Dirty, noisy, and ugly; congested and chaotic; overgrown and overpopulated; the capital of Bangladesh offers little to charm the visitor. But Andrew Moscrop enjoyed himself

My four week elective in Dhaka was often enjoyable and always educational. My exposure to some of the problems faced by the city and its population provided a valuable learning experience.

During my time in the city, I was based at the Centre for Health and Population Research. "The Centre," as it is known, operates a small hospital for the treatment of diarrhoeal diseases and runs several primary care clinics within the city. The hospital and clinics offer medical care to the city's inhabitants and provide focuses for the centre's population based research.

Education
Spending time in the centre's hospital made me an expert in "at a glance" stool analysis (able to distinguish a cholera stool from a shigella stool while maintaining a healthy distance). More valuably, I learnt the vital role that education can play in improving health.

The hospital's nutrition unit runs sessions for the mothers of malnourished children. Staff provide basic education in nutrition, hygiene, and cooking skills. Mothers are taught how to provide their children with a diet that is nutritionally complete while still being palatable, easy to prepare, and affordable. Many of the mothers who attend the sessions--wives of rickshaw drivers and labourers--supplement their husband's meagre income by performing menial and poorly paid chores in addition to looking after their children. The women have little money to buy food and little time to cook, so the cost and convenience of their diet is important. A cheap, easy, and nutritious recipe favoured by the unit staff was kedgeree (freshers take note: one handful of lentils, two handfuls of rice, a spoonful of oil, some spices, and whatever vegetables were in season).

Poverty
Problems of poverty and the necessity of alleviating poverty in order to improve health were powerfully driven home to me in Dhaka. At an outreach clinic in one of the city's slums I saw the health problems commonly suffered by slum dwellers. The monotony of scabies, diarrhoea, and respiratory tract infections was tragically broken by a young girl with Fallot's tetralogy. Keen to employ and exhibit my clinical skills, I eagerly noted the clubbed toes that extended from her ragged dress and placed my stethoscope to the fragile cage of her chest in order to hear the characteristic heart murmur. Naively, I then asked when her curative operation would take place. Needless to say, the parents who could barely afford to feed and clothe their child could not afford to pay for cardiac surgery. The girl was not expected to survive more than a few years.

One of the centre's population research projects involved health workers from the clinic visiting the slums to interview the inhabitants. Accompanying the health workers on these visits provided me with a unique opportunity to witness the living conditions of Dhaka's poor. I entered single room shacks built from corrugated iron and plastic sheeting in which whole families lived. No sewage or waste removal systems existed and a single pump supplied water for the washing, drinking, and cooking needs of a whole row of such shacks. Seeing their home environment enabled me to understand better the slum dwellers' common health problems. It also exposed the inadequacies of medical treatments. The scabies ointments began to seem meaningless in an area where three or four children shared a single bed. Advice on hygiene and hand washing to prevent genitourinary infections was valueless in an environment where children picked through rubbish piles to find a meal. Here, among the poorest of the city's poor, money, not medicine, was the crucial health determinant.

Cultural issues
Prevailing cultural values in Bangladesh mean that girls are less likely than boys to be brought to hospital by their families. Lay health beliefs also affect care seeking behaviour. In the wards of Dhaka's paediatric hospital, I saw several children with severe complications of meningitis. Commonly, the child's parents had decided, or been told by a folk healer, that the best treatment for the child would be traditional remedies and prayer. In one heart breaking case, more than a month had passed between the onset of symptoms and the mother's presentation at hospital with her now severely brain damaged daughter.

Culturally determined problems such as these are difficult to overcome, but it may be appropriate to encourage cultural changes to alleviate gender inequalities and remedy certain dangerous lay health beliefs.

In Dhaka, I gained an appreciation of some of the challenges of improving the health of a poor and poorly educated population, in the context of limited funds and infrastructure. I was forcibly reminded that health care is but one determinant of health and that social and economic developments can often be of greater significance in improving people's health. Such socioeconomic health influences may be more apparent and perhaps more significant in Bangladesh than in Britain. Nevertheless, I hope that seeing the importance of these factors in the developing world will encourage me to consider their potential impact on health wherever I ultimately practise medicine.