**6. Case study: Bangladesh**

In a country whose population exceeds 156 million people and is embedded deep within South Asia (a continent that contains of nearly 40% of the world's poverty) it is a feat that they have accomplished so much over the past four decades [21, 22]. With the help of the World Health Organization, Bangladesh has met a multitude of Millennium Development Goals over these four decades, particularly in terms of maternal and child health. Maternal mortality and both infant and child mortality along with malnutrition have all declined [23]. Concurrently, poverty rates and the number of people living in hunger have declined up to 30% since the 1970s as well [22]. All of these factors have also helped individuals to live longer; the life expectancy in Bangladesh (70 years) exceeds the global average of 69 years [23]. Despite these facts and the future promise they bring, there are still major public health problems that persist in Bangladesh, especially in terms of environmental health.

Bangladesh still ranks in the bottom four countries for maternal health [23]. This may be due to a number of delays in giving birth including the social/cultural decision to come to the health care facility, issue of transportation in getting to the facility and the question of whether the health care facility has the adequate services to aid in delivery (midwives, medications, ability to perform blood transfusions, etc.) Additionally, although child malnutrition is decreasing, poor nutrition is still a main issue of concern, considering that nearly half of Bangladeshi children prior to 1-year-old and up to 5-year-old suffer from anemia; a third of children are also underweight [23].

could educate individuals on the importance of environmental health, including sanitation and ventilation, especially when using indoor cook stoves fueled by biomass [20]. Alternatives such as kerosene or gas energy sources could be encouraged along with handwashing techniques and the use of mosquito nets to lessen vector-borne disease. The use of outreach infrastructure could also be vital in integrating networks from microcredit activities with environmental

Utilizing pertinent governmental agencies and legislators is also invaluable to integrating environmental health in specific trades and in general occupational health practices. This relationship to individuals with power could also make equipment available, or aid in subsidizing the purchase of, which aims to improve environmental health, that is, gas-powered stoves, mosquito nets and water sanitation systems. Legislation could be developed and implemented in specific areas for the safety of large groups, for instance, food safety, waste management and occupational health. Policy could too be integrated with local government to support public-private partnerships; Ministries of Public Health, Ministry of Health, Ministry of Environment or Forest/Agriculture and Ministry of Education can all be leveraged here. With support from these powers, community-level efforts to spread awareness about the importance of environmental health in order to control the burden and spread of disease could be a long-term solution to alleviate these health-deteriorating factors. Unfortunately, education will not be the end all solution, however, due to the interconnectivity of universal poverty. Ensuring access to healthy environments is vital in one's overall health to mitigate environmental health factors, which leads to NCDs and a wide array of chronic diseases that

In a country whose population exceeds 156 million people and is embedded deep within South Asia (a continent that contains of nearly 40% of the world's poverty) it is a feat that they have accomplished so much over the past four decades [21, 22]. With the help of the World Health Organization, Bangladesh has met a multitude of Millennium Development Goals over these four decades, particularly in terms of maternal and child health. Maternal mortality and both infant and child mortality along with malnutrition have all declined [23]. Concurrently, poverty rates and the number of people living in hunger have declined up to 30% since the 1970s as well [22]. All of these factors have also helped individuals to live longer; the life expectancy in Bangladesh (70 years) exceeds the global average of 69 years [23]. Despite these facts and the future promise they bring, there are still major public health prob-

Bangladesh still ranks in the bottom four countries for maternal health [23]. This may be due to a number of delays in giving birth including the social/cultural decision to come to the health care facility, issue of transportation in getting to the facility and the question of whether the health care facility has the adequate services to aid in delivery (midwives, medications, ability to perform blood transfusions, etc.) Additionally, although child malnutrition

lems that persist in Bangladesh, especially in terms of environmental health.

health initiatives [6].

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put many people out of work and into poverty.

**6. Case study: Bangladesh**

Some major communicable diseases include those which are food and water-borne including diarrhea, hepatitis A and E and typhoid fever. Vector-borne diseases are unequally distributed across the population and consist primarily of dengue fever and malaria. Below is a chart highlighting the access to unimproved water and sanitation services, the major contributors of diarrhea, a condition which kills over 2 million children under five annually in Bangladesh [22] (see **Figure 4**).

Additionally, due to the slums, there is also a high rate of tuberculosis (TB) transmission; Bangladesh ranks within the top 10 globally for TB burden [23]. Obviously, this is unequally distributed across the population, concentrating in poor and uneducated communities.

Noncommunicable diseases include many chronic diseases such as cardiovascular and respiratory diseases, cancer and diabetes. This is dependent on socioeconomic status and literacy due to the etiology of cardiovascular and respiratory diseases/infections (namely COPD, acute lower respiratory infection) due to indoor cook stoves that use biomass for fuel, along with access to healthy foods [24]. Moreover, these numbers are increasing in correlation to the surge in urbanization [23]. The first national study conducted showed roughly 1 in 3 women and 1 in 5 men (age 35 and older) had elevated blood pressure, while about 1in 10 had elevated blood glucose, a biomarker indicating diabetes. Conclusively, cancer is also the sixth leading cause of death [23] (see **Figure 5**).

Because environmental health includes factors determined by not only environmental exposures, but also SES, and therefore political influences and built environment, EH is a multisectoral problem, which requires an equivalently holistic solution [22].


**Figure 4.** Statistics on access to clean water and sanitation facilities in Bangladesh (adapted from https://www.cia.gov/ library/publications/the-world-factbook/geos/bg.html).


**Figure 5.** Bangladesh environmental burden of disease (adapted from Ref. [6] presentation).

USAID's Country Office for Bangladesh is aimed at building capacity of pertinent government organizations to "reduce environmental health risks through research, policy advice, and awareness raising activities" [24]. The major goals are aimed at addressing (1) indoor air pollution (IAP), (2) occupational health and (3) arsenicosis [24]. IAP and arsenic have become priorities due to the detrimental effects (i.e., neurological impairments, diabetes, hypertension, heart attack and cancer) and exposure distribution. Arsenic is especially concerning due to the fact that it has been identified in shallow tube wells which supply drinking water to communities throughout Bangladesh, many of them rural and poor [25]. Additionally, women and children are disproportionately burdened by IAP due to their extended hours in the household; nearly 92% of the population use solid biomass for fuel, which creates extensive IAP.

Of course environmental health education is an important factor to use in the multisectoral approach also. This effort could educate Bangladeshi people on the importance of understanding arsenic poisoning, indoor air pollution and occupational health exposures which pose health risks. It could also encourage individuals to use cleaner energy sources or if financially limited, well-designed, improved stoves; this would decrease IAP by at least 50% but possibly up to 90% [24]. Occupational exposures are an important factor to consider due to workers' high frequency and magnitude of exposure. This is also important considering the preexisting tension between entrepreneurs and industry—the stigma that compliance and administrative costs deter worker productivity.

WHO Bangladesh worked in collaboration with Bangladeshi personnel to provide training and awareness programs to necessary occupations (i.e., safety officers, inspectors and physicians) [24]. The team also contributed by provided technical support to develop manuals on indoor air pollution, create a national framework for IAP health impact, national strategy for health and safety (in both English and Bangla), and create a data profile of construction sectors on health and safety (base data for construction injury prevalence) and training health care workers to evaluate and treat arsenic-related illnesses. More studies are currently being developed with a focus on occupational health and arsenic exposures and clinical solutions [24].

Other nongovernmental organizations (NGOs) such as the Environment and Social Development Organization (ESDO), are also working toward improving environmental health across Bangladesh. Their main objectives include (1) protecting the environment, (2) reducing poverty, (3) increasing literacy rates and education, (4) empowering woman in rural communities and (5) improving sanitation and health services. Foci are improving livelihoods, SES and environmental education in the most vulnerable parts of Bangladesh [26]. As seen in the multisectoral approach, it is important to have these private-public partnerships, with NGOs building capacity and relationships with community members, increasing success rates.

Notwithstanding all of these efforts, more can certainly be done to combat the burden on environmental health on the population of Bangladesh. Government health expenditures were recorded to be only 2.4% of the GDP in 2014 [21]. Additionally, only less than 62% of the population can read and write, with education expenses being only 2.2% of the GDP [21]. As aforementioned, health disparities plague the country due to SES; these poor literacy rates and minimal government monetary contribution have exacerbated the environmental health exposures and poor health outcomes without a doubt.

Recognizing that the health care system of Bangladesh has gone through a number of changes since their independence in 1971, some great accomplishments and improvements have been made. MDG 4 reducing childhood mortality was achieved before the 2015 target. Additionally, a number of other key indicators have made improvements including TB, diarrhea and malaria [27]. Nonetheless, there are quite a few improvements, which could be made in the current health care system, collaboratively creating the need for a better multisectoral and multipronged approach:


USAID's Country Office for Bangladesh is aimed at building capacity of pertinent government organizations to "reduce environmental health risks through research, policy advice, and awareness raising activities" [24]. The major goals are aimed at addressing (1) indoor air pollution (IAP), (2) occupational health and (3) arsenicosis [24]. IAP and arsenic have become priorities due to the detrimental effects (i.e., neurological impairments, diabetes, hypertension, heart attack and cancer) and exposure distribution. Arsenic is especially concerning due to the fact that it has been identified in shallow tube wells which supply drinking water to communities throughout Bangladesh, many of them rural and poor [25]. Additionally, women and children are disproportionately burdened by IAP due to their extended hours in the household; nearly 92% of the population use solid biomass for fuel, which creates extensive IAP.

**Figure 5.** Bangladesh environmental burden of disease (adapted from Ref. [6] presentation).

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Of course environmental health education is an important factor to use in the multisectoral approach also. This effort could educate Bangladeshi people on the importance of understanding arsenic poisoning, indoor air pollution and occupational health exposures which pose health risks. It could also encourage individuals to use cleaner energy sources or if financially limited, well-designed, improved stoves; this would decrease IAP by at least 50% but possibly up to 90% [24]. Occupational exposures are an important factor to consider due to


The current inequitable access to services is the greatest limitation in ensuring universal health care coverage in Bangladesh [27]. As the program currently stands, it is also inadequate in addressing environmental health due to the SES disparity across the country, lack of trained professionals and surveillance of environmental issues, which cause many communicable and noncommunicable diseases along with infrastructure.
