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WHERE WE ARE

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1000th of earth land

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BANGLADESH

• On the Bay of Bengal• Largest delta (Ganges, Brahmaputra, Meghna)• Extremely fertile• National symbols: – Anthem .. – Animal: RB Tiger. Mosque: Baitul Mukarram, Poet: K. N.

Islam, Bird: Magpie Robin, Fish: Hilsa, Flower: White Water Lily, Fruit: Jack fruit, Tree: Mango, Sport: Hadudu

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Magpie Robin (Doel)

18Ha-du-du is our national game; popular in villages

19Jatiya Sangsad Bhaban, (Louis Kahn), one of the landmarks of 20C architecture, one of the largest legislative complexes in the world

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Jatiya Smriti Soudha

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Country Profile

• Area: 147,570km2 (94th)• Popn.: 160mln (8th) (2%); density/km2: 1033(12th)Median age: 23y• Total exports >$30B. GDP $160B/y. PC: $1190

Growth: 7%/y. Forex reserve $25B (2nd SAARC)• Poverty reduced to 25%: PL (<$1.25/d). 84%

survive on <$2/dPL: poverty line

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• Division: 7, District: 64, Upazila: 503• Union: 4484, Villages: 87319. Urban popn.: 28%• 800 rivers: 24,140 km• 38 languages. (Bangla 98%; the lingua franca)• Ethnic minority 27 (2 mln). Largest Chakma

4,44,748 Marma 2,02,974• 85% households avail improved water

Country Profile ...

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Ethnic minority 27

25800 rivers: 24,140 km of rivers

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Rural poverty• 72% popn. are rural; ~farmers• Natural disasters and climate change, make rural

living more risky

Urban poverty• Poor migrate to towns; live in slums. Dhaka has 1 of

the biggest slum-populations

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Rural poverty`

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Urban poverty

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Village market

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• 2nd largest RMG exporter ($23 B/y): 4 mln women. Manpower export: $14 B/y

• Exports: leather, jute, drugs, fish/frozen food, etc.• Achieved the MDG 1 target in 2012 • Has food security• Potential of >11,000mw electricity• Extensive solar panels in non grid areas• Extensive mobile network; less to internet

Major future risk: vulnerable to climate change

Country Profile ...

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• Literacy: 75% (15-25y). Life expectancy: 64.5y• Free educn. in 1y and 2y schools. 310 million TB free/y

• School entry: 90%, complete 50%• Cost of higher educn. is minimal• More female students in high schools

• Women’s empowerment: economic activity has increased from 8% to 57% (1983-2011), India (29%), Srilanka (35%), Pakistan (22%)

TB: textbooks

Country Profile ...

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THE BEAUTIFUL LAND

• Full of sceneries, festivals, sports• Full of flowers, fruits, vegetables, medicinal plants• Full of birds, animals, fish• Full of crops• Full of young people

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37Spotted deer in Sundarbans: largest mangrove: 38,500 sq km, 1/3 water; a wildlife sanctuary, 400 RB tigers and ~30,000 spotted deer

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Python in Sundarbans

A Red-Faced macaque

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57Bilimbu

Fruits

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Cham Kathal, like a jackfruit, but only 6” long. pods are similar to a Jackfruit but with a slightly sour taste

Clockwise from bottom: Kath Lichu, Deshi Gab, Bel and Nuinya Fol. Kath Lichu tastes similar to Longan, but is much smaller

Dewaa

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Aloe vera juice and Shorbot are very popular

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Chiku

Bahera

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Golapjam

Wax Apple

Lotkon

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Pomelo

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Velvet Apple

Sugar Apple

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Haor

68Madhabkunda. Hamham

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ShuvalangNafakhum

Apu khagrachari

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Full of Festivals

Eid-E-Miladunnabi

80BISHWA IZTAMA

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Iftar

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Pithas

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Muharram

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Pahela Baishakh

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Rathyatra

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Golden temple, Bandarban

93BUDDHA PURNIMA

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KITE FESTIVALS

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Nabanna Utsab

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SPRING FESTIVAL

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Baishabi: Water Festival: Rakhain NYD. B&G throw water at each other. Boys come across from different places with music and dance; girls throw water to the boys of their likings. Cox’s Bazar

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Traditional Sports in Bangladesh

• Kabaddi, Lathi khela• Kusti (wrestling), balikhela• Chess, Loodu• Kiting• Boat racing (Nouka baich)• Football• Swimming

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101JABBARER BALIKHELA

Lathikhela

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Hundreds of

medicinal plants

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Cottage crafts

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Successes of Bangladesh

• Success in health sector:• Nobel: Prof. Dr. Yunus• Cricket, Everest win• Garments: 2nd largest• Drug act, EPI success• Islami banking

• Language movement• Largest NGO• Inventor of radio• 1 YouTube founder• FR Rahman• Channel winner Brozen

Das

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• MMR fell by 75% since 1980 1

• IMR fell by >50% since 1990 2

• Life expectancy 68.3y, >than India and Pakistan 2

• Remarkable fall in Total Fertility Rate in the last 4D

1. Hogan MC, et al. Maternal mortality for 181 countries 2008: a systematic analysis of progress towards Millennium Development Goal. The Lancet 2010;375:1609-23

2. Chowdhury AMR, et al. The Bangladesh paradox: exceptional health achievement despite economic poverty. The Lancet 2013; published on line 21 Nov. S01040-6736(13)62148-0

3. The Economist. The path through the fields. The Economist 3 Nov, 20124. Abed FH. The Lancet. 2013. http://dx.doi.org/10.1016/S01040-6736(13)62112-1

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Millennium Development Goals (MDGs):Signed in 2000 to achieve by/2015:

1. To halve No. of undernourished people (achieved)2. To achieve universal primary education3. To promote gender equality and empower women4. To reduce child mortality5. To improve maternal health6. To combat HIV/AIDS, malaria, and other diseases7. To ensure environmental sustainability8. To develop a global partnership for development

1,4,5,6 are directly health related

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Hon’ble PM’s 3 UN Awards last 5 years

MDG 4 2010Digital Health 2011

P overty R eduction 2013

Vis iting IT U S ecretary G eneral Dr Hamadoun I T oure is witness ing telemedicine s ervice in S avar UpazilaHos pital (March 2, 2010)

2 for Health

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Nobel Peace Prize in 2006, for alleviation of

poverty

Fazle Hasan Abed. BRAC

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116Bengali Language Movement (Bhasa Andalan) in the early-1950s

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Jawed Karim: YouTube

Channel winner Brozen Das

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Potentials of Bangladesh

• To be the largest garments exporter• Big exporter of drug, food, skilled manpower • Exporter of ship, furniture, cottage crafts• Green (renewable) energy• Unique for tourism• Great Sports country• Outsourcing

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Pharmaceutical Industry

• Make 97% of required medicines • Yearly sales: $1.2B• >100 fold growth in 30y• Exports to >70 countries

National Drug Policy in 1982 allowed the production of generic drugs at competitive price and the

development of local Pharmaceutical Companies

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Mineral Resources in Bangladesh:

mostly untapped

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Problems of Bangladesh

• C o r r u p t i o n• Poverty, Illiteracy• Overcrowding, IDs• Malnutrition (stunting and wasting)• Unplanned cities, traffic jam• Air and water pollution• Bad governance and lack of political will• Lawlessness, violence, brutality• Natural disasters

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Problems of our Children• High mortality• ID, Mn., VADX, anemia • LBW (22%), prematurity• Faulty feeding• Accidents: (drowning,

poisoning, animal bites, fall, RTA)

• Chr. Hemolytic A, worms

• Child labor, no schooling, drop-out domestic violence

• Emotional deprivation• Mutilation, begging,

child trafficking• Slum, Street children

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Child Status in Bangladesh• Child population: 40%• MMR: 240/100,000 LB• U-5MR: 52/1000 LB (IDs, Drowning, accidents)• IMR: 42/1000 LB (Pn., D, Mn, IDs)• NMR 32/1000 LB (BA, NNS, LBW)• U-5 malnutrition: chr. 43%, ac. 13%• Girls married <18y: 70%• Child labor: 7%

125shiree 2009 shiree 2010 shiree 2011 BDHS 20110

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Stunting Underweight Wasted

Stunting, wasting and under-wt. inU-5s

WHO threshold for 'very high‘ prevalence of

stunting (40%)

WHO threshold for 'very high‘ prevalence of

underweight (30%)

WHO threshold for 'very high‘ prevalence of

wasting (15%)

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Challenges our children facing

• Street and slum children• Child-marriage• Child labor, - abuse, no schooling or high

drop-out• Urban slums are the worst in MCH: x6 drop-out and

a vicious cycle of poverty• Lowest birth registration: difficult to save children

from trafficking, labor and marriage

MCH: maternal and child health

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Reduction of MMR (240/100,000LB: 2010)

• ANC, TT, nutrition, hospital delivery• Detection of preg. complications • SBA at community level• 24h emergency service for labor at HCs• Full functioning referral system

SBA: skilled birth attendant. HCs: health centers

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Reducing NMR (BA, NNS, LBW)

• ANC, TT, maternal nutrition and Fe and B9• Steroid for preterm labor. KMC• Essential NB care (clean- place/catch/cut/

chorhexidine for cord, HBB)• Prevention and Rx of NNS, birth trauma• SCaBU at Upazila, district and 3y care hospitals

• BF in first hr (saves 1 million globally). EBFHBB: helping babies breathe. KMC: kangaroo mother care. SCaBU: spl. care baby unit. NNS: neonatal sepsis. EBF: exclusive breastfeeding

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Reduction of U-5 MR (+NMR, +IMR)(IDs, Drowning, accidents)• Reduction of NMR, IMR

• Prevent drowning• IMCI (ARI, D, F, Otitis, Mn, Feeding, HPVAC, EPI)• EBF, CF (IYCF)• Effective referral system• New vaccine (pneumococcal, Flue,) • More trained health workers, more resources

IMCI: integrated management of childhood illness. IYCF: infant and young child feeding. CF: complementary feeding

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U-5MR in Bangladesh

IDs: 62.1%

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WHOEnding Preventable U-5MR by ’35• ANC, nutrition and Fe+B9 in preg, SBA• Steroid in preterm labor, KMC• Essential NB care, cord care, Mx. of NNS• SCANU, EBF / IYCF• Rx of IDs• EPI: new vax• IMCI, injury and drowning prevention• Zn and ORT, management of malnutrition

NNS: neonatal sepsis. KMC: Kangaroo Mother CareSBA: skilled birth attendant

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Special note

• For MDG- 4 the main focus is NMR, drowning• Most births/death occur at home: mother and baby

are secluded for days with unhealthy practices

• Outreach care, healthy home-care practices recognition of danger-signs, seeking skilled care, can lead to great reductions in NMR

1989-93 1992-96 1995-99 1999-2003 2002-06 2007-110

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Neonatal Mortality Infant Mortality under-five Mortality

2016 Aim: 21

Deaths per 1,000 live births

2016 Aim: 482016 Aim: 31

Trends in Child Mortality

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Source: BDHS 2011

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C/death of children 1-17y

• Drowning, trauma, suicide, animal bite (41%)

• IDs: Pneumonia (20%), diarrhea (12%); diarrhoea plus pneumonia (5%), meningitis (7%), septicemia (2%). Total 46%

• Malnutrition (13%)

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Child Injury: greatest killer among 1-17y:

• Reducing injury-mortality is essential for MDG-4• 2,600 injured/d; >80 deaths (53% among 5-17y)– 36 become disabled

• >50% injury deaths are c/by drowning (the biggest killer among 1-4y (26% deaths)

• Injuries are more during floods and cyclones. Drowning caused 77% and snake bite 10% of deaths in 2007 floods. A lack of supervision and skills are the main reasons behind injuries

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Drowning: >97% in 3WC: 57% 1–2y• Bangladesh: 45/d: 1/30min. Near D: 182/d• Mostly in morning (68%), in ponds (69%), mom was

busy (70%)• A silent public health emergency /epidemic• Preventable but few programs• Children aged 1-4y, and 5-9 are at highest riskTo Prevent• Supervision; skills: swimming, CPR, etc.• Raising awareness3wc: third world countries

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• RTAs: leading killer: 10-14y; followed by falls, burn, animal bites, poisoning, violence. RTA loses 2% GDP and make 38,000 children orphans/y

• Suicide among 15-17y: >6 deaths/d

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• Injury Sex Total Male (n = 108) Female (n = 102) No. %

• Burn 10 (9.3) 60 (58.8) 70 33.3

• RTA 47 (43.5) 13 (12.7) 60 28.6

• Occupational injury 19(17.6) 16 (15.7) 35 16.6

• Fall 12 (11.2) 8 (7.9) 20 8.1 • Animal bite 6 (5.6) 3 (2.9) 09 4.3 • Drowning 4 (3.7) 0 (0.0) 04 1.9• Fall from tree 5 (4.6) 1 (1.0) 06 1.4 • Electric Burn 2 (1.9) 1 (1.0) 03 1.4• Poisoning 2 (1.9) 0 (0.0) 02 1.0 • Chemical burn 1 (0.9) 0 (0.0) ` 01 0.5

Injury pattern in urban slums: Dhaka

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ACTIONS• GoB: injury Px as 1/5 priorities for CH• To make homes, schools and communities safeHome: awareness; making homes and play-areas

child-friendly, swimming, proper supervisionSchool: safe learning (physically safe, emotionally

secure and psychologically enabling). Safety risks, injury –prevention, basic first-aid

Community: supervise children 1-5y for 4h/d, 6d/w. Supervisors are trained on ECD, injury Px., healthy practices

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IMPACT• Significant fall in injuries• Drowning among 1-4y in 3 Upazilas is now 72/

100,000 children instead of 96. Injury mortality (1-17y), is now 47/100,000 instead of 51

• While homes, schools and communities have become much safer, an increase in suicides (10-17y) dilutes the success

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Animal bites: significant M&M globally

• 5 million snake-bites/y: 0.5million deaths; mostly in Africa and SEA. Tens of millions dog bites. Awareness is crucial to Px

Snake bites• Death and disability (inf., tetanus, scarring, psycho.

sequelae). Scarcity of antivenom is big• Rx: immobilization of affected part and prompt

transfer. Wound cleansing, supportive (airway, TT)• HCP should be trained in SB, use of AVHCP: health-care provider. Av: antivenom. D&D: death and disability

California Red-Sided Garter Snake

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Dog bites

• Higher in 3WC. Mostly children• Most deaths from Rabies• Rx: depends on the site, immunity of dog:

• Irrigation and cleansing of wound• Primary closure if the wound is low-risk• ABT for high-risk wounds, TT• Post-exposure Rx (dog vaccination status)

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DISCUSSION • After great progress in ID; child trauma must

now be addressed: drowning, RTA, burns, falls, NAI, suffocation

• Diarrhoea is still high; ORT still low• Better Rx of Pn., 2w-Zn Rx may reduce Pn; duration-

severity of D; decrease D and ALRIs in next 2-3mo• Safe water, sanitation, hand washing also important• VADX is potentially-lethal but preventable. Eating

VA-rich F&V and fortified oil and flour are important

NAI: non-accidental injuries. F&V: fruits and vegetables

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Our Public Health Centers

• Most are in disrepair. Widespread absenteeism; bribery, misuse. Dr./nurse: 2:1 (1:3). Poor compliance, monitoring. Workforce is adequate

• Maternal HS and FP yet not reached the needy

• Connection of families with HS is lacking. People avoid HC: negative attitudes, gender bias. Traditional healers or a drug stores treat more pts.

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UNICEF in Bangladesh

>150 countries and territories

• Largest provider of vaccines for DCs (10 for us)• Supports health, nutrition, water, sanitation, basic

educ., protecting from violence, AIDS, exploitation

Funded entirely by the voluntary contributions of individuals, businesses, foundations and Govt.

162Children queue to receive HPVAC and de-worming tablets

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Early education is a strategic investment

• Early years of a child are crucial. ECD is UNICEF’s priority; mainly for underprivileged. But 80% of them are reached. ECD centers teach thinking language, R&R to prepare them for school

• ECD centers make children like Swapna better prepared for school and to complete school. It’s the most efficient way of combating poverty

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• Swapna, unlike most children in the slum attends one: “I like the school because I can study sing dance and meet friends”

• But 1 big challenge is school absenteeism• Most slum children work. Swapna’s brothers, aged 8

and 7 used to go to school but now work• Her father is a taxi driver, mother HW. Today she

could not eat BF

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Swapna, 5, plays with UNICEF’s Arifa at a ECD centre in Dhaka

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UNICEF also addressesChild Abuse, Exploitation and Trafficking• Children are trafficked into bonded labor, brothels; camel

jockeys, abused in home, workplace, school community; also vulnerable to HIV/STDs, drug abuse, failing education, violence, or separation from family. Disabled children are more vulnerable

• UNICEF is working to establish children's rights, reintegrating children in societies

Gender based violence/IPV• Child marriage, dowry, violence

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UNICEF for disabled children

• Disabled children have many abilities, but are often excluded, the most invisible, vulnerable . They face many challenges

• UNICEF brings global attention to them

• Rx for disability is expensive, frustrating• UNICEF encourages to continue Rx and send them

to school as education gives them confidence

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2 Examples• Hridoy, 9, and Bristi, 10, are disabled• Bristi has neuro-, Hridoy mental, physical disabilities. They

try hard to keep up as they dance with other children in a UNICEF drop-in centre in Dhaka. Their smiles sparkling eyes show their enjoyment

• Friends didn’t help rather told mom to let her die. Father abandoned them, mother cares for 3 children. Bristi stood at 3rd y, and she had disfigured hands and legs. Never seen by a Dr

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Bristi and Hridoy dance with their friends during class at a drop-in centre in Dhaka run by UNICEF

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• Hridoy’s mother, took a job in Lebanon. Her money stopped coming

• Hridoy and Bristi got support from UNICEF. They have enrolled in the drop-in-centre. Bristi is intelligent and doing well

• “I want to be a judge”, she says

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Hridoy is picked up at school by his rickshaw puller father

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Bristi attends school in Dhaka

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UNICEF Fights Malnutrition

• 40% U-5 are stunted– nutritious balanced foods and healthy practices– EBF, vaccines, Rx of disease– Changing mindsets, breaking traditions and taboos:

vegetables and some fruits are not good• Gardening and duck and cattle rearing help: add

F&V, eggs milk and can sell the surplus• Flood can completely destroy both. But with the

extra income one can recoverBilquis had to beg to feed 2 children. Now, with vit-protein-rich meals

and a small saving, she’s planning a better future

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Role of CHW

• CHWs have success stories: they counsel women in remote areas for awareness on MCH. They try to change mindsets and encourage immunization

• They conduct sessions with women and midwives on safe delivery, BF, warning s/of illnesses and where to Rx.

• They are a critical link between the villagers and HC

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Violence (IPV: 22%-48%)

Many mothers with children experience IPV. This threatens health of both

• IPV against mothers by husbands is a factor that directly/indirectly cause poor health of children, incapacitation of mothers, miscarriage, fetal and infant death, and neglect of children

IPV: Intimate Person Violence

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Global Key facts

• Globally, U-5MR fell from 12.6/1990 to 6.6 million/2012• In DCs, U5-under-wt dropped from 25% to 15% …• SBA-Births have increased, but are still <50% in Africa• HIV declined by 33%. TB is falling, but MDR-TB increased

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MCQ

• For MDG-4 reduction of NMR is most important• Drowning is the greatest killer among 1-4y children• Diarrhoea causes the highest mortality in children• 1st hour breast-feeding can save a million globally• Most snakes are non-venomous• Child labor is a great hindrance for child

development

182Schoolchildren Climb On Unsecured Wooden Ladders, Zhang Jiawan Village, S China

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184125-Mile Journey To A Boarding School Through The Mountains, Pili, China

185Kids Traveling To A Boarding School Through The Himalayas, Zanskar, India

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Laila Bagge visits children in slums

• She also visited a UNICEF ECD place for children. She learnt their experiences in slums

• She met 9-y Jahanara. Slum-homes are just tents made of plastic sheets on roadside: ~ 6 people live in each: no ventilation, water nor sanitation

• Jahanara lives with her mother, 2 sibs, grandma and 2 uncles. Her mother is a cleaner (900 ta/mo)

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Jahanara

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• Ms. Bagge squeezed into the tent, joining Jahanara as she fed her sick 11-mo brother, Milon. When mother returned, Jahanara left to pick garbage

• “I do not like this difficult and hazardous work, 2-3h/d, earn 30-50 taka. I often cut myself”

• The ECD space is the only place in T&T colony where children receive basic education and life-skills. Jahanara attends whenever she can; she is eager to learn and play

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Next Lec.

ARI

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MDG 1: eradicate extreme poverty and hunger

To halve (1990-2015) proportion of hungry people• Undernutrition: fetal .., stunting, wasting and deficiencies

of A and Zn, suboptimal breastfeeding; is the c/of death in 45% of all U-5MR

• Underweight children in DCs has declined from 25% to 15% between 1990 and 2012. This is close to MDG target, but improvements have been uneven

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Goal 4: reduce child mortality (by 2/3 U-5MR)

• U-5 mortality declined by 47% at 2012 (48/1000LB)• Despite this improvement, the world is unlikely to achieve

the MDG target of a 2/3rd by 2015• More countries are now achieving high levels of

immunization; in 2012, 66% countries reached 90% coverage

• In 2012, measles vax. coverage was 84% with measles deaths decreased by 78%

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MDG 5: improve maternal health

Reduce by ¾, and, universal access to reproductive H

• Despite significant fall in MMR from 523,000 in 1990 to 289,000 in 2013 the rate is <50% of target

• To reduce it, women need access to good reproductive HC. In 2011, 63% of women 15–49y who were using some form of contraception, while 12% wanted to stop or postpone childbearing but were not using contraception.

• ANC at least once in pregnancy was 81% in 2013, but for the recommended min. 4 visits it is 56%

• SBA-births: crucial for reducing NMR and MMR is >90% in 3 of the 6 WHO regions. But in African Region it is <50%

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MDG 6: combat HIV/AIDS, malaria and other diseases• Target 6A. Have halted by 2015 and begun to reverse the

spread of HIV/AIDS• Target 6B. Achieve, by 2010, universal access to treatment

for HIV/AIDS for all those who need it.• In 2012, an estimated 2.3 million people were newly

infected with HIV – 33% less than the 3.4 million people newly infected in 2001. Sub-Saharan Africa accounted for 70% of all the people who acquired HIV infection globally.

• There were an estimated 35 million people living with HIV in 2012, an increase from previous years. As access to antiretroviral therapy in low- and middle-income countries improves (around 9.7 million people in low- and middle-income countries received treatment in 2012), the population living with HIV will continue to grow since fewer people are dying from AIDS-related causes.

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Target 6C. Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases

• Malaria• About half the world’s population is at risk of malaria, and

an estimated 207 million cases in 2012 led to approximately 627 000 deaths – most of these in children under the age of 5 living in Africa.

• During the period 2000–2012, malaria incidence and mortality rates of population at risk have both fallen globally, 29% and 42% respectively. An estimated 3.3 million lives were saved as a result of scaling-up malaria interventions during the same period.

• The coverage of interventions such as the distribution of insecticide-treated nets and indoor residual spraying has greatly increased, and will need to be sustained in order to prevent the resurgence of disease and deaths caused by malaria.

• Tuberculosis• The annual global number of new cases of tuberculosis has

been slowly falling for a decade thus achieving MDG target 6.C to reverse the spread of the disease by 2015. In 2012, there were an estimated 8.6 million new cases and 1.3 million deaths (including 320 000 deaths among HIV-positive people).

• Globally, treatment success rates have been sustained at high levels since 2007, at or above the target of 85%. Between 1995 and 2012, 56 million people were successfully treated for tuberculosis and 22 million lives were saved. However, multi-drug resistant tuberculosis (MDR-TB), which emerged primarily as a result of inadequate treatment, continues to pose problems.

• Other diseases• Neglected tropical diseases are a medically diverse group of

infections caused by a variety of pathogens such as viruses, bacteria, protozoa and helminths.

• The 17 diseases prioritized by WHO are found in 149 countries and can cause multiple infections in one person and are almost always associated with poverty.

• Leprosy has now been eliminated as a public health problem in 119 out of the 122 countries where it was previously endemic. Dracunculiasis (also known as guinea-worm) is a crippling parasitic disease on verge of eradication, with only 148 cases reported in 2013.

• In addition, 728 million people worldwide were treated for at least 1 NTD through preventive chemotherapy in 2011.

• However, neglected tropical diseases still affect more than 1 billion people worldwide.

• Despite renewed momentum characterized by unprecedented progress, some neglected tropical diseases (like dengue) remain a significant obstacle to health, making it harder to achieve the Millennium Development Goals, and pose an ongoing impediment to poverty reduction and overall socio-economic development.

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MDG 7: ensure environ. sustainability• To halve the proportion of people without safe drinking

water and basic sanitation• The world has now met this. In 2012, 90% population used

safe drinking-water compared with 76% in 1990. Progress is however uneven

• With regard to basic sanitation, current rates of progress are too slow for the MDG target to be met globally. In 2012, 2.5 billion people did not have access to improved sanitation facilities, with 1 billion these people still practicing open defecation. The number of people living in urban areas without access to improved sanitation is increasing because of rapid growth in the size of urban populations.

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MDG 8: global partnership for development• Target 8E. In cooperation with pharmaceutical companies,

provide access to affordable essential medicines in developing countries

• Many people continue to face a scarcity of medicines in the public sector, forcing them to the private sector where prices can be substantially higher. Surveys undertaken from 2007-2012 show the average availability of selected generic medicines in low- and middle-income countries was only 57% in the public sector. Patient prices of lowest priced generics in the private sector averaged 5 times international reference prices, ranging up to about 16 times higher in some countries.

• Even the lowest-priced generics can put common treatments beyond the reach of low-income households in developing countries. The greatest price is paid by patients suffering chronic diseases. Effective treatments for the majority of the global chronic disease burden exist, yet universal access remains out-of-reach