Dhaka women suffer more when climate change worsens the dengue situation

In the third week of August - the month Bangladesh recorded the second-highest dengue cases in 2023 - the eighth floor of Dhaka Medical College Hospital (DMCH) was crammed with dengue patients. The hospital authority had to turn the atrium into a large makeshift ward to house the surplus female patients.       

There on the floor, 16-year-old Lamiya was being treated. She had been brought to the hospital after her parents failed to heal her at home for seven days. 

However, after two days at the DMCH, she showed a little improvement. But the teenager wanted a quick release, as she was feeling uncomfortable lying on a floor bed among large crowds, many of whom were men. 

"There is another reason. In two days, half of my father's monthly salary has been spent on my treatment," she said. Her father, Abdul Matin, earns Tk14,000 monthly working at a bicycle shop.

On paper, treatment at DMCH is almost free of cost. A patient can get admitted by buying a ticket with only Tk10. But Matin had to spend much more on medicine as his daughter was one of the surplus patients. 

"We are worried about our daughter's health as well as her treatment costs and other family expenses," said Lamiya's mother Selina. 

Lamiya's case is just one example of how healthcare is inaccessible for the poor in Dhaka, where most of the country's specialised hospitals are situated. 

Such inconvenience leads the poor to more out-of-pocket payments. Many women sacrifice their health to save household incomes. And the consequences are worse when climate change intensifies vector-borne diseases like dengue across the densely populated capital.    

At least 321,179 people were diagnosed with dengue in Bangladesh in 2023. The total number of deaths was 1,705 and 58% of the deaths were from the two city corporations of Dhaka. 

Although males (59.9%) dominated among the hospitalised patients, the fatality rate for females stood at 57.2%, according to the Directorate General of Health Services (DGHS). 

A 2019 study by researchers at Bangladesh Institute of Development Studies (BIDS) measured that the poorest families living in urban Dhaka spend approximately 33% of their household income on healthcare, while the richest spend only 5.2%. The study on people's out-of-payment (OOP) was conducted between May and August 2019. 

For healthcare in Bangladesh, OOP expenditure is the major payment strategy. Any payment related to medical fees, purchases of medicines (prescribed or not), user fees for care and payments for equipment and diagnostic tests are included as OOP.  

"In Bangladesh, on average, 69% of healthcare expenses are borne by service seekers themselves, and here, only solvent people can access proper medical treatment," said Abdur Razzaque Sarker, a research fellow (Health Economics )at BIDS. 

Thirty-three-year-old Arjina Begum, a house help, lives with her two sisters in Bashabo. Their house is nothing but an urban slum - a barrack-style congested facility where lower-income families live.

On 14 July, Arjina was diagnosed with dengue. Despite suffering from high fever, she stayed at home to look after her toddler son. Ten days later, her younger sister Aasia Begum - an RMG worker - was admitted to the dengue ward of the Mugda General Hospital. 

With broken health, Arjina attended to her ailing sister at the hospital. Meanwhile, their elder sister Marjina, also a part-time house help, looked after the joint family. 

On 28 July, Marjina's 8-year-old daughter Shoma Akhter fell sick with dengue.  

One week later, Marjina also contracted the dengue virus while attending to the two patients. By 13 August, Shoma had recovered but Aasia and Marjina were still receiving treatment on floor beds as the 500-bed Mugda Hospital was overwhelmed by huge numbers of dengue patients.   

"Combined, our monthly income is around Tk60,000. In one month, we have spent around Tk one lakh for the treatment of the four patients," said Marjina's husband Jakir, a government office peon. 

BIDS has conducted a post-pandemic study and its result is pending. Razzaque said, "My experience suggests that the OOP payment now has certainly gone high after the Covid-19 pandemic because of rising inflation and income inequality." 

Climate change and dengue outbreaks in Dhaka

Dhaka is one of the fastest-growing as well as the poorest megacities, grappling with many public health-threatening problems such as pollution, unregulated construction work, and unfit vehicles running on fossil fuel. 

Such risks become more severe with the inevitable impacts of climate change.   

A World Bank study published in October 2021 says that climate change or variability, unplanned rapid urbanisation, high population densities, insufficient preparedness, including inadequate public health infrastructure and weak vector-control programmes are factors that contribute to the magnitude and severity of dengue outbreaks in Bangladesh. 

Analysing the changing weather patterns and dengue infection rates between 2000 and 2019, the study asserts that the climate was more conducive to mosquito breeding and vector-borne disease transmission in Dhaka than in other areas when the maximum temperature was in the range of 25°C and 35°C, the maximum temperature above 18°C and the relative humidity in the range of 60 and 80%. 

Another study to trace the association of climate factors with dengue incidence in Bangladesh, Dhaka city, published in May this year, predicts that the number of dengue cases will increase 1.13 times if the maximum temperature increases by 1◦C. 

Similarly, the average dengue cases will increase by 1.03, 1.25, and 1.07 times if the humidity, wind speed, and minimum temperature respectively increase by one unit, one of the authors of the study, Momin Islam, also a faculty at the Department of Meteorology of Dhaka University, said.      

Women suffering more 

Living in urban areas, presumably, offers many opportunities, including potential access to better healthcare. The number of health centres in Dhaka does not contradict the expectation. 

However, the city fails to properly serve the health service seekers, particularly women from poor communities, despite housing 17 specialised public hospitals, eight tertiary-level hospitals, three 500-bed public hospitals, and 10 different capacity (less than 500) hospitals. Moreover, there are 651 registered private hospitals, according to DGHS data. 

Although there is no available data about the number of service seekers at private hospitals, the Health Bulletin 2020 estimated that at least 1,758,967 female patients received outdoor services at 13 Dhaka-based public hospitals (surveyed) in 2019, while the number of female in-patients was only 5.49% of the outdoor patients. 

Earlier in 2015, a Planning Ministry's monitoring report identified the reasons behind women's discomfort in public hospitals. Regarding women-friendly hospital services, the report didn't find all characteristics of women-friendly present at the surveyed hospitals. 

"The reasons for not establishing women-friendly hospitals are absence of protocol, inadequate training, frequent change of manpower, less privacy for women and so on," the report says.

Professor Dr Sharmeen Yasmeen, former chairperson of Public Health Foundation Bangladesh, and currently head of the Department of Public Health and Community Medicine, Bangladesh Medical College, Dhaka, observed that the existing patriarchal society isn't ready to listen to the physical problems of a woman. 

"Inaccessibility to proper healthcare sometimes deteriorates an ailing woman's health condition to the worst point from which recovery becomes very difficult. This happens even in many educated families," Yasmeen told Question of Cities. 

"Women have to raise their voices," she urged. 

Citing the higher death rate of female dengue patients, Yasmeen requested the Health Ministry to conduct a death review so that the social and economic conditions of the women who died could be understood. 

"Maybe we will see that most of the female patients didn't get diagnosed before their death."         

Women from the urban poor segment commonly oversee household chores and also work informal jobs outside. Most of the time, they hide their illness so that their daily jobs are not interrupted and they tend to limit out-of-pocket payments for their healthcare. 

This story was supported by a Fellowship awarded by Question of Cities and Climate Action Network South Asia