BANGLADESH - A REFLECTION by Marjorie Bandy

I first went to Bangladesh by default. Our TA unit had been asked by the Bangladesh Armed Forces Medical Services [AFMS] to provide a team of nursing officers to teach and improve standards within areas of high dependency care for the Military. At that time our unit was commanded by a consultant anaesthetist of some renown, who spent a fair proportion of his time lecturing world-wide. He considered that based on his own experiences in the third world it would be necessary for the team to take with them an administrator to ensure that the team could spend its limited time in the country actually teaching.

It was decided that the unit admin officer should take up this task. Unfortunately, the planned time frame for this exciting venture had to be changed and the admin officer was then not available. Based on my previous experience I was asked to take his place. So it was that I became “the fat controller!” The first team deployed to Bangladesh in 1993 to work in a very administratively efficient AFMS and my skills as a nurse together were far more necessary than my skills as an administrator. To be fair it subsequently proved our CO right that it was essential that a fairly senior officer was needed to head the team to ensure the programme running “nearly” to plan, but able to manage unexpected and sometimes unusual changes.

To be able to appreciate the difficulties of working in Bangladesh at that time it is necessary to have some understanding of the country’s history. Bangladesh was originally part of the Bengal area of India but unlike much of the Indian continent the predominant religion was Muslim. Following independence for India there was conflict between Muslim and Hindu areas resulting in 1947 with an independent Muslim Pakistan of which Bangladesh was part. This was not a happy marriage and following a very bloody war and the loss of 3 million soldiers and civilians, Bangladesh became an independent country in 1973. The country is overpopulated and very poor, despite 3 rice crops a year unable to feed itself without importing food. The discovery of natural gas in the Bay of Bengal has helped to reduce poverty to some extent.

Each year the team was asked to provide a programme to teach three groups of 10 nursing officers,  ICU technicians and medical assistants. The first year was the most traumatic as the team had no idea what to expect. The culture shock and different way of working were much more difficult that we had imagined despite having done our best to be prepared. Added to this many of the hospital staff were not enthusiastic at our arrival, perhaps thinking that we would attempt to change things completely with no account being taken for their customs, culture and religion.

Within their system staff only look after patients of the same sex and indeed female patients and children are treated in a separate building with the exception of theatres, ICU and CCU. Medical officers who had an opportunity to undergo higher professional training in a western hospital were anxious to improve standards and to introduce a more hands-on care approach for nurses. Picture the scene where wards of 50+ beds had only one trained nurse on duty 0800 – 1400 six days a week and then on call for the rest of the time because there is no trained nurse relief. The task of trying to promote change without causing offence was initially daunting.

On the first visit little was available in the way of visual training aids. The maxim being if you need it take it with you. All of this does not take into account the enthusiasm and thirst for knowledge of our students. On the first visit, aids such as Resus Annie were so old they were almost unusable, as was the overhead projector. On future visits equipment was gradually replaced and upgraded.

The initial plan was to run courses for the full duration of the visit, running separate and joint lectures. Lectures had to take into account the necessity for translation and explanation as we were teaching a group who overall, only spoke Bangladeshi. Once we arrived in theatre, we discovered that the students would be expected to sit a final examination in English. This meant some re-arrangement of our initial programme, that continued on for all successive visits, sometimes because of requests of change by our hosts or illness in a member of the team.

One of the most difficult areas was always practical teaching and hands-on practise by the students. Traditionally nursing officers led the wards in a mostly managerial capacity with nursing aids and relatives carrying out basic nursing care. We soon realised the nurses had little strength for such things as lifting. In addition, the Muslim culture doesn’t allow for physical contact with male patients or indeed work as a pair with a male colleague. Once these boundaries had been realised and our teaching plans adjusted it became easier to plan and implement teaching programmes.

Over a period of time changes and improvements took place. This was noticeable in ICU where patients were provided with nursing care such as washing and passive physio for the unconscious patient. Humidifiers were no longer being left with the same water in between patients, increased response times to dealing with emergencies achieved and protocols gradually being written and implemented are examples of improvements. All of this might seem very little for the cost of sending 6 people annually to Bangladesh, but when one considers the cost of extra days spent in hospital because of pressure sores and the lack of infection control measures, it is a cost saving expense. With the numbers passing through the one military hospital in Dakar alone the potential saving is enormous. 

For me personally the greatest satisfaction came in 1997 when I was given a copy of the Defence Advisor’s report to the Foreign Secretary which suggested that our team was one of the most cost -effective sent to aid this Commonwealth Country [military] during that year.

For everyone who took part in this venture it was a challenge and educationally stimulating, requiring a great deal of preparation to ensure the highest standards of teaching despite the limitations. Everyone learnt to be adaptable to meet with the unexpected. Without doubt everyone who took part gained from experiencing the difficulties of the Third world and to appreciate our NHS. Lastly it would not have been such a success without the work and enthusiasm of all the people who accompanied me.



Marjorie Bandy

Chair Jurassic Coast Branch