 I'm representing MSF Mission in Bangladesh. I'm very proud to be a part of that. The country which is hosting one of the biggest refugee crisis in the recent history and where our team is actively engaged in providing the much-needed health care. But today in this presentation, I'll be talking about another marginalized population. I'll be presenting the health and working conditions of the patients that we see in our occupational health clinic located in the capital city of Dhaka in Bangladesh. The city of Dhaka is considered as one of the biggest growing mega cities with a population of 18 millions with more of this expansion occurring in the urban slum areas. So what is occupational health? So it has highlighted in this slide it is a branch of medicines which deals with the maintenance of health in the workplace including the prevention and treatment of disease and injuries. So the key aspect of occupational health is the safety aspect in the workplace including the prevention. So this concept of occupational health can be applied in any working environment. This slide gives the background information about our project location. Kamrangicir is one of the major slum areas in located in the southern part of Dhaka along the Buriganga River. Officially, the population is estimated to be around 440,000 but we know for sure that with the ever-expanding settlements with more congestions, the population at the moment can be easily has 800,000 in a mere area of four kilometers square. This slum area houses a number of small-scale factories which are engaged in many production activities such as metal smelting, welding, plastic recycling, manufacturing of car batteries and production of garments. And until 2017, canneries industry were also located in the neighboring district of Hazaribah. So this is a bit of our project history in the slum area. Since 2014 MSF has been providing the three pillars of medical interventions. Right now we are providing sexual and reproductive health service with special focus on the adolescents. We are providing medical and the psychosocial care to the survivors of the sexual gender-based violence and intimate partner violence survivors. And the focus of our today's discussion, the occupational health. For here we implemented a new model of care targeting our activities in the clinic and in the factories. In the clinic we of course we do the consultation and treatment of the workers seen in our facilities including the injury care and we also do the give the tetanus vaccination. And our activities in the factories we do a active health promotion through our outreach workers. And another important aspect of our activities in the factory is the assessment of the work hazard. And from time to time we also organize the TT vaccination campaign in the selected factories. So the reason for our starting the occupational health program there has been number of reasons but we first conducted the first survey in 2013 and the result of the survey shows the very marginalized populations with poor access to health care with high rate of injury and high prevalence of diseases among the factory workers with low coverage of tetanus vaccinations. And this triggered our project interest in working for such marginalized group especially in a context where safety aspects are very limited and occupational accidents are very common. One of the most notorious accident was the collapse of five-storeyed building called Rana Plaza in April 2013 which resulted in a death of more than 1,000 workers in a single day. This is considered as one of the biggest accident in the modern human history. So as a part of the learning process for MSF to implement a new model of care and to review our program we review the data collected from the factories and from the clinic. So today the objective of this presentation is to share the result of the hazard assessment that was done in the factories with whom MSF has an aggregate concern and secondly to describe the morbidity patterns categorizing them into adults and minor group. So this is how we collected the data. First let's look at our work in the factories Factory hazard man assessment was done in 2017 last year by a very special technical position known as industrial hygienists so we broadly lease 26 items or prepared the checklist and broadly divided them into four broad categories looking at the general physical safety of the factories a regulation of control measures available or protective equipments for the workers and of course we also look at the ergonomic working environment and from the clinic data we conducted the retrospective analysis of our medical record from the patient's scene between 2014 and 2016 and for this we look at the indicators such as demographic behaviors of the workers working hours of the patients in our clinic the presenting morbidities and we also collected the information on the nutritional status and now let's go to see the result of our factory hazard assessment so rough eventually we assess 151 factories representing the working condition of 5000 workers who have an access to our clinic as you can see from this factory distributions the factory participating in the assessment were roughly equally split between the metal garment plastic and metal factories considering the general's physical safety less than 10% of the factories provide safe drinking water for the workers and 78% of the factories did not have any provision of soap. This was much more concerning for the factories where workers are engaged in direct exposure to the chemicals and for the control measures 94% of the factories assess failed to level and store chemical safely and 95% has moving parts uncovered thereby exposing more chances for the accidents and for the protective equipment and has also observed in our everyday visit to the clinic almost none had any provision or personal protective equipment in place there was no eye ear dust protection observed as you can see in this picture this is the plastic recycling factories and for the ergonomics 66% of the metal plastic and garment factory did not provide any ergonomic working condition it was very very common sight to have a very the same repetitive work working for a very long duration of time and 78% of the workers performed tasks above the shoulder level this again shows that the most of the factories did not have any proper working table they were increasing more chance for the development of musculoskeletal disorders and more chances for accidents now let's look at the medical record the data that we have collected from our clinic so in total 5198 workers were consulted between 2014 to 2016 roughly representing a key 2% of the adults and 17% of the miners and for the median age among the adult 27 yeah median age was 27 years for the adults whereas for the miners it was 15 years and for the both age group the in terms of sex distribution it was majority of them were male half of them did not have any history of going to any primary educations and it's also concerning to see that 22% of the miners and 16% of the adults were actually living inside the factories and others might have been living find accommodation elsewhere in the slum area but it was very common to have the workers share one room between 10 to 15 workers staying in a very poor hygienic condition we also collected information about the battle nut addiction this is a kind of a stimulant nuts which is quite common in this community we found that 26% of our workers that we consulted in the clinic have this habit of chewing battle nut but fortunately this number was low at the minor group and for the factory type which represent the number of patients coming the other factory origin of the patients seen in our clinic for the adults majority of the workers in our clinic were coming from the leather and tanneries whereas government industry employed majority of the minor population and we also collected the information about the working ships dividing them into three main categories the ship less than 12 hours the ship which was working for around 12 hours and those working for more than 12 hour ships and it is interesting to observe that more than 60% of the of the adults and minors have the 12 hour shifts and almost close to 10% of the cases have more than 12 hour shifts and just considering that this number was much more higher for the adults and this is the morbidity presentation as you can see the musculoskeletal disorder was the main complaint seen in our clinic and if you look at the adult group beside musculoskeletal disorders it was gastrointestinal tract and skin which was quite prevalent among the adult population for the minors I mean for the minors they have a different presentation their skin disorders ENT disorder respiratory tract infections and injuries were much more higher has compared to adults and this is a very important slide we as I mentioned before like we collected the nutritional indicators of the patients in our clinic this shows that a very high percentage almost 22 percentage of the adult workers were underweight and this number is much more concerning for the minors 46% of the minors seen were underweight and 26% of the minors seen in our clinics were severely underweight and this of course like any as a part of any analysis these are our measure limitations our findings or the analysis findings here may represent patterns of morbidity among those who have come to our clinic and this may not necessarily present the general working population in Kamragiccha and misclassification of condition or disease may have occurred and the factories which agreed to participate in the hazard assessment may have different conditions from the again the general factory conditions in the slum area so in conclusion we can say that this is a new challenging field for MSF that also requires a very special expertise positions such as occupational health specialists and industrial hygienists and they're not always easy to find this analyze clearly document lack of hazard protection and poor working environment in these marginalized populations and the patterns of morbidity that we saw in this analysis are potentially illustrative of poor working conditions and as a part of the lesson learned I think we can conclude that there's a need to improve access to healthcare including systemic nutritional screening and potential nutritional interventions and for any occupational health intervention I think we clearly establish the fact that there is also need to have an activity in the factories which is the hazard assessment and again as a part of occupational health intervention is very important that we support implementations of interventions that aims at improving the work safety and lastly I'd like to acknowledge the MSF team in Kamrangicja especially Sophie Imran Dr. Gabriel Dr. Rashid our AP Lewis and goodie our industrial hygienist Gary Bang and Bill and I also like to appreciate the support that we got from the HQ in both London and in Amsterdam especially from Grazia Martin and Neil Gray and Raphael thank you very much thank you