18. Burdens: Health Care System
• Almost all will require subsidy
• Intake services
• Chronic/Acute conditions
• Vaccination clinics
• Dental clinics
• **Tuberculosis**
19. Burdens: Mental Health
• Identification
• Relocation anxiety
• Religious support
• Cultural adaptation
26. Adaptation Suggestions
• Intake process
• Linguistic aid
• Mentor/contact person
• Immigration assistance
• Patience & compassion
27. References
• Bangladesh Bureau of Statistics. (2009). Facts and Figures of Gender Compendium of Bangladesh
2009. Bangladesh Bureau of Statistics.
• Bangladesh.com. (n.d.). Culture. Retrieved October 28, 2011, from Bangladesh.com:
http://www.bangladesh.com/culture/
• Bhattacharjee, J. (2009). Understanding 12 Extremist Groups of Bangladesh. New Delhi: Observer
India.
• Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's
Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC:
National Business Group on Health; 2006. Updated 2011.
• Chowdhury, M. R., Bhuiya, A., Mahmud, S., Salam, A. K., & Karim, F. (2002, March 2). Who Gets
Vaccinated in Bangladesh? The Immunization Divide. Bangladesh Health Equity Watch,
Paper No. 1.
• CIA. (2009). CIA World Fact Book. Washington DC: Central Intelligence Agency.
• Cost Helper. (2008). Delivery/Newborn Care Costs. Retrieved November 15, 2011, from
http://www.costhelper.com/cost/child/baby-delivery.html
• Cost Helper. (2008). Prenatal Care Costs. Retrieved November 15, 2011, from
http://www.costhelper.com/cost/child/prenatal-care.html
• Cost Helper. (2011). Drug and Alcohol Rehab Costs. Retrieved November 20, 2011, from
http://www.costhelper.com/cost/health/rehab.html
• DGHS. (2009). Communicable Diseases. Mohakhali, Dhaka, Bangladesh.
28. References cont.
• Gazi, R., Chowdry, Z. H., Alam, S. M., Chowdry, E., & Begum, S. (2001). Trafficking of Women and
Children in Bangladesh. Mohakhali, Bangladesh: ICDDR,B: Center for Health and
Population Research.
• Islam, R. (n.d.). Higher Education in Bangladesh: Diversity, Quality and Accessibility. Rajshahi
University: First National Education Conference on Whither Policy Reform: Lessons and
Challenges.
• Karofi, U. A., & Mwanza, J. (2006). Globalisation and Crime. Bangladesh e-Journal of Sociology,
3(1).
• Maps of the World. (2011). Bangladesh. Retrieved November 23, 2011, from Bangladesh:
http://www.mapsofworld.com/bangladesh/bangladesh-location-map.html
• Nation Master. (n.d.). NationMaster.com. Retrieved October 25, 2011, from Bangladesh-Religion:
http://www.nationmaster.com/country/bg-bangladesh/rel-religion
• North Carolina Public Schools. (2011). Facts and Figures 2010-2011. Raleigh, NC: North Carolina
Public Schools.
• PTI. (2010, March 30). Daily News and Analysis. Retrieved November 27, 2011, from 15 Militant
Groups Active in Bangladesh: http://www.dnaindia.com/india/report_15-militant-groups-
active-in-bangladesh-officials_1365350
• Rahman, M., Uz-Zaman, S., Sakamoto, J., & Fukui, T. (2004). How Much Do Drug Users Pay for
Drugs in Bangladesh. Journal of Health, Population and Nutrition, 98-99.
29. References cont.
• Sanisoft.tripod.com. (n.d.). Education in Bangladesh. Retrieved November 15, 2011, from:
http://sanisoft.tripod.com/bdeshedu/index.html
• State Health Facts. (2009). State Health Facts. Retrieved November 15, 2011, from North Carolina:
Medicaid Spending: http://www.statehealthfacts.org/profileind.jsp?sub=47&rgn=35&cat=4
• The World Bank. (February 2011). Non-Communicable Diseases (NCD's)-Bangladesh's Next Major
Health Challenge. The World Bank, South Asia Human Development.
• U. S. Department of State. (n.d.). Bangladesh. Retrieved October 25, 2011, from Bureau of Public
Affairs: http://www.state.gov/r/pa/ei/bgn/3452.htm#political
• UNICEF. (2006). Child Sexual Abuse, Exploitation and Trafficking in Bangladesh. New York:
UNICEF.
• USCIS. (2011, April 27). United States Citizenship and Immigration Services. Retrieved November
27, 2011, from Fingerprints:
http://www.uscis.gov/portal/site/uscis/menuitem.eb1d4c2a3e5b9ac89243c6a7543f6d1a/?vgnextoid=
b6629c7755cb9010VgnVCM10000045f3d6a1RCRD&vgnextchannel=b6629c7755cb9010VgnVCM1
0000045f3d6a1RCRD
• WHO. (2009). Bangladesh Health Profile. Geneva: World Health Organization.
Editor's Notes
Welcome to the 2011 Bangladesh-humanitarian refugee geopolitical briefing
Bangladesh is a country in south Asia. Home to approximately 1.5 million people, and roughly the size of Iowa, it is the second largest Muslim nation in the world (Maps of the world, 2011). As a result of catastrophic flooding, the state will be receiving approximately 40,000 humanitarian refugees from Bangladesh. This 3 part briefing will address the different cultural aspects of the emigrating population, as well as a brief history and description of the political structure of the Bengali people. Part 2 will include a summation of the burdens our state is expected to encounter in response to the arrival of the refugees. And in conclusion, a segment offering suggestions for adaptation of both parties will be reviewed.
Part 1 of the presentation will include a brief history of Bangladesh and the Bengali people.
Prior to the official establishment of the nation of Bangladesh, the country was ruled or governed by a succession of nations including Portugal, France and finally Britain in the 17th century. During the late 19th century a series of conflicts resulted in a conglomerate of new nations including East Pakistan, West Pakistan and India in 1947; eventually resulting in Pakistan, India, and Bangladesh (formerly East Pakistan) in 1971. The Peoples Republic of Bangladesh was officially established on March 26th, 1971 following the proclamation of independence and acceptance of the nations official constitution. The current political structure of Bangladesh consists of a ceremonial figure head (president) elected by the parliamentary legislator every 5 years. Primary political power is held by the prime minister, who is appointed by the president from among the elected parliamentary bodies. In short: the people elect their parliament, parliament elects a president, and the president appoints the prime minister. Parliamentary elections are held every 5 years and include 300 members of which 45 seats are reserved for women, as provided for by a 2004 Constitutional Amendment. These 45 seats however are appointed positions and not attained through legitimate elections. The current President of Bangladesh is M. Zullur Rahman and the current Prime Minister is Sheikh Hasina. Despite what the U. S. State Department calls “a dysfunctional political system, weak governance, and pervasive corruption”, Bangladesh is, nonetheless, one of the few democracies in the Muslim world. (U. S. Department of State). The national symbol for Bangladesh is a Shapla (water lily) surrounded by two sheaves of rice, with four stars and three jute leaves. Their flag is a sea of green surrounding a red circle.
Bangladesh enjoys a very rich and diverse culture. As in most Indian Countries, tribal dance (as a form of story telling and ceremony) and traditional music play a large part in daily life and often include parts for both men and women. For women the Sari is the preferred form of dress and usually consists of elaborate, finely embroidered patchwork cloth produced by village women. While Bengali is the official language of Bangladesh, there are approximately 38 languages spoken in the country, most of which have regional, religious or ethnic origins. Bangladesh has one of the largest Muslim populations in the world with most following the Sunni branch of the religion. While over 80% follow this practice, other religions such as Hinduism, Christianity, and Buddhism are also practiced. A smaller portion follow animism and regional tribal practices. National and religious holidays also play a large role in cultural beliefs. National Holidays include many of the same holidays observed in the U.S., just on different days, such as: Independence Day, labor Day, and National Mourning Day (founders day), however some are particular to the Bengalese people such as the Solar New Year and the Shaheed (Mother Language Day). Mother Language Day is celebrated in recognition of the original struggle for independence when West Pakistan asserted that Urdu was to be the official language of then East Pakistan. The resulting rebellion led to the formation of Bangladesh and the establishment of the official mother language of Bengali. Religious Holidays include most Christian Holidays such as Christmas and Easter, but also include Muslim, Buddhist and Hindu holidays such as Ramadan, Buddha Purnima and Druga Puja (Bangladesh.com).
Bangladesh’s primary religion is Islamic. A vast majority of Bengali follow the Sunni traditions of Muslim beliefs. Historically, Bangladesh was once a primarily Hindu and Buddhist region. A conversion to Islam began in the 13th century and progressively gained prominence throughout the past several hundred years. While religious strife does exist in some areas, Bangladesh is a relatively peaceful nation when compared to other Muslim states. A majority of those practicing Hinduism sided with Western Pakistan during the 1971 war and were repatriated to Pakistan resulting in the decrease in the number of those practicing Hinduism in the country. Those who practice religions other than Islamic beliefs tend to reside in the more rural and peripheral areas of the country, primarily the northern regions. Those who live in the more primitive tribal areas tend to adhere to their own marriage, birth and death rituals. Religious facts provided by NationMaster.com and are approximate.
The Bengali education system consists of 3 basic systems that all appear to co-exist in their secular society. The English Medium, taught in private schools and reserved for the wealthier class, consists of courses taught in English, using English textbooks with the exception of Bengali courses and religious courses which are taught in Bengali and Arabic. The Bengali Medium, funded by the government, is the equivalent of a public school system and is the most prominent for of education in the country. Courses are taught in Bengali with the exception of English Class. Children are educated to the 10th grade level at which point they sit for an exam held annually, nationwide. Passing score for the exam is 60% or above with special recognition to those achieving 80% or above. Those who do not achieve a 60% are allowed to repeat the test the following year. The Religious Medium primarily consists of homeless children who are sheltered, fed and taught by Islamic priests. The children usually serve the mosque in some form and after graduation become priests themselves. Aside from these 3 primary branches of education, military and boarding schools teach a strict military regime and are a common choice for those who wish to join the national army (Sanisoft.tripod.com). Higher education is lacking when compared to other developed nations. There is little funding, a lack of vision and support, and overburdened with political agendas (Islam, R). Literacy rates are equal for males and females and are at about 70-73%, with 40-50% completing primary school and about 20% completing the secondary cycle or high school (Bangladesh Bureau of Statistics, 2009).
Many of the acute issues facing the emigrating population will be related to healthcare and addiction. Bangladesh is a poor country and as such has a limited ability to provide adequate healthcare for its citizens. In addition, it has a high rate of drug addiction, primarily in the 17-30 year old age groups. Bangladesh is also considered a low incidence/high risk HIV situation; meaning that while HIV rates are currently low, climbing drug addiction rates may soon change that status. Women’s health is lacking in Bangladesh, as are most other health care services, contributing to the countries high maternal mortality rate of 340/100000 live births compared to 11/100000 in the United States. Bangladesh also has a high rate of Tuberculosis at 425/100000 (WHO, 2009). Both issues will have an impact on state health care services. Vaccination rates are also low when compared to the United States at about 60-65% (Chowdhury, Bhuiya, Mahmud, Salam, & Karim, 2002). Mental and Dental health services, not surprisingly are underfunded and addiction services are almost non-existent. Mental health issues can expect to be compounded by the stress and anxiety that accompany relocation efforts of this magnitude.
Disease burdens faced by the Bengali people emigrating into the U.S. will have a profound effect on the state. The economic consequences will be addressed in section 2 of this briefing. For now we will address the most prevalent medical issues likely to be observed.
A great number of factors influence the mortality and general health statistics that exist in Bangladesh. The greatest of these factors is the lack of available healthcare facilities for the poorest of an already impoverished nation. As mentioned previously the country has a very high Maternal mortality rate. In addition, 5 out of every 100 babies born will not reach 1 year of age, and another 41% are underweight and malnourished. Poor sanitation and inadequate safe drinking water also adds to the state of ill-health exhibited in the Bengali people. Further compounding the situation is an extremely low doctor to citizen rate of 3 doctors for every 10,000 people. (All statistics provided by the CIA World Fact Book) (CIA, 2009)
Many of the communicable disease burdens will ease once emigrants arrive in the U.S. and have access to antimalarial treatments and clean drinking water. Like Malaria, Dengue Fever, and Filariasis, the Nipah virus can be successfully treated once the population has adequate access to health care. Tuberculosis however is going to involve extensive follow-up to assure outbreaks do not occur in the areas where the population is settled. Bangladesh ranks 6th in the world for its tuberculosis rate and also has a very high rate (20%) of Multi Drug Resistant Tuberculosis (DGHS, 2009). MDRTB occurs when patients do not follow correctly or do not complete treatment. The diseases, caused by a bacteria, then becomes drug resistant and other options for treatment must be explored.
According to a study performed by The World Bank, non-communicable diseases now account for 61% of all deaths in Bangladesh. Cardiovascular disease accounts for a majority of these deaths at 22%. In addition, indoor air pollution caused from burning solid fuels, which is used in 90% of all households, has lead to very high rates of respiratory diseases including asthma and COPD. Bangladesh also has a higher than average smoking rate, which for males is currently at 47%. Bangladesh, like many other nations, is also facing an increase in the aging population growing from 4.5% in 2000 to an estimate of 6.6% in 2025 (The World Bank, 2011).
Bangladesh faces many of the crimes and crime associated issues that all nations face, but given its poverty rate and lack of investment in policing agencies, it also contends with additional issues such as human trafficking, drug trafficking and militant/terrorist groups.
According to a study, drug use is an alarming problem in Bangladesh. There are an estimated 1.7 million drug abusers in the country. Statistics for addicts indicate that 94% are male, 35% are married, and the mean age of abusers is 22. The most prevalent drug of choice is cough syrup, representing about 64% of abusers, followed by heroin at 45%, cannabis at 44% sedatives at 17% and a variety of pain pills and other drugs making up the final 17% (Rahman, Uz-Zaman, Sakamoto, & Fukui, 2004). Also alarming is that most addicts abuse more than one drug. With drug abuse clinics almost non-existent, the problem is only expected to worsen.
The number of women and children being trafficked out of Bangladesh is staggering. Estimates are that 500 women are illegally transported out of Bangladesh every month (Karofi & Mwanza, 2006). Further estimates are that 500,000 Bengali children are currently working in brothels in India and Pakistan with approximately 184 being illegally transported out of the county every month (Gazi, Chowdry, Alam, Chowdry, & Begum, 2001). The reasons for these numbers include: the nations poverty level, child abandonment, inadequate laws and police activities, lack of shelters and safe havens for both women and children, and a socialization that devalues female children. A great number of women who are trafficked are sold to traffickers or organizations by their family, husbands or boyfriends under the promise of obtaining work as a domestic employee in another country. Many of these women become either domestic or sex slaves wherever they happen to be transported to. In addition, due to poverty, some children are simply abandoned by their parents who cannot afford to care for them. Accurate numbers on the children sold or kidnapped and forced into the sex slave are difficult to obtain as the country currently only registers about 10% of all births. No one really knows how many children are missing.
Bangladesh is home to 12-15 officially recognized militant or terrorist groups (depending on source). A large number of these groups are Islamic fundamentalist groups that have a large amount of international funding and support. They are engaged in terrorist activities such as bombings and murder and most, if not all, have roots that can be traced back to Pakistani based organizations (PTI, 2010), (Bhattacharjee, 2009).
The following section was designed to give a brief overview of how the incoming refugees are expected to impact the state.
North Carolina spends between $2,500-3,600 per person on Medicaid funding. Rates for the elderly and disabled are significantly higher at $10,000-15,000 per person (State Health Facts, 2009). Assuming that most, if not all, emigrants will not have prior healthcare coverage, the state can expect to carry 100% of the burden for the healthcare of the incoming population. Intake services will need to be established to determine the health status of all incoming emigrants. They will need to be assessed for all communicable and non-communicable diseases mentioned previously as well as for chronic and acute medical conditions. Every effort should be made to assure proper vaccination of the population including re-vaccination of those who are not able to provide proof of prior vaccination. In addition, all incoming persons should be scheduled for a thorough dental exam and treatment should be provided where applicable. **A prominent concern will be the identification and treatment of tuberculosis patients. Tuberculosis is a highly contagious infectious disease that can have a profound impact on the health and safety of a community. Identifying those who have tuberculosis should be a primary concern of intake personnel during medical evaluations. Tuberculosis costs an average of $200-300 per person with costs for MDRTB at about $4,000 per person under Direct observation treatment or DOT (Campbell et al., 2011). The burden to the state will depend upon the number and type of TB cases identified. In addition, hospitalization costs for tuberculosis patients ranges from $15,000 to $137,000 for MDRTB treatment (Campbell et al., 2011).
Mental health issues can be complex under the best of situations. Relocating a large population into a foreign county with differing languages, values and religious practices is certainly not the best of situations. Even those without prior mental health problems may find it difficult to manage the anxiety of the relocation process and separation from everything that is familiar to them. Identifying and providing care to those in immediate need should be apriority followed by resources made available to those who later develop problems due to the relocation process. Volunteers from local mosques may be invaluable to assist new comers with the process of cultural adaptation. In additions these volunteers may be able to provide spiritual assistance, assistance with day to day activities-such as where to shop, and provide the familiarity of cultural and language likeness.
The needs of pregnant women may be an acute problem. Many of those entering the U.S. may have had little to no prenatal care or support. During the intake process, expectant mothers should be provided access to prenatal and antenatal care in an effort to protect the safety of both mother and child. Non-expectant females should also be provided access to general gynecological services including family planning clinics. Newborns will also require diligent medical care to assess any needs such as nutrition, vaccination and developmental issues. The burden to the state will depend upon the number of expectant females and newborns emigrating into the area. The state has a number or registered practitioners (doctors and midwives) that can be called upon during a crisis to assist. While this registry is primarily used for disaster situations, if the number of females requiring care is sufficiently high, this situation may warrant the use of these practitioners. Public health departments may also fell an increased burden and may require access to additional funding to provide adequate care to both mothers and children. The estimated financial burden to the state is about $2,000 per pregnant female for routine prenatal care only. Delivery and antenatal/newborn care is estimated at $9,000-17,000 per delivery (Cost Helper, 2008).
Bangladesh has a high rate of addiction, especially among the male population. It can be assumed that a number of those emigrating into the U.S. will require some form of rehabilitation services. Depending on the severity of addiction, and drug of choice, rehabilitation efforts can will include either inpatient or outpatient addiction counseling. Costs for this sort of rehabilitation can be substantial ranging from about $6,000 for 60 days of outpatient counseling to $15,000 for 30 days of inpatient services or $25,000 per person for a 60 day inpatient treatment facility (Cost Helper, 2011). Clinical assessment during the intake process can assist in identifying those who will require treatment and which form of treatment would be most beneficial to the addict. It is important to not overlook this segment of the population as drug and alcohol addiction can lead to a number of criminal proclivities including domestic violence and robbery.
The incoming population is going to require a number of social services in order to be successfully integrated into the U.S. population. The first of these needs will be housing, followed by employment assistance. While public housing needs at this time are most likely sufficient to meet the needs of the population, employment may be more difficult. For this reason, other services such as higher education (for those willing and capable) and English tutoring will also need to be provided. Keep in mind that literacy rates among the Bengali are low and employment opportunities might be limited. Lower paying entry level jobs might not fulfill the needs of the families, placing a burden on the state financially so education of the adult population should not be overlooked. In addition, preparing the immigrant population for eventual citizenship should also be a goal.
The State of North Carolina spends over $10,000 per child, per year, on education (North Carolina Public Schools, 2011). These costs are related to actual classroom expenditures, transportation, textbooks and nutritional needs of the student population. Depending on the number of school aged children among the immigrant population, these costs represent a serious financial burden to the state. In addition, many of the children will require tutoring to not only master the English language, but to bring them up to a standard level of education comparable to their peer group. This will be more easily accomplished with the younger, elementary school aged children. Older, high school aged students will require intensive tutoring and mentoring to prevent drop-out.
Accurate identification of the emigrating population will be difficult due to the fact that less than 10% of births in Bangladesh are officially recorded (UNICEF, 2006). A large number of the population can be expected to arrive without an official form of ID. Under most circumstances, all humanitarian immigrants entering the U.S. will be fingerprinted for identification and comparison with international agencies (USCIS, 2011). This process can assist the population with attaining an official form of identification which will be crucial to employment and social service eligibility. Once an identification has been established, comparison with federal and international “watch lists” can be accomplished. This process will help to assure the safety of the U.S. population from the threat of terrorist organizations residing among residents. This entire process will entail a substantial amount of record keeping and a strict adherence to federal laws to prevent potential violations of immigrant rights. In the event that a criminal is found among the emigrating population, adherence to federal laws must be a priority to assure the rights of both the immigrant and the citizens of the U.S. are protected.
The following adaptation strategies can be used to assist in the integration of the Bengali Immigrants.
The intake process for a large number of immigrants is a logistical challenge. Information on the entire process must be understood by the incoming population. For this reason it is very important the information be given in not only English, but in the native Bengali as well. This will help to assure accurate communication by both parties. Translators are going to be an essential part of this process. In addition, volunteers can be harvested from local Islamic, Bengali and immigration groups to provide a mentorship contact person who can assist the immigrants with the cumbersome process and to provide a sense of familiarity in a foreign environment. Immigration assistance person should also be available to assist the population with realizing the goal of citizenship within the U.S. Above all other strategies, patience will be the most helpful as the U.S. and Bengali Nations come together to achieve this humanitarian mission. State officials would be urged to make use of grants and federal funding opportunities to assist the state with the financial burden of accepting such a large group of immigrants. In addition, education of state agencies such as police, education, and public health will help to assist those agencies with the burdens they can expect to encounter. Through a great deal of patience and diligence and a commitment to our humanitarian duties, this process, while cumbersome and challenging, can be met with compassion and grace.
