Beruflich Dokumente
Kultur Dokumente
119-7
30-2
4-0
1-8
4-1
17-0
814
Number of deaths
Projected
324
178
35
13
83
116
154
903
284
241
39
15
109
104
125
917
1,820
Actual
430
241
96
19
127
176
256
1,345
403
359
131
21
132
100
197
1,343
2,688
Excess
106
63
61
6
44
60
102
442
119
118
92
6
23
- 4
72
426
868
These results, in general, conform to historical observations of death patterns at times of
severe food shortage and civil unrest. It has been repeatedly observed that in times of food
crisis, the most vulnerable age groups are young children and the elderly. Women and young
adults tend to have survived better than men and older adults.^^
Some of the reasons underlying these differentials are illustrated by the data presented in
Table 7, where cause-specific death rates are shown for the entire study period. These cause-
specific data are in non-exclusive categories and were obtained from death reports completed
by male fieldworkers who were not medically trained. Caution should, therefore, be exercised
in the interpretation of these results. Despite these limitations, the cause-specific data clearly
show increases in death rates from acute diarrhoea, other gastro-intestinal diseases, and in the
'unknown and other' categories. Interestingly and contrary to expectation, there were no
increases in death rates from respiratory infections or accidents.
" J. Mayer, 'Coping with Famine', Foreign Affairs, October 1974.
BIRTHS AND DEATHS IN THE BANGLADESH CIVIL WAR 99
Age-specific death rates from acute diarrhoea and other gastro-intestinal causes are
depicted in Figure 2. For all practical purposes there is no distinction between these two causes
of death; most are undoubtedly related to infectious diarrhoeal diseases. Most of these deaths
occurred among young children, particularly under the age of five years. Only modest increases
were noted in the adult and elderly age groups. This age differential was not surprising, as
these diseases are known to attack young children disproportionately, particularly recently
weaned children who are no longer protected by breast milk, and who may eat contaminated
food.
Three further aspects deserve comment. First, an underlying condition associated with
many of these deaths was undoubtedly malnutrition. It is commonly acknowledged that most
deaths from malnutrition are not classified as due to starvation per se; but that the cause is
often given as diarrhoeal disease, an illness associated with or precipitating the terminal event.
Secondly, there is evidence that many of these deaths were due to either cholera or shigella
dysentery. Admission statistics of the treatment unit in Matlab Bazar as well as the Cholera
TABLE 7. Cause-specific death rate in Matlab Bazar thana (1966-67 to 1972-73)
Cause of death
Fever
Acute diarrhoea
Other gastro-intestinal
causes
Respiratory
Measles/smallpox
Accidents
Unknown
Others
All causes
1966-67
2-6
0-4
1-8
1-5
0-5
0-7
3-1
4-5
15-0
1967-68
2-6
02
1-8
1-4
1-3
0-8
3-3
5-2
16-6
1968-69
3-6
0-2
1-8
0-4
0-5
0-7
4-3
3-5
15-0
1969-70
1-6
0-1
1-7
2-0
0-2
0-8
4-9
3-6
14-9
1970-71
2-1
0-2
1-9
1-6
0-5
0-8
4-8
3-0
14-8
Five-year
average
(1966-71)
2-5
0-2
1-8
1-4
0-6
0-8
4-1
3-9
15-3
(War)
1971-72
2-5
10
4-8
1-5
0-4
0-9
5-3
4-6
21-0
1972-73
2-7
0-4
3-1
0-7
1-0
0-7
4-3
3-4
16-4
Hospital in Dacca indicated that the annual cholera epidemic in the autumn of 1971 was the
most severe in the past decade. There were, in addition, large numbers of shigella dysentery
cases, with higher case fatality rates than previously. The reasons for these epidemics in 1971-72
are not known but may be related to a general reduction of host resistance as a sequel of
malnutrition or to the unusually large number of migrants who were likely both to contract
diseases and to transmit them more widely. Another reason why diarrhoeal deaths increased
markedly was the temporary closure of the CRL diarrhoeal treatment unit in Matlab Bazar.
The withdrawal of these services probably led to more deaths from diarrhoeal disease than
would have occurred had the treatment unit been fully operational.
An increase in the death rate from measles/smallpox shown in Table 6 occurred one year
after the war in 1972-73. The base rate of 0-6 per 1,000 remained unchanged in 1971-72, but
increased to 1-0 in 1972-73. Because two different causes of death are combined, it is difficult
to separate the relative contribution of measles and smallpox. An attempt to do this is shown in
Figure 3 which illustrates the age-specific death rates from the two diseases combined for the
seven years included in this analysis.
Nationwide statistics of the smallpox programme in Bangladesh have shown that epi-
demics have followed a periodic five-year pattern; the last epidemic before the war occurred in
1967-68.^* By the onset of the war, Bangladesh had been declared essentially smallpox-free
^* A. Sommer, N. Arnt and S. O. Foster, Post-Civil War in Bangladesh: The Smallpox Epidemic in Chen,
op. cit. in footnote 2.
100
G. T. CURLIN, L. C. CHEN AND S. B. HUSSAIN
16 -
14
12
10
OTHER GASTRO-INTESTINAL CAUSES
1-4
WAR
ACUTE DIARRHOEA
<1
66-67 67-68 68-69 69-70 70-71 71-72 72-73
FI GURE 2. Age-specific death rate (per 1,000) due to acute diarrhoea and other
gastro-intestinal causes in Matlab Bazar thana (1966-67 to 1972-73).
Age-group
Under 1
1-4
5+
Under 1
1-4
5-14
15-f
1966-67
1-7
0-8
0-2
4-6
5-8
0-3
1-3
1967-68
1-7
0-3
0-2
Study year
1968-69 1969-70
Acute diarrhoea
1-2
0-3
0-1
0-2
0-3
1970-71
0-8
0-8
0-1
0-2
1970-71
26
3 0
0-1
0-5
(War)
1971-72
1-0
2-0
0-5
0-5
1972-73
2-1
4-3
1-3
01
1-0
with no reported cases in late 1970. But by early 1972, smallpox was again prevalent in epidemic
proportions as a result of importation of the disease by the returning refugees from India. The
Bengali age group found to be at highest risk to smallpox in the 1972 epidemic was that of 5-
9-year-old children. The age-specific rates for this group in Figure 3 reflect this national pattern
very well. Peaks were noted in 1967-68 and 1972-73 with few cases in between, suggesting that
most, if not all, of the deaths in this age group were due to smallpox. Measles deaths usually
occur among younger children.
The rates for the age groups under 1 and 1-4 years, therefore, probably represent a com-
bination of both measles and smallpox, with measles being a significant cause. It seems likely
that measles caused the peak in the mortality rate for 1970-71 when no smallpox was noted in
independent surveys in Bangladesh. As documented previously in Africa,^^ high mortality from
measles superimposed on undernourished children is not unexpected in Bangladesh, since a
high death rate was observed among undernourished refugee children in India when measles
was contracted.^**
" M. L Ogbeide, Measles in Nigerian Children. Journal of Pediatrics, 71, 1967, p. 737.
" J. E. Rohde, L. C. Chen and P. Gardner, Refugees in India: Health Priorities in Chen op. cit. in footnote 2.
102 G. T. CURLIN, L. C. CHEN AND S. B. HUSSAIN
DISCUSSION
Because this study has focused on short-term fluctuations in births and deaths caused by the
Bangladesh civil war, the first issue that deserves comment is the quality of the registration
data, particularly during the conflict when fieldwork was severely disrupted. We have every
reason to believe that registration of births and deaths was reasonably complete during the
war year. The documentation of only 2-7 and 4-9 per cent underregistration of births and deaths,
respectively, in 1971-72 against retrospective histories obtained at the July 1972 Census is
encouraging. Furthermore, the birth rate itself failed to vary significantly from the five-year
base level. Underregistration of births if significant, would have resulted in a lower rate. The
reliability of birth data is such that quarterly rates showed remarkable conformity with
expectation, given the timing of the major disruptions during the conflict.
The death data seemed to be equally valid, showing an overall increase of 40 per cent
above base level. Interestingly, the Matlab Bazar crude death rate in 1971-72 at 21-4 was very
similar to that estimated for the entire nation in a national sample nutrition survey conducted
immediately after the war.^'' Quarterly death rates, moreover, showed a smooth progression.
The chief deficiency in these data centres around migration. The weakness of migration
registration during the conflict was confirmed by the July 1972 Census which showed under-
registration of 17-7 and 32-4 per cent for immigration and emigration respectively. Because of
these deficiencies, migration has been excluded from the current analysis. Migration, however,
does enter into the computation of the base population and, thus, of the denominator of all
rates. Fortunately, the CRL definition of migration (permanent move lasting six months or
longer), minimized the potential magnitude of the error. Those migrants who moved from the
study area to elsewhere within Bangladesh or even to India, but who returned within six months
were considered resident for the entire duration of their absence; vital events occurring in this
group were registered upon their return. The brevity of the conflict and the timing of migration
(beginning May-July 1971 and ending between December 1971 and January 1972) imply that
most movements were temporary, rather than permanent.
The second point is the relevance of this analysis to the nation as a whole. The conflict
undoubtedly had different impacts on different geographical areas within Bangladesh. Indi-
genous food production and the distribution of imported foods varied between one locality
and another. Moreover, those areas containing large numbers of Hindus, the religious minority,
or those in which fighting actually took place were more severely affected. Matlab Bazar thana
was not at the extreme on any of these factors. However, it is unique in that the population was
served by a diarrhoea treatment unit; this unit provided care to about 2,500 in-patients a year.
The base crude death rate in Matlab Bazar of 15-3 per 1,000 is thus probably lower than in the
nation as a whole, commonly estimated at 17-0. Withdrawal of diarrhoea treatment during the
conflict could have led to a further increase in the death rate.-^* Thus, the impact of the war in
Matlab Bazar, while not representative of the nation as a whole, illustrates and reflects in a
qualitative sense the consequences of the civil war.
Accepting these limitations, it appears useful to estimate the probable overall demographic
impact of the war on Bangladesh. Assuming a national population of 70 million in 1971-72 and
the Matlab Bazar base vital rates, there would have been about 3-20 million births and 1-07
million deaths in 1971-72 in the absence of the war. The decline in the crude birth rate by eight
2' United Nations Relief Operations, Dacca, 1972, ibid.
28 Of the 2,500 cases hospitalized annually in Matlab Bazar for acute, dehydrating diarrhoea, 40 per cent
have documented cholera. 30 per cent of the patients belong to the population studied, and epidemiologists
estimate that approximately 30 per cent of patients would have died in the absence of treatment. Thus, about
225 deaths per year were averted by medical services. This implies that the crude death rate in the absence of
CRL health services would be 17.0 per 1,000, paralleling the national level. In the war year, the number of
hospitalized cases was 2,633, slightly higher than the annual average. Thus, it seems unlikely that the treat-
ment centre affected the death rate substantially.
BIRTHS AND DEATHS IN THE BANGLADESH CIVIL WAR IO3
per cent in 1972-73 suggested that there were approximately 260,000 births either averted or
postponed by the conflict. With increases in the death rate in 1971-72 and 1972-73, of 40 and
six per cent respectively, this implies an overall excess number of deaths of nearly 500,000. By
any standard this was a major disaster.
In 1971, there was considerable dispute whether Bangladesh was actually experiencing a
^^ As noted in the introduction, probably the most useful definition of famine is
widespread food shortage accompanied by a significant increase of the death rate.^ In Matlab
Bazar and in Bangladesh as a whole, these two criteria were unquestionably fulfilled. Thus, the
data presented in this paper strongly suggest that a major famine did occur in Bangladesh
during 1971.
The most prominent feature of fertility during and after the conflict was its relative stability.
As recorded in quarterly birth rates, a small increase was noted in November 1971-January
1972 and a modest decrease in May-October 1972. Each reflected corresponding alterations of
conception rates nine months earlier. Considering the intensity of the social upheaval, the small
variation in births may appear surprising. It is, however, consistent with what happened in
demographic crises among pre-industrialized populations and fully confirmed by the reproduc-
tive pattern of the Bangladesh population.
During a famine in seventeenth-century France, Wrigley also found only modest fluctua-
tions in birth rates.^^ According to parochial records, the number of births decreased, after
rather than during the famine and then only by a small amount. Following the decline, there
was an increase in births to above base levels before full recovery. The Matlab Bazar crude
birth rate in 1972-73 fell, but in 1973-74 it increased to 45-6. While this level was within the
five-year base range, it was nevertheless higher than in the four previous years and could
represent a post-conflict rise. Only more detailed disaggregation of the data would permit us to
substantiate this rise more precisely.
The explanation of this modest post-conflict decline and subsequent rise, lies in the repro-
ductive pattern in Bangladesh. Both in seventeenth-century France and in Bangladesh to-day,
the populations are essentially non-contracepting.^^ On average, it takes a married fecund
woman about 30 months to produce a pregnancy.^^ Of this time, only eight months are spent in
an ovulatory state when the woman is menstruating regularly and at risk of conceiving. The
remaining time is characterized by periods of temporary sterility, due to either post partum
lactational amenorrhoea or pregnancy. At any one time, therefore, only about 30 per cent
(8/30) of married fecund women are at risk of pregnancy. With disruptions of brief duration,
only a small portion of the reproductive population would be at risk and only the conception
rate of these women would be affected. Women in a state of temporary sterility would find it
difficult, even if they desired to do so, to modify their fertility during the brief crisis.
A post-conflict rise in fertility could be explained by several factors. The conception
rate is the outcome of two variables: the conception rate among women at risk of pregnancy
and the proportion of women in the ovulatory state. High death rates of children during the war
could have led women who had lost children to attempt to replace them. This would be expressed
by an increase in the conception rate of women exposed to the risk of pregnancy. Such an
explanation, unfortunately, can neither be confirmed nor refuted in this investigation. Three
additional factors, increasing the number of women exposed to the risk of pregnancy, however,
may be more pertinent. Because the fertility decline reflected reduced conception rates among
women at risk of pregnancy during the conflict, more would be at risk after the conflict. The
^' L. C. Chen and J. E. Rohde, 1971, loc. cit. in footnote 6; S. R. Bose, 'Foodgrain Availability and Possi-
bilities of Famine in Bangladesh', Economic and Political Weekly, 7, 1972, pp. 293-303.
30 G. Blix, Y. Hofvander and B. Vahlquiet (eds.), 1971, op. cit. in footnote 5.
'^ E. A. Wrigley, Population and History, 1969.
' ^ I. Sirageldin, M. Hossain and M. Cain, 1975, loc cit in footnote 3.
" L. C. Chen, S. Ahmed, M. Gesche and W. H. Mosley, 1974, loc. cit. in footnote 11.
104 G- T. CURLIN, L. C. CHEN AND S. B. HUSSAIN
high death rate would further increase those at risk after the conflict because child deaths would
prematurely interrupt lactation which in turn would hasten the return of post partum ovulation.
Some of those women therefore who would normally have been temporarily sterile after the
war would, because of child deaths, be exposed to the risk of another pregnancy. Finally, as
noted earlier, preliminary data from Matlab Bazar showed that marriages were delayed during
the war. After the confiict ended, there was an increase in marriages causing a sudden increase
in the number of women exposed to the risk of pregnancy.
In contrast to fertility, mortality proved to be very sensitive to social disruption. The value
of death rates as measures of the extent and severity of a crisis was evident in three ways. First,
mortality levels corresponded well with the intensity of the conflict. Secondly, temporal
fluctuations in mortality followed the course of the confiict closely. There was little or no lag
between the two events. Finally, age-sex differentials in mortality appeared to provide dis-
criminating guidelines to the impact of the disruption on various sub-groups of the population.
The very young and very old experienced high mortality. Young adults and women fared
comparatively better. Interestingly, the infant mortality rate, commonly assumed to be the
most reliable measure of the health status of a community, was only a fair indicator of the
crisis. So, too, were stillbirths. The relative constancy of these ratios presumably refiected the
brevity of the crisis and the importance of biological and maternity-care variables in Bangladesh
where neo-natal mortality predominates in infant mortality.
At highest risk were children under the age of ten years. Many excess deaths occurred in
the 1-4 year age group. In this group female deaths far outnumbered male deaths. Surprisingly,
the death rate at ages 5-9 was most sensitive to the disruption, and nearly trebled. This was
an unexpected finding. One possible explanation is age misreporting but this is unlikely,
given the registration system which started in 1966. Most 5-9 year olds in 1971-72 would have
been aged 0-4 years in 1966-67, an age where errors would not have been large. A more
plausible explanation is that when infectious diarrhoeal diseases occurred in epidemic form,
large numbers of children were involved and the death rate among the older group, too,
increased. Base death rates in the 1-4-year-old age group were already very high (25-8 per 1,000)
compared with the corresponding level among 5-9 year olds (3-7 per 1,000). Because of relative-
ly lower base rates among 5-9-year-old children, the increase would have been larger than the
1-4 year age group. All of this suggests that in future disasters, the 5-9 year age group may be
the most sensitive sub-group as an index of the severity and duration of crisis. Remedial
programmes will need to focus on this age group as well as on younger children.
Although there are limitations to the interpretation of cause-specific data, certain con-
clusions can be drawn by noting trends in the registration system. Expected numbers of deaths
from specific causes are more reliable for categories which are not subject to epidemic fluctua-
tions. Thus, the expected number of deaths due to smallpox and measles, based solely on an
average of the previous five years, may be misleading, for smallpox occurs in epidemic form in
Bangladesh in a five-year cycle. In the base period, deaths due to acute diarrhoea and other
gastro-intestinal causes did not exhibit any notable periodicity, but since most events in this
category are due to infectious diarrhoeal diseases, this rate, too, could have been influenced by
epidemics. After the war, vastly increased numbers of cases of Shigella dysentery were seen
throughout Bangladesh.^"^ This was also the experience within Matlab Bazar thana. Even
with treatment, the case fatajity rate of dysentery is high and the closing of the treatment unit
in Matlab would have raised it even more, so that deaths attributable to the two diarrhoeal
disease categories accounted for 57 per cent of excess mortality. Interestingly, in the age group
under one year, in which total breast feeding is the rule, only 21 per cent of the excess deaths
^* M. M. Rahman, I. Huq, C. R. Dey, A. K. M. G. Kibria and G. Curlin, 'Ampicillin Resistant Shiga Bacillus
in Bangladesh'. Lancet, 1, 1974, pp. 406-407; D. M. Mackay, The Effects of Civil War on the Health of a Rural
Community in Bangladesh'. Journal of Tropical Medicine and Hygiene, 11 y 1974, pp. 119-127.
BIRTHS AND DEATHS IN THE BANGLADESH CIVIL WAR IO5
were in the diarrhoeal categories. Excess deaths among children in the 1-4 and 5-14 year age
groups attributable to the two diarrhoeal disease categories amounted to 65 and 73 per cent of
the total, respectively. Most deaths from dysentery in the treatment unit occurred in severely
malnourished children, and it is not unreasonable to speculate that excess deaths in these
categories were a reflection of a combination of higher than expected attack rates and the
generally poorer nutritional state which existed following the war.