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30 JUN 2016
In the 1960s, a group of American and Bangladeshi scientists embarked on a barge, turned floating cholera hospital that drifted around a cholera-prone sub-district of Bangladesh aiming to treat patients and save lives.
The barge used to float around Matlab – the sub-district around 50 kilometres away from the capital Dhaka – which was then a low-lying marshy land. People at Matlab suffered frequent cholera outbreaks leading to a high loss of lives. The doctors and researchers aimed to improve the treatment of cholera patients, who were brought to the floating hospital from remote areas by boat and to find appropriate preventive strategies for control of cholera including evaluation of vaccines against cholera.
Nobody at the time could know that the barge, originally used as a field hospital by the Pakistan-SEATO Cholera Research Laboratory (now icddr,b), would develop into the Matlab Health Research Centre - a full-fledged health care facility and one of the most important research sites in the global South.
Besides treating patients, the scientists also spread health messages and gained invaluable experience needed for cholera research. “Treating cholera patients and doing cholera research were not easy tasks because we needed to gain the trust of people by showing that lives of deadly cholera patients can be saved by taking great care in treating them,” says Dr Mohammad Yunus, an emeritus scientist at icddr,b.
Dr Yunus has spent four decades of his life at Matlab, from the barge to the mainland, witnessing the Liberation War in 1971 when the Matlab hospital remained in operation. “The hospital case fatality (death tolls) had always remained less than 1% at Matlab and it showed the effectiveness of our treatment,” adds Dr Yunus.
One of Matlab’s most important early contributions was the role it played in the further development of oral rehydration solution (ORS), an inexpensive drinking saline made from salt, molasses and water, which was first applied at Matlab in 1968. Described by the prestigious medical journal the Lancet as “potentially the most important medical advance of the 20th century,” ORS is estimated to have saved the lives of 50 million people globally.
50 years of health monitoring
In 1966, a Health and Demographic Surveillance System (HDSS) was introduced at Matlab to maintain records of birth, death and migration initially in order to conduct cholera vaccine trials and also to gain deeper insights into public health problems in a typical rural area of Bangladesh on a large scale.
Doctors at the Matlab hospital in the 1970s. Photo: icddr,b
Dr Peter Kim Streatfield, an emeritus scientist who has been involved with Matlab for long, feels that the implementation of sound scientific research on health and population requires accurate data on births, deaths, and illnesses. However, the national civil vital registration (CVR) systems to record these events are expensive, and over 100 developing countries, including Bangladesh, still do not have efficient comprehensive CVR systems.
Complete and accurate data on demographic and health events on a small population is better than incomplete and poor quality data on a large population – the approach taken by Matlab HDSS, says Dr Streatfield. This is the whole basis of HDSS, he adds.
Over the years, these data contributed to a number of breakthrough studies, including the tetanus toxoid vaccine’s protection for newborns, assessing effectiveness of cholera and rotavirus vaccines, family planning, use of zinc supplementation in childhood diarrhoea, and the effect of flooding on water-borne disease.
Since the 2000s, HDSS data have been used in studies of other health problems, such children’s risk of drowning and the health consequences of arsenic contamination. Matlab studies have also helped to reveal the upsurge of non-communicable diseases in Bangladesh.
Who can use these data?
“Data from Matlab HDSS are published in annual reports like census reports that are publicly available,” says Mr Taslim Ali, Senior Manager of HDSS at Matlab. “If health researchers are looking for further disaggregated-level data, icddr,b has a policy through which researchers can place their requests,” he adds.
[Click to enlarge] Infographic: icddr,b
The longest-running HDSS in the developing world now covers a population of 230,000 in 142 villages at Matlab. Some of the salient data trends from the HDSS show that total fertility rates and under-five mortality, including infant and neonatal mortality rates, have steadily declined in the study area, while life expectancy at birth and mean age of marriage have steadily increased over the years.
With icddr,b responsible for healthcare services across much of the HDSS area, Matlab provides a site where novel public health interventions can be put to test at scale, to obtain scientific evidence to inform health policy and strategies. icddr,b’s experience of running a kangaroo mother care (KMC) project in its Matlab hospital is one such example. By drawing on this experience, icddr,b researchers participated in a national-level advisory group and contributed to the development of KMC guidelines.
Adding to its significance at a global level, Matlab HDSS has been a model for the international INDEPTH Network, an umbrella organisation for HDSS initiatives in 20 low- and middle-income countries, which are generating a wealth of data to inform national and international health policies.
Dr Streatfield says that the approach taken by Matlab HDSS to have complete and accurate data on demographic and health events on a small population was innovative at the time, and its spread across the developing world through the INDEPTH Network has proven to be a very efficient way for resource poor settings to conduct world class trials of health, population and nutrition interventions, and contribute to development and better health of their populations.
Recent HDSS data have confirmed that, 50 years on, Matlab continues to provide outstanding clinical care to cholera patients. In 2014, no children under 5 years of age died due to diarrhoea in Matlab area – a condition that, globally, claims more lives than malaria, AIDS and tuberculosis combined.
icddr,b scientists expect that Matlab has a lot to offer for future research with its wealth of data and community resources. For example, a major study is underway to identify factors responsible for preterm or stillbirths. Matlab is also hosting an important trial of a new vaccine against hepatitis E virus, which is responsible for the deaths of many pregnant women. In addition, the huge amounts of data, spanning four generations of residents, provide opportunities for many retrospective studies.
Dedicated to the community
Matlab Hospital, run by icddr,b, is a vital and highly respected community resource, providing treatment and routine check ups to the local community over generations. Working at Matlab Hospital for almost two decades, Dr Chandra Shakhar Das, Senior Medical Officer says that he has always perceived Matlab as an ideal place to serve people because of its vision and service despite its remote location.
Living close to the hospital, Sufia Khatun has spent her whole life at Matlab and is now in her late 70s. For over five decades, she and her family have been receiving free treatment at Matlab Hospital. She acknowledges how it has benefited four generations from her family.
Sufia’s daughter Rina, in her 40s, granddaughter Nasrin in her 20s and great-granddaughter Nadia (4) have all benefited from treatment, advice and regular check-ups at the hospital. “My daughter suffered from post-birth pneumonia but we decided not to take her to Dhaka,” says Nasrin. “Instead, we admitted her at Matlab Hospital where she recovered after 11 days’ of treatment and care.”
Not only Sufia’s family, but the whole area has been benefiting from this health facility, and many people from the local communities have found employment in Matlab’s projects and field work. Many of these people are pleased to be involved with an institution dedicated to saving lives.
The attachment of many of these people with Matlab Hospital can sometimes be measured in decades rather than years and it’s not only the people of Matlab who share this attachment, icddr,b’s current Executive Director, Professor John D. Clemens, also holds a strong connection to the Matlab barge, having worked and lived on it, serving the people of Matlab, in the 1980s.
icddr,b executive director Professor John Clemens was once a researcher working in the barge. Photo: icddr,b
Mr Nur Islam Gazi has been feeding the sick for six decades as the chief cook of Matlab Hospital. His experiences span the Pakistan period, the Liberation War and post-war Bangladesh. “I just feel good to be here, I am not really ambitious and never felt like moving away.”
Mr Tajul Islam has worked as a laundry operator at Matlab Hospital for over three decades. “I feel good that I am in the process of helping ill people who come here,” he says. Mr Mohammad Selim has been a speedboat driver at Matlab for almost two decades. He carries patients with cholera, diarrhoea and pneumonia to the hospital via the narrow canals that still survive at Matlab. “I like that the hospital provides treatment in this rural and remote area. Without these speedboats, many people would have faced trouble to come to the hospital,” he says.
In the midst of these people, the old barge now stands still on the Matlab Hospital premises. Made in the British period sometime during the 1800s, it bore witness to many interesting events. It was a prison for the pirates captured from the canals, who were then judged and jailed by a resident judge on board. Refurbished, the barge sailed the same canals again 100 years later, this time saving the lives of ill people. Its legacy now lives on in Matlab Hospital, delivering life-saving care to the community and hosting research that will shape the healthcare of the future.