Dhaka by night

I’m currently on an extended work trip to Bangladesh, teaching a couple of intensive seminars on epidemiology and related topics in Dhaka. This is the second time I have come here, and I plan to write a separate post soon on my impressions of this country – there is a lot to say about it. For those of you who don’t know, Bangladesh is a Muslim-majority country of 170 million people neighbouring India, and is very poor. It is currently ranked 136th out of 189 countries on the Human Development Index, putting it in about the bottom third of national wealth globally. Per capita GDP is about 1,800 USD, with huge inequality. Although the government of Bangladesh is angling to have the country ranked as a lower middle-income country it is still very poor, with no serious functioning health insurance system, limited skilled employment and a weak industrial sector outside of an extremely well-performing garment sector. Even the Tuk-tuks are imported from India. Bangladesh is something of a success story in health, outperforming expectations for its HDI and in particular making huge gains on maternal and child health. Nonetheless, life here is tough for all but its wealthiest residents. For example a basic garment worker job, which is a sought after thing here, pays about 80USD per month. I learnt this from my local colleagues, who are running a project on the health of these women, and I also helped interview a senior researcher position for a local organization, which was looking to pay a person with a master’s degree and several publications about $500 per month. It’s not a rich place! In particular there is a very large population of unskilled and/or illiterate young people, who are not able to engage in the garment sector or any higher-paid work, and for whom employment opportunities are limited. So it is that these people go to quite outrageous lengths to earn money, including some quite entertaining scams. Here I report on two, one of which I was told about and one of which I and my colleagues almost became entangled in.

Dhaka city centre, with metro works (I think)

The Elephant Man

I took a few hours after work this week to visit a tailor that my colleague Doughty S recommends. This tailor could make me a tailor-made suit, three shirts and a pair of trousers for a mere 170 USD, so is probably worth the two hour slog I had to endure to get there, and the 3 hour slog home. Did I mention that traffic in Dhaka is insane? Traffic in Dhaka is literally insane. It’s exhausting, depressing and soul-destroying, a problem of many cities in developing nations, and about this I will write more in my report on Bangladesh. At one point, driving relatively fast for the time of day, we passed an elephant standing by the side of the road, eating grass from a building site while its rider lounged about atop its broad back. It wasn’t huge as elephants go, but it was still big and more to the point I have never in my life seen an elephant just ambling along in public doing its thing. So I naturally declared “elephant!” and tried (and failed) to get a photo from the car that was suddenly and perversely actually moving for once.

My colleague Doughty S informed me that this elephant wasn’t a working elephant in the sense that it lifts and carries and drags things like an elephant should; rather, it was an essential participant in a money-making scam. Basically the dude on top of the elephant will manoeuvre it in front of your car, forcing you to stop, and then refuse to move the elephant until you pay him. Since it’s an elephant, you probably aren’t going to try and hit it; and if you’re in Dhaka traffic you probably won’t be able to outmanoeuvre it; and you can’t reach the dude to punch him since he’s on an elephant. It’s really a quite foolproof way of extorting a bit of money from passing motorists. So the scam unfolds, but on this occasion we were fortunate enough to be on the opposite side of the road, so no elephant extortion came our way.

Doughty S also told me that the same people who ride the elephant also sometimes have a box with a snake in that they threaten to curse you with unless you cough up some money. But I think we can all agree the elephant scam is way more elegant.

The Sand Gang in action

The Sand Gang

This is a devilishly cunning plan that seems worth far less than the effort and risk required to pull it off, but you have to admire the chutzpah of its architects. I spent two days at a resort town, Cox’s Bazar, during the break between seminars, to unwind a little and get some beach air. Cox’s Bazar is a kind of peninsula, with a single road heading south along the beach side, and over a line of hills the Rohingya refugee camps. The Rohingya fled violence in Myanmar to camps near Coxs Bazar, and there is now a huge industry of aid groups and Bangladesh army tending to their needs[1]. Most of the aid workers stay in Coxs Bazar, and every morning they drive along the road south to the camp. However, recently the government closed a 200m section of road near the hotels for repairs, and now there is no road south from the southern part of the town. Rather than head north and around, the aid workers drive onto the beach in their white SUVs and use the beach as a short cut, as do all the locals who live in the southern stretch of Coxs Bazar. It’s ridiculous that there is only one road and that it has been closed now, but this is Bangladesh so everyone just rolls with the punches.

So, when our time came to do a little beach tourism our driver took us onto the beach – me, Doughty S, his wife and child, in a rundown old van without seatbelts, along the beach and up to the part of the beach where we are to rejoin the road – where we found a couple of cars bogged down, and a queue of cars waiting to get up the hill. You can see the scene pictured above. We sat here for perhaps 10 or 15 minutes waiting our chance to drive up the hill but it seemed every time we tried to gun the engine and go up the hill someone let a tuk-tuk down in front of us, or someone cut in, or a group of people got in our way. Doughty S got out of the car and went up to direct traffic, and we watched as various cars floundered and then got pushed up the hill of sand by gangs of eager men. Eventually a gap appeared, our driver took a risk, and even though a woman in a sari and a tuk-tuk nearly cut us off we gunned up the sand hill, the driver throwing the car left and right with ferocious energy until we bounced up a huge lump and onto smoother, firmer sand, then onto the road where Doughty S rejoined us.

Doughty S reported to us the real story of the floundering cars: a kind of local syndicate of young men had set up a scheme where every time a car attempted to take the hill at speed someone would step in front of it, or they would direct a car coming in the opposite direction into its path. They made sure that children were the ones stepping in front of the car, so that it was guaranteed to slow down, though not so carelessly as to make it stop entirely. Its power gone the car would then hit the bank and flounder, and then the men would offer to push it out for a small fee. The fee was about 30 taka (30 cents or so) for a Tuk-tuk, up to perhaps 100 taka for a car like ours. Many of the drivers were not locals or were not used to driving on sand, and were easy marks; somehow the UN vehicles were never affected by this scam, and neither was the military truck that was just rolling away when we arrived. They obviously knew how to select their targets. Doughty S also told us some drivers suspected the sand gang had sabotaged the road to start with, undermining the sand bank.

Dhaka traffic comes to the bazar

By the time we returned from our tourism trip, the sand gang had also managed to expand to the other slope near our hotel, where I witnessed the traffic jam above. When you see a picture of Bangladesh traffic it is important to remember it’s not just a throng of cars; it’s also a cacophony of horns, because everyone uses their horn all the time for everything, and even the small jam pictured above was raising an enormous racket. Needless to say, we jumped out here and walked the rest of the way to our hotel.

Libertarian dreams

There is a cyberpunk air to Dhaka, in the sense that there is no smooth and ordered government-run system and everything is a chaotic mesh of competing businesses and money makers. There are no traffic lights or traffic police, no road rules, most of the time not even any lanes, and in the chaos of the traffic it’s every man for himself. With a weak state and a populace with limited work opportunities and not much money there is a big atmosphere of scamming, grift and graft. Funnily enough despite this lack of oversight no enterprising soul has managed to set up a toll road, or offer some advanced business plan that can cut through the dust haze and klaxon roar to somehow make money distilling all this essence of chaos down to pure profit. It just remains barely controlled chaos, mostly held together not by profit motives so much as by the common decency people usually show each other despite their situation. It’s a bit of a cliche to tell libertarians that if they want a world without a government they should move to Somalia or something, but I think for your everyday Bangladeshi worker that’s pretty much what they face: undiluted libertarianism. Out of pocket payments for healthcare and rubbish disposal, a completely uncontrolled transport system with very little public investment, a government sector where everyone accepts that services are purchased not given, and some dude with an elephant making a living (of some dubious kind) by extorting motorists. This is the reality of unimpeded libertarianism: the elephant man and the sand gang. If you want to see where it takes you, come and enjoy the traffic in Dhaka… but look out for the elephants!

fn1: The Rohingya are a sad story but I don’t get the impression that anyone here resents them. The Bangladesh army set up camps early, and have done what they can given their resources, and the town is generally welcoming of the aid workers and happy to take their money. Bangladeshis I speak to are universally proud of the social harmony in their country, “unlike India,” and don’t consider for example Hindus or tribal people (who apparently live around here) to be lesser people. The government wants to send the Rohingya back but seems willing to not force them while they are still at risk, and although it’s not a pleasant situation everyone seems to be doing what they can. I wonder if the Rohingya have elephants …?

This week a student and I published an article in PLOS ONE examining the relationship between healthcare-related expenditure and financial catastrophe in Bangladesh. Because PLOS ONE is an open access journal it is possible to read the entire article free online, here. Our study was a statistical analysis of data from a probability-sampled survey of households in Rajshahi, an urban area in Northwest Bangladesh. We collected data on their self-reported illness, household consumption and healthcare-related payments, and used it to estimate the prevalence and risks of financial catastrophe.

Bangladesh doesn’t really have any effective risk-pooling mechanisms, and a large portion of all health financing is derived from direct payments by individuals, usually referred to as out-of-pocket (OOP) payments. The lack of risk-pooling mechanisms mean that households with limited savings are at risk of financial catastrophe from unexpected healthcare costs, and may have to use a wide range of quite unpleasant coping mechanisms to deal with the costs. Our research project aimed to identify the drivers of costs, factors associated with financial catastrophe, and the coping mechanisms used to deal with high costs.

These kinds of research projects have a lot of challenges, and are necessarily flawed as a result. In low-income nations like Bangladesh it is difficult to assess wealth directly, since households often obtain income in kind or through bartering or intensive production (family gardens, etc); and often official income is not declared in order to avoid taxes or other costs. This is usually dealt with through assessing household consumption, rather than income, adjusting for fixed and productive assets. It’s also difficult to assess illness, which is usually done through self-report, and obviously also medical expenses can be hard to keep track of. There is an extensive body of literature on how to deal with those problems though, and we used mostly quite standard methods to handle them. Despite the obvious limitations in such a survey, I think this one presents fairly robust results.

We found a high prevalence of financial catastrophe, with an average of 11% of household consumption spent on healthcare and 9% of households facing financial catastrophe under our definition. Financial catastrophe was much more likely in the poorest households, even though these households spent considerably less on healthcare, and financial catastrophe was also associated with inpatient service use. Chronic illness was associated with higher OOP payments. Bangladesh is currently passing through the “epidemiological transition,” in which chronic non-communicable disease (NCD) prevalence is rising, but infectious diseases remain a significant problem, so the finding that chronic illness is associated with increased OOP payments is concerning: with a baseline proportion of their income already consumed by such illnesses, households will be less able to adapt to unexpected sudden illness or injury, both of which are relatively common in low-income countries compared to high-income countries.

Our findings suggest that Bangladesh needs to move rapidly to implement and scale-up risk-pooling mechanisms; deal with problems in public facilities that mean they don’t seem to be protective against financial catastrophe even though they are ostensibly free or heavily-subsidized; and prioritize NCDs in its health policy agenda. We’re currently conducting more research on disease-specific costs, coping mechanisms, and other aspects of the health-financing challenges facing Bangladesh. Other countries in Asia are moving towards universal health coverage (UHC) and Bangladesh lags some of them; but with care, a little reform, and some coordinated action to target NCDs, there’s no reason that despite its poverty Bangladesh can’t follow in the footsteps of other countries like Vietnam in reducing risk of financial catastrophe and improving healthcare access for the poorest members of its population.

As an aside, 9% is a very high prevalence of financial catastrophe, but I’d be interested to see how it compared with the USA (which also doesn’t have widespread and effective risk-pooling mechanisms). I don’t think the research is done the same way for US systems as in low-income countries, but there appears to be some evidence that financial catastrophe can be high, at least amongst the poor. For example, this New England Journal of Medicine article suggests that Medicare provides limited protection against financial catastrophe, and shows figures indicating that 4% of recipients pay >$5,000 on medical expenses in any one year, which would probably qualify them for financial catastrophe (since most Medicare users have low incomes). I would be interested to see the rates of financial catastrophe amongst the uninsured in the USA, and to compare them before and after Obamacare is introduced, but I don’t think research on the topic is done in the same way in the high-income countries, so I doubt it will be possible. Although health insurance (private or public) is supposed to protect against unexpected medical expenses, it can still be ineffective, and furthermore access to health insurance enables people to purchase healthcare they might otherwise have neglected, which could put them at risk of financial catastrophe where the insurance system fails to provide adequate coverage. Obamacare is going to extend no-frills coverage to the currently uninsured, but this doesn’t mean they’ll get benefits sufficient to prevent financial catastrophe, so it will be interesting to see whether it meets both of the goals of a health-financing system (improving access and reducing financial risk), just one of them, or neither. And if it fails on either or both of those goals, does this mean that Bangladesh will achieve effective UHC before the USA? That would be interesting … but first Bangladesh needs to start the move toward UHC, and hopefully this research will provide useful information and a little impetus in support of that process …