Poor healthcare coupled with widespread poverty (45% of the population live under the poverty line) and infectious diseases are a major cause of mortality in Bangladesh.

Around half of the country lacks adequate sanitation facilities.Over half of children under five years are underweight. The issue worsens during the floods each year when crop destruction and the mixing of sewage and flood water leads to poor nutrition and unhygienic conditions.

The catastrophic proportions of this was only made clear to me when I spent some time at a small clinic for the poor, in Khulna, Bangladesh, where I shadowed two general practitioners. Patients came to them with many problems that included cholera, typhoid, dengue fever and tuberculosis.

It soon struck me that many did not seek healthcare unless they had waited a considerable amount of time for their symptoms to go away. The treatment of patients is subsidised by the community but many patients could still not afford the treatments, suffer from malnutrition and cannot afford to take time off work.

One such example was a patient who had tolerated a cough, breathlessness and night sweats for weeks. He only came in when he observed blood in his sputum and was eventually diagnosed with tuberculosis (TB). Around a quarter of TB cases in Bangladesh go by undetected and over 80,000 people die each year from the disease despite highly effective treatment being available.

Many patients were barely able to pay the doctor's fees and could not afford to pay for treatment. Sometimes the doctors could give their free drug samples from pharmaceutical companies. Some patients began treatment regimes but discontinued them, sometimes later coming back in a more serious condition. Some just decided that their body would have to deal with the problem itself.

In addition to this there were those who opted to take advice from an authoritative family member, or selfprescribed.Antibiotics were easily available from local pharmacists without a prescription and, with paracetamol, were the most commonly taken medications, especially for high temperatures and diarrhoea. For example, one patient had started taking Amoxicillin for dengue fever (a viral disease) and only sought help when there was no improvement after a couple of days and worsening pain of NGOs Bangladesh has begun taking steps to tackle some of these issues.

I left the clinic with a very bleak outlook on the state of infectious diseases in Bangladesh. Fortunately all is not as bad as it seems. With the help of NGOs Bangladesh has begun taking steps to tackle some of these issues.

One of the major developments has been the adoption of the directly observed treatment short-course (DOTS) for tuberculosis. DOTS treatment, which is provided free of charge, has an 84% success rate and with increasing case detection the horizon looks a little brighter. Moreover, drives to increase vaccination against tuberculosis (95% coverage among one year olds), tetanus, diphtheria, polio have all helped to target infectious diseases and decrease mortality rates.

In addition there have also been recent attempts to increase sanitation coverage and improve hygiene. Organisations such as BRAC, UNICEF and other NGOs are now working with the government to ensure 100% sanitation and safe water coverage by 2010. Approaches include providing water purifying tablets, advice on cooking food and the building of sanitary latrines.

Although there is progress being made there still remains a lot more to do to give the poorest populations of the world an opportunity at life. As medical students we can also help Bangladesh and countries suffering from similar problems.. For example we can volunteer with organisations to work in these countries. I hope to do this in the summer with the Bangladeshi NGO BRAC. If this is not a plausible option, many of us often forget that there are many chances to work with local branches of international NGOs in our own countries to campaign and help raise money. It is a rewarding experience and you feel that you are making a difference to those in need.

Faisal Rahman is a second year medical student at Oxford University,UK.