As a new doctor back in the early 2000s, Dr. Rajiv Chowdhury learned quickly that there weren't enough medically qualified care providers in Bangladesh to meet the needs of the country's large population.
"The quantity was a huge issue, and then came the quality issue," he shared, adding that top medical professionals were educated abroad in countries like the U.S. and the U.K. After completing their studies, some would return to Bangladesh to work in private hospitals in big cities, leaving people in rural areas without options for quality health care. "The medical professionals found in these areas were limited in their training, their global knowledge, and the latest updates on treatment procedures," he said.Chowdhury points to this revelation as the spark that set him on the path to a career in global health—one where he could focus on the health of communities instead of individual patients.
Today, as chair and professor of global health at the FIU Robert Stempel College of Public Health & Social Work, he works to open doors for research and educational opportunities that address health disparities and improve health access for people in Bangladesh and across the globe.
Recently, FIU received a $3 million grant from the National Institutes of Health to develop and test strategies for implementing the WHO's Type 2 Diabetes (T2D) control and prevention guidelines in Bangladesh, one of the top 10 countries for diabetes prevalence. Dr. Chowdhury will lead this work in collaboration with a team of researchers from FIU, Johns Hopkins Bloomberg School of Public Health, and UTHealth Houston, with technical assistance from the WHO.
This work builds on Dr. Chowdhury's long-term working relationship with Abdullah Baqui, DrPH, MPH, a professor in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health.
"While our earlier projects focused on transforming primary healthcare to tackle maternal and childhood conditions, we will now extend this effort to addressing major non-communicable diseases (such as T2D and hypertension)," said Dr. Abdullah Baqui, a co-investigator on the project and the director of the International Center for Maternal and Newborn Health at the Bloomberg School.
The work also builds on Chowdhury's decade-long collaboration with the WHO. In 2014, while teaching at the University of Cambridge, he served as the organization's external advisor for its Global Status Report on Noncommunicable Diseases. He's also done work with the organization on cardiovascular disease, serving as a co-investigator in a working group that helped identify cardiovascular risk for 21 global regions.
Targeting T2D in underserved communities
T2D, the most common form of diabetes, occurs when the body is unable to use insulin properly. Unmanaged, T2D can increase the risk of several health issues like cardiovascular disease, kidney disease, blindness, and more.
In countries like Bangladesh, Dr. Chowdhury shares it is possible that lifestyle factors such as limited physical activity, high tobacco use, and local diets rich in rice and refined cooking oil, as well as unique hereditary factors, play a significant role in the high prevalence of the disease.
To keep the disease at bay, making lifestyle changes is key— exercising, eating healthy foods, and not smoking are a few medical recommendations. Once someone has the disease, controlling it can be a challenge without access to quality health care.
In Bangladesh, which today has a ratio of 5 health care professionals for every 10,000 people, getting the medical attention needed to ward off diseases like T2D can be difficult. Limited access to health care professionals makes prevention and early diagnosis close to impossible for many, particularly those in rural areas.
To address this challenge, the research group will implement HEARTS-D, a module developed by the WHO that aims to improve cardiovascular health by targeting T2D in low-and-middle income communities.
"Think of HEARTS-D as a comprehensive how-to guide packed with the latest diabetes prevention, diagnosis and management tools," said Dr. Chowdhury. "If implemented properly, it has the potential to transform the primary health care system from the grass roots level up for diabetes care."
The work will be done over a span of five years, focusing on neighborhoods across Sylhet, a northern city in Bangladesh.
An integrated approach to health care
Given the inadequacy of the healthcare providers in Bangladesh to treat patients based on the HEARTS-D module, Chowdhury's team will test a strategy to engage the community members to partner with the care providers. In this "integrated" approach, in addition to the local doctors and nurses at the health care facilities, the team will also train community health workers.
"We are going after a principle called task sharing," said Chowdhury. "This is where we engage with the less specialized community health workers, who are from the local community, to help increase health care access and service coverage."
Chowdhury shares how this process would look in action: HEARTS-D-trained community health workers would visit people in their homes, provide lifestyle advice, conduct health assessments, and refer those at high risk of diabetes—or showing signs of it— to nearby community clinics. At the clinics, patients would meet with HEARTS-D-trained medical professionals, like doctors and nurses, to get the care needed to help prevent or manage the disease. After they receive their treatment, community health workers will then monitor them at home for appropriate medication adherence and sugar control.
"We are hoping that this type of integrated care will be effective in reducing diabetes burden, as well as improve the control of diabetes," said Chowdhury. He adds that the research group also aims to better understand the barriers and enablers that come with implementing a program like this in Sylhet.
"This will help make it easier for governments to uptake, not only in Bangladesh, but in other countries experiencing similar issues," he says, adding that his goal is to do similar studies in other low-and-middle income countries such as those in South America and Sub-Saharan Africa.
