Fazila Begum grinned as she lifted up her hem to reveal a fading patch of scaly skin around her ankle.
"Who knew this one little cream would work so fast?" she says.
Fazila, 34, has been dealing with eczema for the past five years but never got it treated. The nearest hospital is an hour away, by boat and rickshaw, and her skin condition didn't seem serious enough to make the trek, so she ignored it — until a new technology brought the doctor to her.
Fazila lives on Golna char, a remote river island in northern Bangladesh. Chars are low-lying, temporary sand islands that are continuously formed and destroyed through silt deposition and erosion. They're home to over six million people, who face repeated displacement from flooding and erosion — which may be getting worse because of climate change — and a range of health risks, including malnutrition, malaria, chronic diarrhea and other water-borne diseases.
"The most dangerous thing for char dwellers is land erosion. The second one is the lack of access to medical supplies and doctors," says Naveeda Khan, an anthropologist and expert on Bangladesh at Johns Hopkins University's Krieger School of Arts & Sciences.
"There are no doctors within miles," she says. "Child mortality and maternal death have gone down in the rest of the country, but not in the chars. The medical situation is so bad that it really takes away from their quality of their life."
Yet for many char inhabitants — some of Bangladesh's poorest — paying for health care is a costly ordeal. Victims of erosion lose their houses, agricultural land and jobs as farmers, fishers and day laborers. Though government hospitals are free, many people hesitate to go, citing long commutes, endless lines and questionable diagnoses. For convenience sake, one-third of rural households visit unqualified village doctors, called "kabirajs," who rely on unscientific methods of treatment, according to a 2016 study in the peer-reviewed journal Global Health Action.
On the chars, there's even a colloquial expression for the idea of making medical care your lowest priority: It's known as "rog pushai rakha" in Bengali, which roughly translates to "stockpiling their diseases" — waiting to seek medical attention until a condition becomes dire.
Now, a new virtual medical service called Teledaktar (TD) is trying to make health care more easily accessible. Every week, TD's medical operators travel to the chars by boat, carrying a laptop, a portable printer for prescriptions and tools to run basic medical screenings such as blood pressure, blood sugar, body temperature and weight. They pinpoint an area of the char with the best internet reception and set up a makeshift medical center which consists of plastic stool and small tables borrowed from the locals' homes, a tent in case of rain and a sheet that is strung up to give the patients privacy during their session.
Launched in October 2018, TD has eight centers in towns and villages across rural Bangladesh and on three chars, including Golna. It's funded by The Steps.org, a nonprofit founded by Bangladeshi entrepreneurs, finance and technology professionals.
Inside the center, the laptop screen lights up to reveal Dr. Tina Mustahid, TD's head physician, live-streamed from the capital city of Dhaka for free remote medical consultations. Affectionately called Doctor Apa — "older sister" in Bengali — by her patients, she is one of three volunteer doctors at TD.
"I diagnose them through conversation," says Dr. Mustahid. "Sometimes it's really obvious things that local doctors don't have the patience to talk through with their patients. For example, a common complaint mothers come in with is that their children refuse to eat their meals. The mothers are concerned they are dealing with indigestion, but it's because they are feeding the children packaged chips which are cheap and convenient. I tell them it is ruining their appetite and ask them to cut back on unhealthy snacks."
Dr. Mustahid says building awareness about health and nutrition is important for char patients who are cut off from mainland resources.
Even off the chars, Bangladesh faces a critical deficit of health services. The country has half the doctors-per-person ratio recommended by the World Health Organization: Roughly one doctor per 2,000 people, instead of one doctor per 1,000 people. And of those physicians, many are concentrated in cities: 70% of the country's population live in rural areas, yet less than 20% of health workers practice there.
"Telemedicine is gaining popularity and can help close the gap in access to medical care in the most remote areas of the country," says M.A. Yousuf, a telemedicine expert and coordinator of the Dhaka University Telemedicine Programme in the Department of Biomedical Physics and Technology. "For a majority of the population, there is still a psychological barrier regarding the importance of medical care, which can be normalized through telemedicine."
Over 70% of TD's 3,000 patients are female, in part because many are not comfortable speaking with local doctors who tend to be male, says Pima Imam, CEO of the Steps.org.
"The rural women are mostly not literate or confident enough to travel on their own to the nearest town to visit medical facilities on their own," she says.
Many have spent their entire lives cutting sediment and land to move and rebuild their homes when the islands flood. Early marriage and young motherhood, which are prevalent in these parts of Bangladesh, also contribute to the early onset of health problems.
For most TD patients on the chars, Dr. Mustahid is the first big-city doctor that they've ever consulted, she says. TD doctors aren't meant to treat serious illnesses or conditions that require a doctor to be physically present, such as pregnancy. But they can write prescriptions, diagnose common ailments — including digestive issues, joint pain, skin diseases, fever and the common cold — and refer patients to doctors at local hospitals.
The visit is also an opportunity for the patients, especially women, to air their concerns about aging, motherhood and reproductive health, Dr. Mustahid says. The doctors also offer health, dietary and lifestyle advice where necessary, including insight on everything from recognizing postnatal depression to daily exercise (Dr. Mustahid recommends a daily thirty-minute morning walk before the sun gets too intense).
"They think I'm crazy for telling them to do such simple things and pester me for medicines, but I tell them to try [the daily walk]. And it usually works. Arthritis patients come back to tell me their joints feel less tight and throb less," she says.
The first time Fazila saw Dr. Mustahid, it was for a gynecological issue, which, along with joint pain, is a top concern for women on the chars. Eventually she opened up about something else that was bothering her: persistent eczema.
"It can get expensive to travel to the doctor, so usually us women describe our illness to our husbands and they go to the pharmacy, tell them what is wrong and they come back with some random medicines," Fazila says. "But nothing ever worked for my skin problem until I started seeing Doctor Apa."
Other nonprofits are also starting to provide health services in the chars. A local NGO called Friendship operates floating boat hospitals that provide health services to chars all over Bangladesh, docking at each for two months at a time. Friendship also runs satellite clinics in which one medic and one clinic aide who are residents of the community disperse health and hygiene information.
TD still has a few major challenges, including how patients can pay for medicine they're prescribed.
"The government isn't doing anything for the chars. No one sends us anything here," bemoans 40-year old Mira Begum, who lives in Khidirpur char and has been seeing Dr. Mustahid regularly for gynecological problems. "Each medicine is 25 to 30 taka [$0.25-0.35], how can we afford it? Buying medicine is killing us, it is becoming bigger than human life."
Imam says the group is working to procure drug donations from pharmaceutical companies.
"Patients have asked why the medicine isn't free along with the consultations," says Imam. "We are linked to local pharmacies and offer discounts to our patients, making sure to prescribe the most cost-effective brands, but still, there are some residents who can't even afford that."
Nevertheless, TD's remote consultations seem to be popular: Of 3,000 patients, at least 200 have returned for follow-ups, according to TD. The reason, explains Manjuara Khatun, who is a regular patient at the TD facility in a town called Tanore, might be the simple gesture of treating the char inhabitants with respect.
"Doctor Apa is patient," he says. "At the government hospitals, the doctors treat us very badly, but here they listen to us, I can repeat myself many times and no one gets annoyed."
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