International Café: Bangladesh Chapter of the ACS

The People’s Republic of Bangladesh is a small (92nd largest in the world, covering an area of 147,570 kilometers), densely-populated (eighth-most populous, exceeding 162,952,000 in population), low-lying (average elevation of 279 feet above sea level), mainly riverine (700 rivers) country. It is located in the world’s largest Ganges delta region of South Asia, with a coastline of 580 kilometers on the northern littoral of the world’s largest bay—the “Bay of Bengal“ of the Indian Ocean. Bangladesh is a low-middle-income country (it graduated from a low-income country in 2015) with a current annual per capita income of US $1,888.

It has the world’s longest natural sea beach (120 kilometers at Cox’s Bazar) and the largest mangrove forest (the Sundarbans, a UNESCO World Heritage site). Straddling the Tropic of Cancer, Bangladesh has a tropical monsoon climate characterized by heavy seasonal rainfall (average 2,000 millimeters per year), high temperatures (30 to 400 C), and high humidity (70 to 100 percent). Natural disasters such as floods and cyclones, accompanied by storm surges, periodically affect the country. The country also is one of the most prone to global climate changes.

Despite these problems, as a humanitarian act, Bangladesh gave shelter to 1.2 million Rhohinga refugees from neighboring Myanmar who fled their homeland to escape persecution, brutality, and death by their own government.

Most of the country is intensively farmed. Rice is the main crop, and it is grown in three seasons. Rapid urbanization is taking place with associated industrial and commercial development. Exports of garments (world’s second highest after China), shrimp, and remittances from Bangladeshis working abroad (more than 10 million) provide the country’s main sources of foreign income.

Ranked 88th in overall health care performance by the World Health Organization (WHO), life expectancy is 71 years for males and 73 years for females. The total government expenditure on health care is 5 percent of the total budget (1.02 percent of the GDP), which equals approximately US $32 per capita allocated to the health sector. Because of this small amount, most health care expenditures are paid directly by patients. However, the relative success in health care delivery is a result of country’s strong primary health care system, which focuses on preventive services such as immunization, maternity care, and child care through 14,000 community clinics in rural areas. A future goal is to have 24,000 community clinics in these areas.

At the other end of the health care delivery system, there are total 5,816 governmental and private hospitals in three categories:

• Primary (31 to 50 beds): hospitals in 492 sub-districts of the country
• Secondary (100 to 250 beds): hospitals in 42 districts
• Tertiary (500 to 1000 beds): 90 (36 public; 54 private) medical college general hospitals functioning throughout the country, 15 specialty-based hospitals, and one medical university hospital at the capital

Currently, there are 67,600 medical graduates in the country, and the doctor to population ratio is 1:2,500. The hospital bed to population ratio is 1:3,000, and the nurse to population ratio is 1:5,000.

Surgery in Bangladesh

In Bangladesh, MB BS is a medical graduation degree conferred after five years of education in medical colleges. Graduates must complete one more year of rotatory internship in a recognized hospital in order to receive registration from the Bangladesh Medical and Dental Council (BMDC) to start practicing as a general practitioner. To specialize and get registration from BMDC as a specialist surgeon in a specific surgical discipline, MB BS doctors in the country must have one of the following:

• Postgraduate university degree, master of surgery by enrolling in a five-year full-time residency and completing a thesis at a recognized institute/hospital under a medical university. This way is similar in design to U.S. training.

OR

• Fellowship from the Bangladesh College of Physicians and Surgeons, which does not have any hospitals of its own. Doctors get postgraduate training for four years in recognized hospitals, complete a dissertation, and then sit for the Fellowship examination. This is similar in design to the Royal Colleges of the United Kingdom, Canada, and Australia.

Currently, there are approximately 9,000 specialist surgeons in various capacities practicing in Bangladesh.

ACS in Bangladesh

In my early days of training I was fortunate enough to find two ACS Fellows to serve as mentors. I met M. Kabir Uddin Ahmed, MBBS, FACS, FRCS (England), during my training in general surgery at Sylhet Osmani Medical College, Sylhet, Bangladesh, and I met Ronald J. Garst MD, FACS, during my orthopedic residency at the Rehabilitation Institute and Hospital for the Disabled (RIHD) in Dhaka, Bangladesh. RIHD has since been updated to 1,000 beds providing solely orthopaedic care in National Institute of Traumatology and Orthopaedics by the Bangladesh government.

I have been an ACS Fellow since 2001, and it was always my dream to form a local ACS Chapter; however, due to the lack of Fellows in the country, it was not possible to achieve this goal until 2017. At my initiative, a meeting was held January 25, 2017, at the Dhaka Club to begin this process. At the meeting, my esteemed colleagues unanimously nominated me as the first Governor with an aim to form a chapter. On June 9, 2017, the Bangladesh Chapter of the American College of Surgeons was officially approved by the ACS Board of Regents.

Our inaugural meeting of Founding Officers was held on January 25, 2017.

Sitting from left to right: Shafiqul Hoque, MBBS, FCPS, FACS; A. K. M Anowar-Ul Azim, MB BS, FCPS, FACS; Motior Rahman, MB BS, FRCSEdin, FACS; Murtuza K. I. Q. Choudhury, MB BS, MS(Ortho), FRCSGlasg, FACS; and M. Khademul Islam, MBBS, FCPS, FRCSGlasg, FACS. Standing from left to right: Tanveer Ahmed, MBBS, FCPS, FACS; S. M. Munirul Huq, MBBS, FCPS, FRCSGlasg, FACS; Sarder A Nayeem, MBBS, PhD(Tokyo), FACS; Sayeed Ahmed Siddiky, MBBS, FCPS, FRCSGlasg, FACS; Mohammed Shadrul Alam, MBBS, MS, FCPS, FRCSGlasg, FACS; Md. Kamruzzan Khan, MBBS, FCPS, FACS; Chowdhury Iqbal Mahmud, MBBS, MCh, FRCSGlasg, FACS; Hriday Ranjan Roy, MBBS, FCPS, FACS; and M. Muinul Hafiz, MBBS, MS, FACS

Since its inception, the Bangladesh Chapter of the American College of Surgeons has grown to include 148 active members (37 Fellows, 86 Initiates, 18 Associates, and seven Residents). The number of Fellow applicants from Bangladesh in 2018 was so enormous that Brian Frankel, ACS Manager, International Chapter Services and Special Initiatives, contacted the Chapter to say, “I am pleased to see the high number of ACS Fellowship applications from surgeons in Bangladesh. If fact, to date, we have received more than 60 applications, which is the highest of all countries outside the United States and Canada, and almost double the current number of ACS Fellows in Bangladesh. Last year, Bangladesh had 12 applicants, and in the three years prior to that, there were only one to three applicants each year.”

We attributed the impressive increase in the number of Fellowship applications to the following activities:

• Approval of the Bangladesh Chapter–The Chapter’s incorporation into the ACS website motivated surgeons to join.
• Dedicated Efforts from Chapter Officers/Councilors/Governor–The efforts by these individuals were praiseworthy, especially on a personal level and helped to recruit candidates.
• CME Programs–Over the past two years we invited more than 100 non-ACS surgeons to attend complimentary presentations on several different surgical disciplines by senior Fellows. During the programs the Chapter President discussed ACS membership benefits and distributed brochures.
• Clinical Congress Participation–Invitations to the President and Secretary General of the Society of Surgeons of Bangladesh to participate in the Clinical Congress also helped to further develop interest in the College and Chapter membership.
• Chapter Officers–In addition to being Chapter Officers, these leaders also are involved in several different surgical specialty societies in the country and helped to circulate ACS information among the respective members of their societies.
• Advanced Trauma Life Support Course®–We have been working on the advancement and improvement of surgical care in Bangladesh, and we are pleased to announce that in February 2019, the American College of Surgeons Committee on Trauma (COT) Advanced Trauma Life Support (ATLS^®) Course 10th edition was promulgated, with a Student and Instructor Course held at the Bangladesh College of Physicians and Surgeons in collaboration with the Society of Surgeons of Bangladesh.
• The Chapter also had the privilege and honor of having ACS First Vice-President-Elect John A. Weigelt, MD, DVM, FACS, as a keynote speaker. Dr. Weigelt gave a talk entitled “Perioperative Prophylaxis and Treatment of Intra-Abdominal Infection” at the Chapter’s Second Annual General Meeting held April 26-27, 2019, at Bangabandhu Sheikh Mujib Medical University, Dhaka.
• The Chapter also plans to have several junior doctors in Dhaka be instructors for the Stop the Bleed^® basic course, but the lack of the tourniquet availability is a primary barrier.