiction centers in the vulnerable most places of Bangladesh where no or less similar programs are available. In those areas, Life will contact and communicate with the local actors including Government, NGO and local elites. The community committees, local government members, local elites and cultural leaders will be involved in the establishment of the community detoxification and de-addiction centers (CDD), collection of the drug abusers and retaining them in the centers till detoxification, then to handover them to the their families for de-addiction processes and in need to transfer more resistant cases to the Life drug rehabilitation center in Dhaka for better management.
VIII. HIV/AIDS Awareness program:
The HIV/AIDS issues for drug addicts in Bangladesh are extremely pressing. The links between intravenous drug use, prostitution and unsafe sex are strong. Life is already in preliminary discussion with local NGOs regarding the possibility of collaborating on a project which targets this issue and the ever increasing 'at risk' population. This program will be existing as a cross cutting issue in all Life drug and substance abuse programs. The necessary components will be the screening, counseling and life skills for HIV/AIDS among the drug abusers and their families wherever necessary.
RISK AND PROTECTIVE FACTORS FOR YOUNG PEOPLE AND DRUGS
Level Risk factors Protective factors
Community Availability of drugs Cultures of cooperation
Poverty Stability and connectedness
Transitions and mobility in schooling and community Good relationship with an adult outside the family
Low neighborhood attachments and community disorganization Opportunities for meaningful contribution
School Detachment from school and poor relationships in school A sense of belonging and ‘fitting in’
Positive achievements and evaluations at school
Academic failure, especially in middle years
Early and persistent antisocial behavior and bullying Having someone outside your family who believes in you
Low parental interest in education
Attendance at pre-school
Family History of problematic alcohol and drug use A sense of connectedness to family
Inappropriate family management Feeling loved and respected
Family contact Proactive problem solving and minimal conflict during infancy
Alcohol/drugs interfere with family
Maintenance of family rituals Warm relationship with at least one parent
Harsh/coercive or inconsistent parenting Absence of divorce during adolescence
Marital instability or conflict
Favorable parent attitudes towards risk-taking behaviors
A ‘good fit’ between parents and child
Individual/peer Constitutional factors: alienation, rebelliousness, hyperactivity, novelty seeking Temperament/activity level, social responsively, autonomy
Development of special talents, hobbies and zest for life
Seeing peers take drugs
Friends engaging in problem behavior Work success during adolescence
Favorable attitudes towards problem behavior High intelligence (not paired with sensitive temperament)
Early initiation of the problem behavior
Time Chart
Sl. # Activity MONTHS
1 2 3 4 5 6 7 8 9 10 11 12
1. Preparatory: i) Reviewing secondary literature ii) visiting similar facilities iii) consultation with resource persons/experts iv) communication with donor, Government and other stakeholders etc. v) Recruiting vi) Renting the premises vii) Arrangement of the logistics
2. Establishment and commencement of operation of drug
de-addiction center
Identification of addicts
Awareness building
Motivational counseling
Preventive education
Screening of abuses-addicts
Detoxification / De-addiction
Formation of Self Help Groups
Vocational rehabilitation
After care and re integration into the
social main stream.
3. Production and Dissemination of Educative and Publicity Material
a)Posters/FlashCards/Flannel Charts/Flip Charts
b) Pamphlets/Brochures/Leaflets
c) Hoardings/Panels/Banners
d) Booklets/Periodicals etc.
4. Community Participation Programs
a)Corner meetings/Workshops/Conferences
b) Essay/Debate/Slogans/Drama/One Act Play Competitions
c) Pantomime Shows/Street Plays/Folk Media, etc.
5. Training Camps for Voluntary Workers
6. Any Other Activity for Awareness building programme against drug/alcoholism
7. Residential Treatment/ Rehabilitation:
8. Awareness, Prevention, Demand and Harm Reduction
9. Community Outreach Project:
• operate community based participatory detoxification and de-addiction centers in the vulnerable most places of Bangladesh where no or less similar programs are available. In those areas,
• Life will contact and communicate with the local actors including Government, NGO and local elites.
• The community committees, local government members, local elites and cultural leaders will be involved in the establishment of the community detoxification and de-addiction centers (CDD),
• collection of the drug abusers and retaining them in the centers till detoxification,
• Handover them to the their families for de-addiction processes and
• Transfer more resistant cases to the Life drug rehabilitation center in Dhaka for better management.
CHAPTER-II: BUDGET
SECTION: 1. NORMS FOR SETTING UP OF DRUG AWARENESS AND COUNSELING CENTERS
(Expenditure in Tk..)
S.No Name of the Post No. of posts Monthly exp. Yearly exp Minimum qualifications
A. RECURRING EXPENDITURE (ESTT.)
1. Project In charge-cum
Senior Counselor 1 15000 180000 A masters in psychology or sociology with minimum experience of 3 years in Addiction counseling in a Drug De-addiction centre or a experiential counseling
(recovered addict) with 2 years of sobriety. Preference will be given to the persons who have acquired specific qualifications in the field of addiction counseling.
2. Accountant-cum-Clerk
(Part-time) 1 7000 84000 A graduate with experience of accounts work
3. Counselor/Community
Worker/Social Worker 2 10000 240000 A Masters in psychology or sociology with minimum experience of 2 years in Addiction counseling in a Drug De-addiction centre or a experiential counselor
(recovered addict) with 2 years of sobriety. Preference will be given to the persons who have acquired specific qualifications in the field of addiction counseling.
4. Sweeper/Peon 1 2500 30000
TOTAL A 34,500 414000
B. RECURRING EXPENDITURE (OTHER THAN ESTT.)
1 Rent 30000 360,000
2. Contingencies
(Water, electricity, telephone, stationery, etc.) 10000 120,000
3. Publicity 15000 180,000
4. Transport 10000 120,000
TOTAL B 65,000 780,000
TOTAL A AND B 15, 60,000
C. NON RECURRING EXPENDITURE
(Admissible once only during the setting up of the Centre)
Furniture, Almirah, Computer and accessories, Bedsheets etc. 250,000
A+B+C= BDT 1810000
SECTION: 2. NORMS FOR SETTING UP OF 50-BEDDED REHABILITATION-CUM-
TREATMENT CENTRES
S.No Name of the Post No. of posts Monthly exp. Yearly exp Minimum qualifications
A. RECURRING EXPENDITURE (ESTT.)
a. Administrative
1. Project Director 1 25000 300,000 A Medical Professional or masters in psychology or sociology minimum experience of 3-5 years in directing an De-addiction and rehabilitation centre Preference will be given to the persons who have acquired specific qualifications in the field of de-addiction and detoxification protocols
2. Accountant-cum-Clerk
(Part-time) 1 7000 84,000 A graduate with experience of accounts work
3. Sweeper/Chowkidar 2* 5000 60,000
b. Medical
1. Medical Officer 1 15000 180,000 M.B.B.S. or equivalent Degree recognized by the Bangladesh Medical & Dental Council, should have 2-3 years experience in management of drug addicts.
2. Counsellor / Social
Worker/Psychologist 7* 70000 840,000 A Masters in psychology or sociology with minimum experience of 2 years in Addiction counseling in a Drug De-addiction centre or a experiential counselor (recovered addict) with 2 years of sobriety. Preference will be given to the persons who have acquired specific qualifications in the field of addiction counseling.
Preference will be given to candidates with degree/diploma in Addiction counseling.
3. Yoga/faith based other
Therapist (Part-time) 1 6000 72000 Adequate experience in the discipline recognized
4. Nurse/Ward Boys etc. 5* 25000 300,000 Nurse: High School or equivalent with certificate in Nursing from a recognized institution.
Boy: VIII th Class Pass. Good health, mentally sound, good character preferably experienced in such centres.
TOTAL A 153000 1,836,000
B. RECURRING EXPENDITURE (OTHER THAN ESTT.)
1 Rent 40000 480,000
2. Medicines 25000 300,000
3. Transport 15000 180,000
4. Contingencies
(Water, stationery, electricity, telephone, etc.) 15000 180,000
TOTAL B 95,000 1,220,000
TOTAL A and B BDT 1836000 + 1220000 =3056000
C. NON RECURRING EXPENDITURE
(admissible once only during the setting up of the Centre)
60 beds, tables, sets of linens BDT 3,50,000
blankets, other office equipments etc.
A+B+C= BDT 3406000
SECTION: 3 NORMS FOR EXPENDITURE ON HOLDING OF DE-ADDICTION CAMPS FOR TREATMENT OF DRUG ADDICTS
(Intentions will be refer the resistant abusers to the main centre)
1. Number of Patients Not less than 25 and not more than 40
2. Duration of each camp 15 (fifteen) days
(Expenditure in Tk..)
Sl. No. Item In Rural Areas In Urban areas
1. Allowances for the staff 25000 15000
2. Medicines 10000 10000
3. Transport 8000 7000
4. Contingencies
(including rent, water, electricity, charges, hiring of beds and other essential equipments and expenses on follow-ups) 43000 42000
TOTAL 86000
74000
= BDT 75000
Total Budget:
1. SECTION 1+SECTION 2+SECTION 3= BDT 1810000+3406000+75000=
BDT 5291000 in 1 year =US $ equivalent 85000 (Approx.) ($@ BDT 62.00)
2. For 2 years, BDT 10582000= US $ equivalent 171000
DE-ADDICTION AND HIV HARM REDUCTION PROGRAM
CAPTER-1: INTRODUCTION
A. History:
As with other South Asian nations Bangladesh has a long history of illicit drug use, particularly of opium and cannabis. Before 1948, Bangladesh was a part of an undivided India and therefore much of its history mirrors eastern India, particularly Bengal. From the time of British colonisation until 1984 it was possible to purchase opium from government controlled vendors (Ray 1998). Cannabis has been widely used in Bangladesh society for many years and was often not perceived as a drug of abuse (Kabir 1998). In the late 1970s consumption of opium was strictly restricted and the scheme of compulsory registration identified about 1,600 chronic opium addicts (Spencer and Navaratnam 1981). Since 1987 production of cannabis has been banned and most is now smuggled across the Indian border (Hossain 2000). Until the mid 1980s the drugs of use, among the young, were cannabis, local wine and prescribed tablets (Mandrax and Prodrom). Heroin, generally called brown sugar, did not appear until the mid to late 1980s. It had low potency and became the drug of choice (Ray 1998) among the lower socio-economic sector and some students (Kabir 1998). In 1991, the majority of drug users in treatment indicated heroin as their drug of choice, followed by pethidine. At this time the level of education and affluence tended to influence drug-taking practices; 15% of the poor injected compared to 42% of the more affluent (Gibney 1999). At the same time as heroin addiction increased, a shortage in supplies emerged as a result of law enforcement activities. As a result drug users turned to the pharmaceutical buprenorphine from India (Habib 2000, Hossaine 2000). The emerging popularity of buprenorphine (commonly know as Tidegesic) stems from its cheapness, availability, longevity of effect and as a result of some pharmacies promoting the drug as a way of treating heroin addiction (Kabir 1998). By the mid 1990s individuals dependent on buprenorphine started to appear in treatment centres (Ray 1998).
B. Current situation:
Bangladesh is surrounded by one of the largest drug producing regions in the world. While it is not a significant producer of narcotics, opium cultivation near the Myanmar border, albeit small, has been detected in some districts. In 1999, 90 acres of poppy fields were destroyed by the army (Narcotics 2001, Henry 1999) and 28 kilograms of heroin and 2.3 metric tons of cannabis were seized. The drug Phensidyl (a cough syrup containing codeine) has become increasingly popular among drug users. In 2000, 140,000 bottles were seized by law enforcement officials (International 2000). Phensidyl is readily available and remains the most visible illicit drug: it requires no prescription and is easily accessed by many illegal traders in various parts of the country (Habib 2001).
In 1996, a Rapid Situation Assessment (RSA) of the drug use in three major cities (Dhaka, Rajshahi and Chittagong) was conducted; 1,750 participants were selected at random. The results of this survey reported the most commonly used drugs in descending order were cannabis, cough syrup (codeine based), sedatives and heroin. For those surveyed in treatment centres the most commonly used drugs in descending order were heroin, codeine, cough syrup, buprenorphine, cannabis and sedatives (Ray 1998). Among all the participants the life time use of selected drugs show cannabis at 25.8%; cough syrup at 11.3% with heroin and buprenorphine, 2.9% and 0.5% respectively (Ray 1998). However, a recent study in Dhaka showed buprenorphine as the most commonly used drug among users (70%) (Mallick and Gomes 2000). It is widely agreed among experts that there is increasing evidence of the widespread use and availability of illicit drugs (Ahmed 1999; Habib 2001; Ray 1998; Hossain and Ahmed 1999; Malibubur 1999).
In the northern part of the country, drug use, including injecting, has been reported in the cities of Coxes Bazar, Chittagong, Jessore, Khuna, Rajshahi and Chapainawabganj and drug use is common in several areas of the capital, Dhaka (Jenkins 1999a; Begg 1999). While drug use is mainly confined to the urban centres it has also been reported in several rural areas and villages (Ray 1998; Jenkins 1999a).
In 1998, a study was undertaken to assess the vulnerability of an estimated 200,000 street children (aged between 5- 14 years) living in the metropolitan area of Dhaka.
While the study found many of the children were the victims of exploitation, harassment and abuse (including sexual) it also found that some were addicted to injectable drugs and other substances. Awareness on HIV/AIDS issues was reported to be poor among this group (Milky 1999).
C. Drug taking practices and risk factors:
While the most popular routes for taking drugs is reported as ingesting or inhalation (Malibubur 1999) injecting does appear to be gaining popularity (Hossaine and Ahmed 1999). The injecting of drugs is believed to have commenced in 1990 (Hossaine 2000) and data recorded in treatment centres reports an increase in the rate of injecting from 6% in 1993 to 17% in 1995 (Ray 1998). The time frame from using different types of drugs before switching over to injectables ranges from six to fifteen years (Jenkins 1999a; Mallick and Gomes 2000). In 1996, a study in Rajshahi reported the injecting of sedatives as widespread (78%), followed by buprenorphine (21%) (Habib 2001). The behavioural surveillance study of 1998-99 showed that for those who injected, the drug of choice was buprenorphine which was frequently mixed in a cocktail of substances including diazepam, promethazine hydrochloride and chlorpheniramine. A recent study also reported that 29% of participants injected a cocktail of drugs (Hussaine, 2000; Mallick and Gomes 2000). Heroin was used by only 2% of participants, and was usually dissolved in lemon juice before injecting (Hussaine, 2000). One study shows that 90% of all injectors had once smoked heroin (Begg 1999).
Reports of drawing up blood in the syringe in order to dilute the drug and front or back loading (moving the drug from one syringe to another) occurs, even though in small numbers (<10%) (Jenkins 2001, Mallick and Gomes 2000). In 2000, a study in Dhaka reported the average number of injections per day was two and the sites of injecting varied; 26% injected into the vein, 56% into muscle and the rest (18%) used both the vein and the muscle (Mallick and Gomes 2000). Another earlier study reported that 59% always injected into the vein (Jenkins 1999b).
In the city of Rajshani most IDUs used the services of a professional injector in an adda: an adda is a place where IDUs gather to inject and where the drugs and the professional injector can be found. While the same practice is likely to occur in Dhaka it is not as common (Hussaine 2000; Jenkins 1999b) It has been suggested the professional injectors are able to maintain business through a good supply of drugs, connections to wholesalers and by providing the injecting services. In 1999, in Rajshani an estimated 50 adda injectors operated and there were an estimated 94 addas in the city. These facilities are often located in disused buildings and lane ways but some also operate in hotel rooms (Hossaine 2000). For a small additional cost, people can ask to be injected at their homes. In one study it was reported up to 90 persons a day used a single adda injector, often for multiple injections. Being an adda injector was not exclusively the domain of men as several women had also become involved (Jenkins 1999a).
Reports suggest an adda injector will use the same needle for 20-50 people and that it is not unusual for it to be used for 2-3 days. (SHEAS, 1996). Studies in the late 1990s reported widespread sharing of needles among all IDUs (60% - 90%) and that professional injectors did not sterilise their needles and syringes (Hossaine 2000; Begg 1999; Ashaful 1999). The sharing of injecting equipment has also been documented among street children (Gibney 1999). Among professional injectors it has been observed that a needle is only changed when it becomes blunt and glass syringes are rarely changed or discarded (Hossaine 2000). New needles add an expense that few poor IDUs can afford thus explaining the reasons for the widespread sharing (Jenkins 1999a) and why some people have been known to use syringes rejected by hospitals (SHEAS 1996). It costs an average of three Taka (US$0.05) to buy a disposable syringe and needle. There are regulations in place requiring a prescription to buy such equipment but this is often ignored. It is not difficult to find a needle and syringe in most parts of the country (P.S. Mallick personal communication 2001). Cleaning of needles by those who shared their needles is nearly always inadequate. Some methods included using cotton or paper to clean the needle or using distilled water (Mallick and Gomes 2000). Some IDUs used saliva to clean their needles believing this would destroy any poisons found in the blood (SHEAS 1996).
The establishment of needle and syringe programs (NSP) from May 1998 has shown some behavioural changes. Results from a recent study between two surveys show the overall sharing of needles in Dhaka appears to have been reduced from 93% to 75% of people ever sharing in the last week. In Rajshahi the reduction is from 96% to 55% (Jenkins 2001). The government recognises that NSP clearly impacts on the proportion of injections shared (Government of Bangladesh 2001).
D. Prevalence and profile:
The number of drug users has been estimated to be between 100,000 to 1.7 million (Ray 1998; Rhaman 2000; Narcotics 2001; WHO 2001). In the early 1990s it was estimated that there were 100,000 heroin users in the country but this figure is likely to have lessened as buprenorphine has become the favoured drug (Hossaine 2000). It has been estimated there could be 20,000 to 25,000 IDUs in the country (Hossaine 2000; Jenkins 1999a; Wodak 2001). In the capital Dhaka, reports suggest there are 7,650 injectors and at least 11,000 heroin users (Begg 1999). In northern Bangladesh there are an estimated 12,000 to 15,000 injectors, most of whom are found in the cities of Rajshahi and Chapainwabganj (Jenkins 1999b). However, these figures are disputed by others: a Rapid Situation Assessment (RSA) in 2000 found there was no more than 2,000 IDUs in Rajshahi and 1,000 IDUs in Chapainawabgonj (Mallick and Rabbani 2000).
The majority of drug users, and those who inject, are reported to be male with less than 2.5% females (Government of Bangladesh 2001; Hossaine 2000; Begg 1999). The number of female drug users could be greater but reaching out to this sector of the community is difficult when most are very hesitant to identify themselves as IDUs (Begg 1999). One outreach program in Dhaka has contact with about 40 female IDUs most of whom are also sex workers (Begg and Nizam 1999). In one southern city a survey found 14% of street female sex workers injected drugs and in the brothels 6% stated they were IDUs. Among male IDUs a high proportion paid for sex. A survey in various cities has shown that half to three-quarters of male injectors paid for sex and close to one in ten bought sex from men or transvestites; less than 25% used a condom the last time they paid for sex (MAP 2001).
In 1986, HIV was first detected in a foreign drug trafficker and in 1989 the first case of HIV in a citizen of Bangladesh was recorded (Gibney 1999; Hussaine 2000). While the HIV prevalence levels have remained relatively low there has been a sizeable increase since 1989 (Gibney 1999). As of December 2000 the total number of HIV/AIDS cases was 157 (127 males, 30 females). Between December 1999 and December 2000 the number of identified HIV infections was 31 cases, the highest number in a single year. A breakdown of the transmission route is not available but it is likely the majority are sexually acquired (Department of Virology 2001). In 1999 an estimated 7,500 adults and children lived with HIV infection (UNAIDS 2000) but in 2000 this increased to 13,000 (WHO 2001). It has been calculated that the annual number of AIDS cases was 1,100 in 2000 which will rise to 1,700 by 2005 (WHO 2001). A sero-surveillance of 1998-1999 reported that among IDUs coming into detoxification centres, 2.5% were found to be HIV positive and among the 880 surveyed the rate of needle and syringe sharing was about 90% (Hussaine 2000).
A follow up survey for the second national expanded HIV surveillance in mid 2000 reported that of the 418 participants from a central NSP, 6 people (1.4%) were found to be HIV positive (Government of Bangladesh 2001). The low levels of HIV infection in the two rounds of surveillance have yet to be fully explained considering widespread sharing of needles was still occurring. Studies have shown that Hepatitis C can be found in 25% of IDUs: this was associated with the sharing of needles and the longer duration of drug injecting (Shirin 2000). Surveys conducted on IDUs have shown a wide age range (15 to 70 years) with the average age being 30 to 35 years (Mallick and Gomes 2000; Hossaine 2000, Hussaine 2000). Many have poor education and unskilled occupations, a substantial number are married, and the majority had previously been to jail, mostly for drug offences (Begg 1999; Jenkin 1999b; Hussaine 2000; Habib 2000) A recent study found most family members were aware of the users drug using behaviour (Habib 2001). Use of commercial sex workers, particularly among the unmarried, was fairly common and the use of condoms was generally very low; condoms are rarely a consideration and are seen as mainly for family planning (SHEAS 1996; Jenkins 1999b; Malibubur 1999; Ashaful 1999; Hussaine 2000; Mallick and Gomes 2000). Many sex workers were aware of colleagues having sex with drug users without condoms (Gibney 1999). A 1997 study showed 21% of IDUs donated their blood and many did so as a way to raise money (Jenkins 1999a). This is clearly a problem when none of the blood banks test the blood for HIV (Begg, 1999).
E. Government responses to illicit drug problems:
In the Narcotics Control Act, 1990, there is provision for the establishment of narcotic addiction treatment centres and when it is deemed treatment is necessary the person is directed to a competent physician or a treatment centre (Ray 1998). However, detoxification and rehabilitation programs are scarce in the country and few drug users have the resources to attend them. As occurs in most countries of the world recidivism is high for those receiving treatment. A 1998-99 study showed 90% of the participants who had made attempts to stop drug use had failed (Hussaine, 2000). It has been suggested that the drug prohibition laws enacted under the Narcotics Act of 1990 are not an effective strategy for harm reduction (Habib 2000). The government does not view drug addiction as a high priority issue and it is seen as a self-created problem (Hossain and Ahmed 1999). If a person is found in possession of heroin, cocaine and coca derivatives, and the quantity does not exceed 25 grams, imprisonment will not be less than two years and not exceed 10 years. If the quantity exceeds 25 grams the penalty can be the death sentence or life imprisonment. For possession of pethidine, morphine or tetrahyrocannabinol, if the quantity does not exceed 10 grams, imprisonment will be no less than two years and no more than 10 years. If the quantity exceeds this amount the penalty is a death sentence or life imprisonment. There are various A class narcotics which is where buprenorphine is likely to be classified. Being in possession of this drug is also likely to incur a severe penalty. The penalty is an imprisonment of not less than two years and no more than 15 years: the possession amount is not specified (Rahman 1990). There is usually no provision for arrested drug users to be sent to drug treatment centre. The only option appears to be prison (P.S Mallick, personal communication 2001).
The Department of Narcotics Control has recently initiated a community level of coordination to streamline the activities of the non-governmental organizations (NGOs) to strengthen existing and future drug prevention activities in the country (Ahmed 2001). There are four government de-addiction centres in the country with a total of 55 beds (Ray 1998).
The traditional approach to treating drug users is in the psychiatric units of hospitals. The shortage of beds results in few being able to receive treatment. Other problems include physicians being discouraged from offering their services to treatment centres because they can lose their seniority if they are not properly released by the Ministry of Health and placed under the Department of Narcotic Control (Hossain and Ahmed 1999).
The two models of treatment are the ashram model, run by non-medical social activists, and the medical hospital model run by medical professionals. Most drug users are serviced by government health care facilities and at the Dhaka centre people stay for four weeks. There is only one program designed to cater for female drug users (Hossain and Ahmed 1999) Only one government- run detoxification centre exists in Dhaka, which has 40 beds and charges a nominal fee (Begg 1999). Many drug users have tried various ways to stop their drug use and a study shows 68% had been in prison at least once. However, even here drug injecting occurs (Jenkins 2001).
F. Government response to drug use and HIV:
The government is aware of the link between HIV/AIDS and drug use as has been shown in the two sero-surveillance surveys. It has been acknowledge NSP can play a role in reducing the amount of needle sharing and impact upon HIV transmission.
However, there are reports of IDUs being arrested for carrying syringes and needles even though no ‘paraphernalia laws’ exist (Begg 1999; Hussaine 2000). Substitution therapy is currently not available. Information about HIV/AIDS which directly targets drug users is reported to be unavailable.
G. National AIDS policy:
The Ministry of Health and Family Welfare produced a National HIV/AIDS Policy which received approval by the cabinet in 1998. In the policy there is a special focus on IDU and approval of harm reduction as a useful strategy. However, the Ministry of Home Affairs, whose focus includes narcotic laws, does not approve of harm reduction believing such a policy cannot supersede the law of the land. As a result of these contradictions serious threats from the Narcotics Department and police have emerged with this policy. In recent times the Narcotics Department has indicated they acknowledge the existence of NSP and at this stage have tended to ignore the operations of such programs.
H. Non-government responses to drug use and HIV:
In 1999, the SHAKTI project CARE-Bangladesh (NGO) operated seven drop in centres in Dhaka, which are open six hours per day, six days per week and offer needles and basic primary health care for drug users (Begg 1999). A NSP has been set up at a professional injector site in Rajshahi, reaching approximately 10-20% of the local IDUs. In 1999, SHAKTI was estimated to have access to 3,500 IDUs; peer educators distributed two new syringes and six needles every other day, per person at their drop in centres (Jenkins 2001). About 90,000 needles and syringes per month are exchanged at the DIC with a reported high return (>80%) (Wodak 2001). As there is no incinerator in Bangladesh, there has been no other option for NGOs but to burn collected needles and syringes at the drop in centres in the open air (Begg 1999). CARE-Bangladesh also has programs in Rajshahi and in early 2001 they set up a program in Chapai Nawabgonj which reaches 200 IDUs. In this latest project they have trained five adda educators who are current drug users. Their role is to educate other IDUs and professional drug injectors on STD/HIV issues and to exchange old needles and syringes for new ones (CARE-Bangladesh 2001). It has been reported there are nine NGOs focused on drug demand reduction with a total of 190 beds between them for in-patient treatment (Ray 1998).
Estimated number of drug users : 100,000 - 1.7 million
Estimated number of IDUs : 20,000 - 25,000
Drugs used : cannabis, cough syrup, buprenorphine, sedatives, heroin, codeine
Drugs injected : sedatives, buprenorphine, heroin, drug cocktails
Estimated number of HIV infection : 2.5% of IDUs in detoxification centres among IDUs are HIV +
J. Life, the proposing NGO:
Like-mindedness and the urge to achieve a common goal aided by knowledge, skill and experience is that has given birth to NGO life. It is an organization committed to all out development of the society and its approach to development is a people oriented one. Life believes in an integrated approach, which included both humans and materials aspects of development. For any development effort to be meaningful it must integrated both human material components of development organically. In other words, our scope of activity encompasses the whole gamut of development issues obtaining in Bangladesh.
Our motto is to build self-confidence and capabilities in human races by development critical consciousness in them or other words, humanize them. We do not believe in relief or loan as an end in itself. Hence we are for building adequate human infrastructure as a prerequisite for introducing material imputes within any community. For the task, empowerment of community and person is the most desired intervention by “Safe Life”. Also community based solution is the dream as that will be the utmost sustainable development of a community or the person. Participatory methodology of development is the most important technique in which “Safe life” believes. The primary beneficiaries of the “Safe Life” development approaches are the most vulnerable sections of the rural and urban population especially the landless poor, children and women groups. It is a national organizational its jurisdiction of activities spread all over the country.
Life is a non-profit, voluntary non-Government organization working for the uplift of the people in Bangladesh since decades. Life’s main objective is to uplift the social condition of the poorest of the poor living mostly in rural areas as well as in the urban centers of Bangladesh. As because poverty is responsible from the social and natural environment conditioning the lives of the people Life include in its activities and ambitions program for developing the natural and social environment around the people habits. Achieving household food security, to ensure fundamental rights for the population accepted and ratified by the UN and Bangladesh constitution, structural poverty alleviation, community actions to stop drug abuse, harm reduction of the drug abuse, detoxification and rehabilitation of the drug abusers, health and nutrition including the issues relating HIV/AIDS, environmental protection and regeneration, improvement in women's status, increasing people's participation in the public institution, increasing people's capacity to gain and exercise democratic and human rights etc. are among the important mottos of the NGO Life.
In recent years, along with other interventions, Life is working on the drug abusers to refrain them from abusing drugs through mainly community based participatory awareness raising, advocacy and other holistic approaches. However, from the experiences of Life it is now evident that only the awareness program is not sufficient to restrict the massive damage of the community and persons made by the drug abuse and the dimension of the drug related program has be widened by establishing drug abuse detoxification and rehabilitation centers to intervene the already addict population, to save their lives and to stop any more propagation of the addiction by them.
I. OBJECTIVES:
The objectives of the program are as follows:
1. To establish a fellowship of recovering addicts living in a healthy atmosphere, helping fellow addicts and their families recover from addiction.
2. To disseminate knowledge of basic facts about drug abuse, addiction, the Twelve Steps Program of Narcotics Anonymous and the recovery process.
3. To provide an environment in which addicts review their lifestyle, develop healthy attitudes, demonstrate sobriety and form good habits in daily life and work.
4. To provide an environment in which addicts acquire sufficient skill training, education and other preparatory knowledge that will lead to constructive and gainful employment.
5. To enable recovering addicts to make a full and active positive contribution to family and society, living a happy drug free and crime free life, who are constructively and gainfully employed, motivating others to stay off drugs or to get off drugs. Special emphasis is on high-risk youngsters of the nearby slums.
6. To provide drug prevention, motivational and training assistance for young drug addicts and high-risk youngsters, especially those from poor and/or dysfunctional families.
7. To create awareness and educating the people about the ill effects of alcoholism and substance abuse on the individual, family and the society at large.
8. To evolve culture-specific models for the prevention of the alcoholism and substance and the treatment and rehabilitation of addicts.
9. To provide for the whole range of community based services for the identification, motivation, counseling, de-addiction, after care and rehabilitation of addicts.
10. To promote collective initiatives and self help endeavors among individuals and groups vulnerable to addiction are found at risk.
11. To establish appropriate linkage between Government interventions and voluntary efforts in the field of prohibition and substance abuse prevention.
12. To increase community participation and public co-operation in the reduction of demand for dependence-producing substances. Creating Awareness
J. Activities:
Life’s target group will be the poor and young addicts of the local area but people come for treatment from all over Bangladesh. Those who come to Life pay according to the family means; as a result many of those who come for assistance pay little or nothing. The activities of Life will cover all aspects of drug addiction treatment and after care rehabilitation for male addicts, including prevention and awareness activities. These activities can be grouped into the following main forms of service provision:
(i) Identification of addicts.
(ii) Awareness building
(iii) Motivational counseling
(iv) Preventive education
(v) Screening of abuses-addicts
(vi) Detoxification / De-addiction
(vii) Formation of Self Help Groups
(viii) Vocational rehabilitation
(ix) After care and re integration into the social main stream.
Program components:
I. Production and Dissemination of Educative and Publicity Material
a) Posters/Flash Cards/Flannel Charts/Flip Charts
b) Pamphlets/Brochures/Leaflets
c) Hoardings/Panels/Banners
d) Booklets/Periodicals etc.
II. Community Participation Programs
a) Corner meetings/Workshops/Conferences
b) Essay/Debate/Slogans/Drama/One Act Play Competitions
c) Pantomime Shows/Street Plays/Folk Media, etc.
III. Training Camps for Voluntary Workers
IV. Any Other Activity for Awareness building programme against drug/alcoholism
V. Residential Treatment/ Rehabilitation:
The principles of Narcotics Anonymous 12 Step Program form the basis of this program of treatment and rehabilitation/habilitation. The importance of structure, work production, exercise, prayer and relaxation is acknowledged and these are all essential elements in this holistic program.
VI. Awareness, Prevention, Demand and Harm Reduction:
This is comprised of:
i) A series of meetings that all Life residents participate in on a daily basis.
ii) The Children's Program that is focused on removing 'at-risk' children from potential drug abuse situations.
iii) An important educational service for addicts, their families and the general community.
iv) Aftercare and Halfway House with Skill Training and Income Generation: This incorporates a range of post rehabilitation meetings and also a strong support network (Life based) to assist with the continued recovery of the addict. Additionally the aftercare service provides participants with the option to obtain skill training and to contribute to the income generation of the program.
VII. Community Outreach Project: With the program, Life will operate community based participatory detoxification and de-addiction centers in the vulnerable most places of Bangladesh where no or less similar programs are available. In those areas, Life will contact and communicate with the local actors including Government, NGO and local elites. The community committees, local government members, local elites and cultural leaders will be involved in the establishment of the community detoxification and de-addiction centers (CDD), collection of the drug abusers and retaining them in the centers till detoxification, then to handover them to the their families for de-addiction processes and in need to transfer more resistant cases to the Life drug rehabilitation center in Dhaka for better management.
VIII. HIV/AIDS Awareness program:
The HIV/AIDS issues for drug addicts in Bangladesh are extremely pressing. The links between intravenous drug use, prostitution and unsafe sex are strong. Life is already in preliminary discussion with local NGOs regarding the possibility of collaborating on a project which targets this issue and the ever increasing 'at risk' population. This program will be existing as a cross cutting issue in all Life drug and substance abuse programs. The necessary components will be the screening, counseling and life skills for HIV/AIDS among the drug abusers and their families wherever necessary.
RISK AND PROTECTIVE FACTORS FOR YOUNG PEOPLE AND DRUGS
Level Risk factors Protective factors
Community Availability of drugs Cultures of cooperation
Poverty Stability and connectedness
Transitions and mobility in schooling and community Good relationship with an adult outside the family
Low neighborhood attachments and community disorganization Opportunities for meaningful contribution
School Detachment from school and poor relationships in school A sense of belonging and ‘fitting in’
Positive achievements and evaluations at school
Academic failure, especially in middle years
Early and persistent antisocial behavior and bullying Having someone outside your family who believes in you
Low parental interest in education
Attendance at pre-school
Family History of problematic alcohol and drug use A sense of connectedness to family
Inappropriate family management Feeling loved and respected
Family contact Proactive problem solving and minimal conflict during infancy
Alcohol/drugs interfere with family
Maintenance of family rituals Warm relationship with at least one parent
Harsh/coercive or inconsistent parenting Absence of divorce during adolescence
Marital instability or conflict
Favorable parent attitudes towards risk-taking behaviors
A ‘good fit’ between parents and child
Individual/peer Constitutional factors: alienation, rebelliousness, hyperactivity, novelty seeking Temperament/activity level, social responsively, autonomy
Development of special talents, hobbies and zest for life
Seeing peers take drugs
Friends engaging in problem behavior Work success during adolescence
Favorable attitudes towards problem behavior High intelligence (not paired with sensitive temperament)
Early initiation of the problem behavior
Time Chart
Sl. # Activity MONTHS
1 2 3 4 5 6 7 8 9 10 11 12
1. Preparatory: i) Reviewing secondary literature ii) visiting similar facilities iii) consultation with resource persons/experts iv) communication with donor, Government and other stakeholders etc. v) Recruiting vi) Renting the premises vii) Arrangement of the logistics
2. Establishment and commencement of operation of drug
de-addiction center
Identification of addicts
Awareness building
Motivational counseling
Preventive education
Screening of abuses-addicts
Detoxification / De-addiction
Formation of Self Help Groups
Vocational rehabilitation
After care and re integration into the
social main stream.
3. Production and Dissemination of Educative and Publicity Material
a)Posters/FlashCards/Flannel Charts/Flip Charts
b) Pamphlets/Brochures/Leaflets
c) Hoardings/Panels/Banners
d) Booklets/Periodicals etc.
4. Community Participation Programs
a)Corner meetings/Workshops/Conferences
b) Essay/Debate/Slogans/Drama/One Act Play Competitions
c) Pantomime Shows/Street Plays/Folk Media, etc.
5. Training Camps for Voluntary Workers
6. Any Other Activity for Awareness building programme against drug/alcoholism
7. Residential Treatment/ Rehabilitation:
8. Awareness, Prevention, Demand and Harm Reduction
9. Community Outreach Project:
• operate community based participatory detoxification and de-addiction centers in the vulnerable most places of Bangladesh where no or less similar programs are available. In those areas,
• Life will contact and communicate with the local actors including Government, NGO and local elites.
• The community committees, local government members, local elites and cultural leaders will be involved in the establishment of the community detoxification and de-addiction centers (CDD),
• collection of the drug abusers and retaining them in the centers till detoxification,
• Handover them to the their families for de-addiction processes and
• Transfer more resistant cases to the Life drug rehabilitation center in Dhaka for better management.
CHAPTER-II: BUDGET
SECTION: 1. NORMS FOR SETTING UP OF DRUG AWARENESS AND COUNSELING CENTERS
(Expenditure in Tk..)
S.No Name of the Post No. of posts Monthly exp. Yearly exp Minimum qualifications
A. RECURRING EXPENDITURE (ESTT.)
1. Project In charge-cum
Senior Counselor 1 15000 180000 A masters in psychology or sociology with minimum experience of 3 years in Addiction counseling in a Drug De-addiction centre or a experiential counseling
(recovered addict) with 2 years of sobriety. Preference will be given to the persons who have acquired specific qualifications in the field of addiction counseling.
2. Accountant-cum-Clerk
(Part-time) 1 7000 84000 A graduate with experience of accounts work
3. Counselor/Community
Worker/Social Worker 2 10000 240000 A Masters in psychology or sociology with minimum experience of 2 years in Addiction counseling in a Drug De-addiction centre or a experiential counselor
(recovered addict) with 2 years of sobriety. Preference will be given to the persons who have acquired specific qualifications in the field of addiction counseling.
4. Sweeper/Peon 1 2500 30000
TOTAL A 34,500 414000
B. RECURRING EXPENDITURE (OTHER THAN ESTT.)
1 Rent 30000 360,000
2. Contingencies
(Water, electricity, telephone, stationery, etc.) 10000 120,000
3. Publicity 15000 180,000
4. Transport 10000 120,000
TOTAL B 65,000 780,000
TOTAL A AND B 15, 60,000
C. NON RECURRING EXPENDITURE
(Admissible once only during the setting up of the Centre)
Furniture, Almirah, Computer and accessories, Bedsheets etc. 250,000
A+B+C= BDT 1810000
SECTION: 2. NORMS FOR SETTING UP OF 50-BEDDED REHABILITATION-CUM-
TREATMENT CENTRES
S.No Name of the Post No. of posts Monthly exp. Yearly exp Minimum qualifications
A. RECURRING EXPENDITURE (ESTT.)
a. Administrative
1. Project Director 1 25000 300,000 A Medical Professional or masters in psychology or sociology minimum experience of 3-5 years in directing an De-addiction and rehabilitation centre Preference will be given to the persons who have acquired specific qualifications in the field of de-addiction and detoxification protocols
2. Accountant-cum-Clerk
(Part-time) 1 7000 84,000 A graduate with experience of accounts work
3. Sweeper/Chowkidar 2* 5000 60,000
b. Medical
1. Medical Officer 1 15000 180,000 M.B.B.S. or equivalent Degree recognized by the Bangladesh Medical & Dental Council, should have 2-3 years experience in management of drug addicts.
2. Counsellor / Social
Worker/Psychologist 7* 70000 840,000 A Masters in psychology or sociology with minimum experience of 2 years in Addiction counseling in a Drug De-addiction centre or a experiential counselor (recovered addict) with 2 years of sobriety. Preference will be given to the persons who have acquired specific qualifications in the field of addiction counseling.
Preference will be given to candidates with degree/diploma in Addiction counseling.
3. Yoga/faith based other
Therapist (Part-time) 1 6000 72000 Adequate experience in the discipline recognized
4. Nurse/Ward Boys etc. 5* 25000 300,000 Nurse: High School or equivalent with certificate in Nursing from a recognized institution.
Boy: VIII th Class Pass. Good health, mentally sound, good character preferably experienced in such centres.
TOTAL A 153000 1,836,000
B. RECURRING EXPENDITURE (OTHER THAN ESTT.)
1 Rent 40000 480,000
2. Medicines 25000 300,000
3. Transport 15000 180,000
4. Contingencies
(Water, stationery, electricity, telephone, etc.) 15000 180,000
TOTAL B 95,000 1,220,000
TOTAL A and B BDT 1836000 + 1220000 =3056000
C. NON RECURRING EXPENDITURE
(admissible once only during the setting up of the Centre)
60 beds, tables, sets of linens BDT 3,50,000
blankets, other office equipments etc.
A+B+C= BDT 3406000
SECTION: 3 NORMS FOR EXPENDITURE ON HOLDING OF DE-ADDICTION CAMPS FOR TREATMENT OF DRUG ADDICTS
(Intentions will be refer the resistant abusers to the main centre)
1. Number of Patients Not less than 25 and not more than 40
2. Duration of each camp 15 (fifteen) days
(Expenditure in Tk..)
Sl. No. Item In Rural Areas In Urban areas
1. Allowances for the staff 25000 15000
2. Medicines 10000 10000
3. Transport 8000 7000
4. Contingencies
(including rent, water, electricity, charges, hiring of beds and other essential equipments and expenses on follow-ups) 43000 42000
TOTAL 86000
74000
= BDT 75000
Total Budget:
1. SECTION 1+SECTION 2+SECTION 3= BDT 1810000+3406000+75000=
BDT 5291000 in 1 year =US $ equivalent 85000 (Approx.) ($@ BDT 62.00)
2. For 2 years, BDT 10582000= US $ equivalent 171000
Monday, July 21, 2008
ICDDR,B Develops A Performance Enhancing Drink For the US Military In Iraq (contents collected from web)
ICDDR,B Develops A Performance Enhancing Drink For the US Military In Iraq
Investigative , by Mahmood Ali , 31-July-2006
[Blog]
The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), is the continuation of the Cholera Research Laboratory (CRL), originally established in 1960 as a result of the military alliance between Pakistan and USA under the umbrella of the South Asian Treaty Organization (SEATO). In this article Mahmood Ali documents the ICDDR,B’s collusion with the US Military in developing a performance enhancing drink for the US soldiers in Iraq. This is one more example of the ICDDR,B’s defiance to the guidelines of the charter under which it is obliged to function.
Introduction:
The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), is the continuation of the Cholera Research Laboratory (CRL), originally established in 1960 as a result of the military alliance between Pakistan and USA under the umbrella of the South Asian Treaty Organization (SEATO). Historically, diarrhoea is one of the most common medical conditions afflicting military personnel that greatly reduces their combat efficiency (1). It is with the objective to providing better health care for the American soldiers that the Centre was established almost half a century ago. In 1978 the Government of Bangladesh granted a charter to the ICDDR,B to operate as a research centre to work on diarrhoeal diseases “with special relevance to developing countries” (Ordinance No LI of 1978 Government of Bangladesh; 6th Dec 1978). The charter did not permit the ICDDR,B to work for foreign military forces. However the ICDDR,B has grossly violated the charter on a number of occasions by colluding with foreign military forces, details of which have been described elsewhere (2, 3). The present article documents the ICDDR,B’s collusion with the US Military in developing a performance enhancing drink for the US soldiers in Iraq. This is one more example of the ICDDR,B’s defiance to the guidelines of the charter under which it is obliged to function.
Dehydration – a major health problem for the U.S. Military in Iraq:
Dehydration arising out of excessive heat and diarrhoeal illness is a major health problem for the U.S. Military in Iraq resulting in tremendous costs both in terms of dollars and loss of active personnel. Frequently soldiers suffer from heat exhaustion and other heat-related illness in combat operations in Iraq where daytime temperatures can soar above 50 °C. As a consequence many of them have died since the conflict began in 2003 (the Gulf War II), according to iCasualties.org, a Web site that monitors combat deaths there (4). The US Military strategists took this matter into consideration in invading Iraq in March 2003, thus avoiding the hottest season. But the illegal invasion of Iraq by the US led coalition forces did not become a cakewalk. Instead it led them into a quagmire that has cost the US more than 2500 lives and several thousands more being injured. A recent study published by the US Military demonstrates that more than one-third of the US troops in Iraq are suffering from migrane headaches arising out of factors such as physical exhaustion, dehydration and exposure to extreme heat (5). These migranes have significantly impaired their combat efficiency. A US Army laboratory found that dehydration can cut performance by 8% even in temperate weather of 20 °C. (6). Efficiency can be reduced to 60%, if a soldier is dehydrated 2-3% on being exposed to extreme high temperatures rising above 50 °C. During battles, soldiers can sweat away 2 litres of water an hour, but the body can only absorb only 1.2 litres in the same time, regardless of how much is consumed (7). In addition, body armour and equipment, weighing up to 20 kg. can raise a soldier’s body temperature by five degrees. Steel M-16 rifles can heat up so much, they become literally too hot to handle. In the summer sun, the military fighting vehicles such as tanks turn into “virtual ovens” with inside temperatures surpassing 65 °C. Thus soldiers who fought first on foot and then climbed back inside tanks suffer most from serious heat-exhaustion. Excessive heat in Iraq has been described as “a serious morale-buster for troops leading to shortened tempers, aggressive behaviour and battlefield mistakes” (7). In brief, heat is a potential health hazard for the US led occupation troops in Iraq.
Diarrhoeal diseases constitute another major health problem for the US soldiers. During the Gulf War I of 1991, 57 % of the soldiers had at least one episode of diarrhoea, with 20 % temporarily unable to carry out their duties (8). The percentage of soldiers getting diarrhoea has increased during the Gulf War II (9). Thus 70% of the soldiers had reported at least one episode, and 56% had multiple episodes of diarrhoea with 43% reporting reduced efficiency in carrying out combat operations. Glucose-based oral rehydration salts (ORS), first successfully applied to treat diarrhoea by an Indian scientist in 1953, have been used to prevent or treat dehydration from diarrhoea (10).
ICDDR,B develops AQUIS for use by the U.S. Military:
Recently Phlo Corporation, a biotechnology company from the U.S., has supplied the US soldiers in Iraq an oral rehydration solution termed AQUIS. According to Phlo corporation, AQUIS was designed and developed for use by the U.S. Military by Dr. David Sack, the American Director of the ICDDR,B (11). AQUIS consists of carbohydrates and salts incorporated into liposomes, which are microscopic globules of lipids manufactured to enclose medications. AQUIS is claimed to provide higher level of absorption into the blood stream upon oral ingestion. The special forces of the U.S. Military in Iraq use the product (12).
An enthusiastic advocate of AQUIS wrote in an Internet discussion forum in 2004, “Imagine soldier never being burdened by the heat or dehydration. If a soldier is dehydrated 2-3%, he is at 60% efficiency. Even with the top warfare equipment in the world the soldier still must be able to perform. Think about a soldier at 90-95% efficiency he will be smarter, faster, and sharper, in all a product has turned a military into a force multiplier; thank God the USA will have it soon. AQUIS…does not have the salt taste and is extremely effective. The best scientists in the world created AQUIS. You can do all the research on us and will see that it's not made up any false claims. It will prevent all heat related injuries and is a force multiplier.” (13).
Who are those “best scientists” of the world that created AQUIS? The answer has been provided by Phlo Corporation on a number of occasions as it cites the name of Dr. David Sack and his team at the ICDDR,B as the top scientists behind AQUIS (11, 13).
After using AQUIS, Captain Van Taylor, a Platoon Commander of the U.S. Marine Corps in Iraq stated, “Marines in C Company, 4th Reconnaissance Battalion used AQUIS during a long range patrol and found the product easy to use, tasty, and performance enhancing even in the hot summer sun. We worry about bullets, but dehydration can kill too. I have seen many heat casualties significantly over the years in the [Marine] Corps. AQUIS reduces these unnecessary casualties significantly.” (14). The mother of an AQUIS consuming American soldier in Iraq stated, “My son who is a Marine part of the first Fast Company…informed me that there is a product called AQUIS, a rehydration product designed for the US Military. He tried it in Baghdad when they protected the Republican Palace when Paul Bremer was there and loved it.” (15). Phlo Corporation has recruited a few former high ranking US Department of Defense officials with working experience in Iraq in order to “bring to the company extensive experience and knowledge of the infrastructure of the U.S. Military and other allied military establishments” (13). AQUIS is an expensive product. One day’s recommended regime can cost about 8 US Dollars (16).
ICDDR,B repeatedly flouts the charter:
This is not the only example that the ICDDR,B has flouted the charter and colluded with foreign military forces. The Government of Bangladesh does not recognize the State of Israel. Yet the Centre’s Director Dr. David Sack has been collaborating for decades with Swedish scientists Dr. Jan Holmgren and his wife Ann-Mari Svennerholm who have been carrying out research at the ICDDR,B on behalf of the Swedish and the Israeli Military (17, 18). Dr. Ann-Mari Svennerholm acts as a go-between the ICDDR,B and Israel. She had been collaborating with the Israel Defence Force for several years with a view to enhance combat efficiency for the Israeli soldiers so that they can slaughter the Palestinians and the Arabs more efficiently as they are doing now (18). She tests her biological products on Bangladeshis using them as experimental guinea pigs for eventual use by the military of countries such as Israel and USA (19). In 1985 the ICDDR, B tested on behalf of these two Swedish scientists a highly expensive oral cholera vaccine of short term protective efficacy on 90,000 women and children of Bangladesh for use by soldiers and tourists of rich nations (20). The vaccine that has brought huge financial gains to the Swedish scientists was sold to the US Military during the Gulf War I of 1991 (21).
The ICDDR,B is currently testing on Bangladeshis a Vibrio cholerae strain Peru-15, which has been developed by scientists of the U.S. Army using techniques of genetic engineering (22). AVANT Immunotherapeutics Inc., a vaccine company from Massachusetts (USA), has been awarded the license to market Peru-15 for commercial purposes such as the development of a cholera vaccine entitled CholeraGrade TM (23). AVANT Immunotherapeutics Inc. maintains very close contact with the U.S. Department of Defence as it has been working on several Defence department’s projects aimed to provide better health care to the U.S. Army personnel. To develop CholeraGrade TM as a traveller’s vaccine to be used predominantly by soldiers has been one of the goals of AVANT Immunotherapeutics Inc. This has been mentioned by the company President Dr. Una Ryan, in her report to the U.S. House of Representative’s Biological Warfare Programs on October 23, 2001 (24). Thus the ICDDR,B’s research on Peru-15 demonstrates the use of Bangladeshis as experimental guinea pigs for a product to be used by the US Military.
The Government of Bangladesh did not recognize the apartheid regime of South Africa. The ICDDR,B’s total disrespect for the charter was further demonstrated when it was revealed in 1985 that the ICDDR,B had been colluding with the apartheid regime of South Africa thereby prolonging the sufferings of the black population (25).
The timing of the ICDDR,B’s research to develop AQUIS for the US Military coincided with the agenda of the present US government to take military control of the Gulf region, even under the pretext of lies. The blue print for a regime change in Iraq was drawn before 2001 and implemented soon after the present US government took control in 2001 (26). The ICDDR,B’s development of AQUIS was reported in September 2002, just half-a-year before the invasion of Iraq. Therefore it appears that the ICDDR,B was working to fulfill the need of the US Military by completing the task shortly before the invasion of Iraq.
One leading Bangladeshi newspaper has recently described the ICDDR,B “ to have become a one-man show with its executive director deciding over controversial recruitment and alleged unethical researches.” (27). Although the Centre has a 16-member board that meets twice a year, its Director David Sack decides almost everything unilaterally making the Trustee Board an object of symbolic importance (27). Yet the Centre collects millions and millions of dollars from tax-payers of various countries using the name of the diarrhoea suffering poor people of Bangladesh. It is a failed institution in tackling the diarrhoeal problem of Bangladesh (2, 3, 27). Instead, as documented in this article, the ICDDR,B’s American Director utilizes the Centre’s facilities and resources to help the US soldiers for the illegal invasion and occupation of Iraq, an act the Government of Bangladesh hosting the Centre did not endorse.
References:
1. Cook GC (2001) Influence of diarrhoeal disease on military and naval campaigns. J. R. Soc. Med 94: 95-97.
2. Ali M. (2004) What is for the ICDDR,B?
(http://www.meghbarta.org/nws/nw_main_p02b.php?issueId=9§ionId=30&articleId=99)
3. Ali M (2005) ICDDR,B's procurement of the Independence Day Award - an insult to the martyrs in the War of Liberation of Bangladesh
(http://www.meghbarta.org/nws/nw_main_p01b.php?issueId=6§ionId=14&articleId=65)
4. http://icasualties.org/oif/
5. More Than One-Third of Iraq Troops Suffering Migraines (2006)
(http://www.nlm.nih.gov/medlineplus/news/fullstory_35215.html)
6. A water tale for all seasons (http://www.physorg.com/news6196.html).
7. Sanders E. Heat can be withering enemy. Los Angeles Times, August 11, 2004.
8. Hyams KC, Bourgeois AL, Merrell BR, Rozmajzl P, Escamilla J, Thornton SA, Wasserman GM, Burke A, Echeverria P, Green KY , et al. (1991). Diarrheal disease during Operation Desert Shield. N Engl J Med. 325:1423-8.
9. Sanders JW, Putnam SD, Riddle MS, Tribble DR, Jobanputra NK, Jones JJ, Scott DA, Frenck RW. (2004) The epidemiology of self-reported diarrhea in operations Iraqi freedom and enduring freedom. Diagn Microbiol Infect Dis. 50:89-93.
10. Chatterjee HN (1953). Control of vomiting in cholera and oral replacement of fluid. Lancet. 265(6795):1063.
11. Phlo Corporation. Tests by Top Scientists at the ICDDR,B Demonstrate the Superiority of Phlo’s Oral Rehydration Solutions. Business Wire. June 4, 2003. 12. Phlo Corporation. Phlo Corporation Hires Former Defense Departments and Coalition Provisional Authority Officials. Primezone. May 18, 2004.
13. http://www.strategypage.com/messageboards/messages/478-1104.asp
14. Phlo Corporation: Phlo Announces That a Corporate Group Has Commenced Sales of AQUIS to the U.S. Coast Guard. October 26, 2004.
15. http://forums.military.com/
16. http://www.drinkaquis.net/
17. SAREC Report on Developmental Research in Sweden, (Editor: Cecilia Molander) R2: 1981, Stockholm, Sweden
18. Cohen D, Orr N, Haim M, Ashkenazi S, Robin G, Green MS, Ephros M, Sela T, Slepon R, Ashkenazi I, Taylor DN, Svennerholm AM, Eldad A, Shemer J. 2000. Safety and immunogenicity of two different lots of the oral, killed enterotoxigenic escherichia coli- cholera toxin B subunit vaccine in Israeli young adults. Infection and Immunity, 68:4492-7.
19. Qadri F, Wenneras C, Ahmed F, Asaduzzaman M, Saha D, Albert MJ, Sack RB, Svennerholm A. 2000. Safety and immunogenicity of an oral, inactivated enterotoxigenic Escherichia coli plus cholera toxin B subunit vaccine in Bangladeshi adults and children. Vaccine. 18:2704-12.
20. Clemens JD, Sack DA, Harris JR, Chakraborty J, Khan MR, Stanton BF, Kay BA, Khan MU, Yunus M, Atkinson W, Svennerholm A-M, Holmgren J. 1986. Field trial of oral cholera vaccines in Bangladesh. Lancet. 19;2(8499):124-7.
21. Finkelstein RA. 1995. Why do we not yet have a suitable vaccine against cholera? Advances in Experimental Medicine and Biology. 371B:1633-40.
22. Kenner JR, Coster TS, Taylor DN, Trofa AF, Barrera-Oro M, Hyman T, Adams JM, Beattie DT, Killeen KP, Spriggs DR, et al. 1995. Peru-15, an improved live attenuated oral vaccine candidate for Vibrio cholerae O1. J Infect Dis. 172:1126-9.
23. Avant Immunotherapeutics Inc. USA, Business Wire, January 20, 2004.
24. The U.S. Congress, Subcommittee on National Security, Veterans Affairs and International Affairs, Hearing on Biological Warfare Defense Vaccine Research & Developmental Programs, 23 October 2001.
25. Turnbull PC, Lee JV, Miliotis MD, Still CS, Isaacson M, Ahmad QS. 1985. In vitro and in vivo cholera toxin production by classical and El Tor isolates of Vibrio cholerae. Journal of Clinical Microbiology, 21:884-90.
26. Mackay N. Bush planned Iraq “regime change’ before becoming President. Sunday Herald, September 15, 2002.
27. M. A. Khan. Mismanagement mars ICDDRB's reputation. The Daily Star (Dhaka, Bangladesh), June 16, 2006
Investigative , by Mahmood Ali , 31-July-2006
[Blog]
The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), is the continuation of the Cholera Research Laboratory (CRL), originally established in 1960 as a result of the military alliance between Pakistan and USA under the umbrella of the South Asian Treaty Organization (SEATO). In this article Mahmood Ali documents the ICDDR,B’s collusion with the US Military in developing a performance enhancing drink for the US soldiers in Iraq. This is one more example of the ICDDR,B’s defiance to the guidelines of the charter under which it is obliged to function.
Introduction:
The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), is the continuation of the Cholera Research Laboratory (CRL), originally established in 1960 as a result of the military alliance between Pakistan and USA under the umbrella of the South Asian Treaty Organization (SEATO). Historically, diarrhoea is one of the most common medical conditions afflicting military personnel that greatly reduces their combat efficiency (1). It is with the objective to providing better health care for the American soldiers that the Centre was established almost half a century ago. In 1978 the Government of Bangladesh granted a charter to the ICDDR,B to operate as a research centre to work on diarrhoeal diseases “with special relevance to developing countries” (Ordinance No LI of 1978 Government of Bangladesh; 6th Dec 1978). The charter did not permit the ICDDR,B to work for foreign military forces. However the ICDDR,B has grossly violated the charter on a number of occasions by colluding with foreign military forces, details of which have been described elsewhere (2, 3). The present article documents the ICDDR,B’s collusion with the US Military in developing a performance enhancing drink for the US soldiers in Iraq. This is one more example of the ICDDR,B’s defiance to the guidelines of the charter under which it is obliged to function.
Dehydration – a major health problem for the U.S. Military in Iraq:
Dehydration arising out of excessive heat and diarrhoeal illness is a major health problem for the U.S. Military in Iraq resulting in tremendous costs both in terms of dollars and loss of active personnel. Frequently soldiers suffer from heat exhaustion and other heat-related illness in combat operations in Iraq where daytime temperatures can soar above 50 °C. As a consequence many of them have died since the conflict began in 2003 (the Gulf War II), according to iCasualties.org, a Web site that monitors combat deaths there (4). The US Military strategists took this matter into consideration in invading Iraq in March 2003, thus avoiding the hottest season. But the illegal invasion of Iraq by the US led coalition forces did not become a cakewalk. Instead it led them into a quagmire that has cost the US more than 2500 lives and several thousands more being injured. A recent study published by the US Military demonstrates that more than one-third of the US troops in Iraq are suffering from migrane headaches arising out of factors such as physical exhaustion, dehydration and exposure to extreme heat (5). These migranes have significantly impaired their combat efficiency. A US Army laboratory found that dehydration can cut performance by 8% even in temperate weather of 20 °C. (6). Efficiency can be reduced to 60%, if a soldier is dehydrated 2-3% on being exposed to extreme high temperatures rising above 50 °C. During battles, soldiers can sweat away 2 litres of water an hour, but the body can only absorb only 1.2 litres in the same time, regardless of how much is consumed (7). In addition, body armour and equipment, weighing up to 20 kg. can raise a soldier’s body temperature by five degrees. Steel M-16 rifles can heat up so much, they become literally too hot to handle. In the summer sun, the military fighting vehicles such as tanks turn into “virtual ovens” with inside temperatures surpassing 65 °C. Thus soldiers who fought first on foot and then climbed back inside tanks suffer most from serious heat-exhaustion. Excessive heat in Iraq has been described as “a serious morale-buster for troops leading to shortened tempers, aggressive behaviour and battlefield mistakes” (7). In brief, heat is a potential health hazard for the US led occupation troops in Iraq.
Diarrhoeal diseases constitute another major health problem for the US soldiers. During the Gulf War I of 1991, 57 % of the soldiers had at least one episode of diarrhoea, with 20 % temporarily unable to carry out their duties (8). The percentage of soldiers getting diarrhoea has increased during the Gulf War II (9). Thus 70% of the soldiers had reported at least one episode, and 56% had multiple episodes of diarrhoea with 43% reporting reduced efficiency in carrying out combat operations. Glucose-based oral rehydration salts (ORS), first successfully applied to treat diarrhoea by an Indian scientist in 1953, have been used to prevent or treat dehydration from diarrhoea (10).
ICDDR,B develops AQUIS for use by the U.S. Military:
Recently Phlo Corporation, a biotechnology company from the U.S., has supplied the US soldiers in Iraq an oral rehydration solution termed AQUIS. According to Phlo corporation, AQUIS was designed and developed for use by the U.S. Military by Dr. David Sack, the American Director of the ICDDR,B (11). AQUIS consists of carbohydrates and salts incorporated into liposomes, which are microscopic globules of lipids manufactured to enclose medications. AQUIS is claimed to provide higher level of absorption into the blood stream upon oral ingestion. The special forces of the U.S. Military in Iraq use the product (12).
An enthusiastic advocate of AQUIS wrote in an Internet discussion forum in 2004, “Imagine soldier never being burdened by the heat or dehydration. If a soldier is dehydrated 2-3%, he is at 60% efficiency. Even with the top warfare equipment in the world the soldier still must be able to perform. Think about a soldier at 90-95% efficiency he will be smarter, faster, and sharper, in all a product has turned a military into a force multiplier; thank God the USA will have it soon. AQUIS…does not have the salt taste and is extremely effective. The best scientists in the world created AQUIS. You can do all the research on us and will see that it's not made up any false claims. It will prevent all heat related injuries and is a force multiplier.” (13).
Who are those “best scientists” of the world that created AQUIS? The answer has been provided by Phlo Corporation on a number of occasions as it cites the name of Dr. David Sack and his team at the ICDDR,B as the top scientists behind AQUIS (11, 13).
After using AQUIS, Captain Van Taylor, a Platoon Commander of the U.S. Marine Corps in Iraq stated, “Marines in C Company, 4th Reconnaissance Battalion used AQUIS during a long range patrol and found the product easy to use, tasty, and performance enhancing even in the hot summer sun. We worry about bullets, but dehydration can kill too. I have seen many heat casualties significantly over the years in the [Marine] Corps. AQUIS reduces these unnecessary casualties significantly.” (14). The mother of an AQUIS consuming American soldier in Iraq stated, “My son who is a Marine part of the first Fast Company…informed me that there is a product called AQUIS, a rehydration product designed for the US Military. He tried it in Baghdad when they protected the Republican Palace when Paul Bremer was there and loved it.” (15). Phlo Corporation has recruited a few former high ranking US Department of Defense officials with working experience in Iraq in order to “bring to the company extensive experience and knowledge of the infrastructure of the U.S. Military and other allied military establishments” (13). AQUIS is an expensive product. One day’s recommended regime can cost about 8 US Dollars (16).
ICDDR,B repeatedly flouts the charter:
This is not the only example that the ICDDR,B has flouted the charter and colluded with foreign military forces. The Government of Bangladesh does not recognize the State of Israel. Yet the Centre’s Director Dr. David Sack has been collaborating for decades with Swedish scientists Dr. Jan Holmgren and his wife Ann-Mari Svennerholm who have been carrying out research at the ICDDR,B on behalf of the Swedish and the Israeli Military (17, 18). Dr. Ann-Mari Svennerholm acts as a go-between the ICDDR,B and Israel. She had been collaborating with the Israel Defence Force for several years with a view to enhance combat efficiency for the Israeli soldiers so that they can slaughter the Palestinians and the Arabs more efficiently as they are doing now (18). She tests her biological products on Bangladeshis using them as experimental guinea pigs for eventual use by the military of countries such as Israel and USA (19). In 1985 the ICDDR, B tested on behalf of these two Swedish scientists a highly expensive oral cholera vaccine of short term protective efficacy on 90,000 women and children of Bangladesh for use by soldiers and tourists of rich nations (20). The vaccine that has brought huge financial gains to the Swedish scientists was sold to the US Military during the Gulf War I of 1991 (21).
The ICDDR,B is currently testing on Bangladeshis a Vibrio cholerae strain Peru-15, which has been developed by scientists of the U.S. Army using techniques of genetic engineering (22). AVANT Immunotherapeutics Inc., a vaccine company from Massachusetts (USA), has been awarded the license to market Peru-15 for commercial purposes such as the development of a cholera vaccine entitled CholeraGrade TM (23). AVANT Immunotherapeutics Inc. maintains very close contact with the U.S. Department of Defence as it has been working on several Defence department’s projects aimed to provide better health care to the U.S. Army personnel. To develop CholeraGrade TM as a traveller’s vaccine to be used predominantly by soldiers has been one of the goals of AVANT Immunotherapeutics Inc. This has been mentioned by the company President Dr. Una Ryan, in her report to the U.S. House of Representative’s Biological Warfare Programs on October 23, 2001 (24). Thus the ICDDR,B’s research on Peru-15 demonstrates the use of Bangladeshis as experimental guinea pigs for a product to be used by the US Military.
The Government of Bangladesh did not recognize the apartheid regime of South Africa. The ICDDR,B’s total disrespect for the charter was further demonstrated when it was revealed in 1985 that the ICDDR,B had been colluding with the apartheid regime of South Africa thereby prolonging the sufferings of the black population (25).
The timing of the ICDDR,B’s research to develop AQUIS for the US Military coincided with the agenda of the present US government to take military control of the Gulf region, even under the pretext of lies. The blue print for a regime change in Iraq was drawn before 2001 and implemented soon after the present US government took control in 2001 (26). The ICDDR,B’s development of AQUIS was reported in September 2002, just half-a-year before the invasion of Iraq. Therefore it appears that the ICDDR,B was working to fulfill the need of the US Military by completing the task shortly before the invasion of Iraq.
One leading Bangladeshi newspaper has recently described the ICDDR,B “ to have become a one-man show with its executive director deciding over controversial recruitment and alleged unethical researches.” (27). Although the Centre has a 16-member board that meets twice a year, its Director David Sack decides almost everything unilaterally making the Trustee Board an object of symbolic importance (27). Yet the Centre collects millions and millions of dollars from tax-payers of various countries using the name of the diarrhoea suffering poor people of Bangladesh. It is a failed institution in tackling the diarrhoeal problem of Bangladesh (2, 3, 27). Instead, as documented in this article, the ICDDR,B’s American Director utilizes the Centre’s facilities and resources to help the US soldiers for the illegal invasion and occupation of Iraq, an act the Government of Bangladesh hosting the Centre did not endorse.
References:
1. Cook GC (2001) Influence of diarrhoeal disease on military and naval campaigns. J. R. Soc. Med 94: 95-97.
2. Ali M. (2004) What is for the ICDDR,B?
(http://www.meghbarta.org/nws/nw_main_p02b.php?issueId=9§ionId=30&articleId=99)
3. Ali M (2005) ICDDR,B's procurement of the Independence Day Award - an insult to the martyrs in the War of Liberation of Bangladesh
(http://www.meghbarta.org/nws/nw_main_p01b.php?issueId=6§ionId=14&articleId=65)
4. http://icasualties.org/oif/
5. More Than One-Third of Iraq Troops Suffering Migraines (2006)
(http://www.nlm.nih.gov/medlineplus/news/fullstory_35215.html)
6. A water tale for all seasons (http://www.physorg.com/news6196.html).
7. Sanders E. Heat can be withering enemy. Los Angeles Times, August 11, 2004.
8. Hyams KC, Bourgeois AL, Merrell BR, Rozmajzl P, Escamilla J, Thornton SA, Wasserman GM, Burke A, Echeverria P, Green KY , et al. (1991). Diarrheal disease during Operation Desert Shield. N Engl J Med. 325:1423-8.
9. Sanders JW, Putnam SD, Riddle MS, Tribble DR, Jobanputra NK, Jones JJ, Scott DA, Frenck RW. (2004) The epidemiology of self-reported diarrhea in operations Iraqi freedom and enduring freedom. Diagn Microbiol Infect Dis. 50:89-93.
10. Chatterjee HN (1953). Control of vomiting in cholera and oral replacement of fluid. Lancet. 265(6795):1063.
11. Phlo Corporation. Tests by Top Scientists at the ICDDR,B Demonstrate the Superiority of Phlo’s Oral Rehydration Solutions. Business Wire. June 4, 2003. 12. Phlo Corporation. Phlo Corporation Hires Former Defense Departments and Coalition Provisional Authority Officials. Primezone. May 18, 2004.
13. http://www.strategypage.com/messageboards/messages/478-1104.asp
14. Phlo Corporation: Phlo Announces That a Corporate Group Has Commenced Sales of AQUIS to the U.S. Coast Guard. October 26, 2004.
15. http://forums.military.com/
16. http://www.drinkaquis.net/
17. SAREC Report on Developmental Research in Sweden, (Editor: Cecilia Molander) R2: 1981, Stockholm, Sweden
18. Cohen D, Orr N, Haim M, Ashkenazi S, Robin G, Green MS, Ephros M, Sela T, Slepon R, Ashkenazi I, Taylor DN, Svennerholm AM, Eldad A, Shemer J. 2000. Safety and immunogenicity of two different lots of the oral, killed enterotoxigenic escherichia coli- cholera toxin B subunit vaccine in Israeli young adults. Infection and Immunity, 68:4492-7.
19. Qadri F, Wenneras C, Ahmed F, Asaduzzaman M, Saha D, Albert MJ, Sack RB, Svennerholm A. 2000. Safety and immunogenicity of an oral, inactivated enterotoxigenic Escherichia coli plus cholera toxin B subunit vaccine in Bangladeshi adults and children. Vaccine. 18:2704-12.
20. Clemens JD, Sack DA, Harris JR, Chakraborty J, Khan MR, Stanton BF, Kay BA, Khan MU, Yunus M, Atkinson W, Svennerholm A-M, Holmgren J. 1986. Field trial of oral cholera vaccines in Bangladesh. Lancet. 19;2(8499):124-7.
21. Finkelstein RA. 1995. Why do we not yet have a suitable vaccine against cholera? Advances in Experimental Medicine and Biology. 371B:1633-40.
22. Kenner JR, Coster TS, Taylor DN, Trofa AF, Barrera-Oro M, Hyman T, Adams JM, Beattie DT, Killeen KP, Spriggs DR, et al. 1995. Peru-15, an improved live attenuated oral vaccine candidate for Vibrio cholerae O1. J Infect Dis. 172:1126-9.
23. Avant Immunotherapeutics Inc. USA, Business Wire, January 20, 2004.
24. The U.S. Congress, Subcommittee on National Security, Veterans Affairs and International Affairs, Hearing on Biological Warfare Defense Vaccine Research & Developmental Programs, 23 October 2001.
25. Turnbull PC, Lee JV, Miliotis MD, Still CS, Isaacson M, Ahmad QS. 1985. In vitro and in vivo cholera toxin production by classical and El Tor isolates of Vibrio cholerae. Journal of Clinical Microbiology, 21:884-90.
26. Mackay N. Bush planned Iraq “regime change’ before becoming President. Sunday Herald, September 15, 2002.
27. M. A. Khan. Mismanagement mars ICDDRB's reputation. The Daily Star (Dhaka, Bangladesh), June 16, 2006
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