“How is bed 54 today?” This is how doctors refer to patients in the orthopedic ward in a Bangladeshi hospital where I was conducting an ethnographic study (Zaman 2005). It is probably only in hospitals where people are referred as ‘beds’. It is therefore valid that we consider hospital beds when we discuss beds.
Before further elaboration, I would like to briefly introduce my previous ethnographic research in an orthopedic ward of a government teaching hospital in Bangladesh. The research had two major goals: first, to depict various social and cultural dimensions in the life of a Bangladeshi hospital, and thus demonstrate the local nature of biomedical practice, and second, to illustrate how the values and norms of Bangladeshi society are expressed in the hospital life. Although there is a typical biological reality in the hospital that makes it a cosmopolitan biomedical institute, I showed how the social dynamics necessary to deal with that reality give hospital life a local character. To portray the local character of the hospital life, I depicted the behaviour, ideas and concerns of different actors in the ward. I examine how ‘beds’ take on a distinct character in the hospital.
For this article, I have kept the Chinese proverb in mind, “A picture is more powerful than a thousand words.” I will discuss hospital beds with the help of a few photographs that have been taken in the same ward where I did my research. I don’t have enough photographs to support all my observations about the various dimensions of beds, but I will take the photographs as the point of departure for this essay.
Beds and privacy
Beds are generally a private space, but they become public in a hospital ward. This is certainly true in a Bangladeshi hospital ward, and was particularly the case in the orthopedic ward where I did my study. This is to note that the hospital is a public one where mainly poorer people of the community go for treatment, which is more or less free of charge.
The orthopedic department in which I did research has a large open ward which has two sections, one for male patients and the other for female patients. The larger male ward is filled with beds lining both sides, with a wide aisle in between them. More than halfway down the male ward, there are two rooms on both sides. On the left is the room for the intern doctors. On the right is a room for the duty nurses. The nurses’ room is glassed in with transparent glass. Nurses can keep an eye on the entire ward while sitting in there. After passing the nurses’ room, one would see the female section of the ward, which is much smaller than the male section. Officially, this is a one hundred bed ward, 85 beds for male and 15 beds for female. However, in reality, because of budget crisis there are ‘only’ 92 beds in the ward: 81 beds in the male section and 11 in the female section. While the female section remains mostly empty, the male section has 100 patients on average. The extra patients are placed on the floor with only a mattress or even just a sheet to lie on.
There is little concern for privacy. The photographs (1,2,3 and 4) reveal the situation of the ward and the issue of privacy. The demand for privacy in Bangladesh is definitely not as strong as in ‘Western’ countries. Poor Bangladeshi people do not have problems sleeping in the same room with others. In fact, it is almost impossible for a poor person to afford that level of privacy in his or her life. Nevertheless, after being admitted to the ward, patients face unanticipated situations that threaten even poorBangladeshi peoples’ sense of privacy. As mentioned, the ward is an open hall with nearly 100 beds placed in rows. The distance between the beds is generally four or five feet at the most. Few patients are fortunate enough to get one of the 17 small lockers beside their bed to store their private possessions in. The patients who get a corner bed, with a wall on one side and a bedside locker consider themselves fortunate because they have a kind of enclosed mini-world of their own in this vast open space. No matter the position of one’s bed, everyone’s privacy is still threatened in some way or other.
Defecation is one example of loss of privacy. Most of the patients in the orthopaedic ward are non-ambulatory; their traction or plasters confine them to the bed. These patients have to use bedpans for their toilet needs. I observed that when a patient defecates into a bedpan, he usually keeps his eyes closed, probably to avoid embarrassment. There are no bed curtains due to the budget crisis. One patient told me: “See, what punishment Allah has given me; now I have to defecate in front of so many people.” To avoid that situation, most patients try to delay defecation as long as possible. I found that one strategy patients used to avoid defecation was to refuse food completely, or to just eat very little. Public defecation and urination are not uncommon in Bangladesh. One can see people in rural areas defecating on the bank of the river, in the city slum areas or along the side of the railway. However, defecating inside a hospital ward, surrounded so closely by other people, is experienced as excruciatingly embarrassing by patients.
In addition, the patients are under the scrutiny of a number of doctors, medical students and staff members during both the clinical and teaching rounds. As the professor talks about a certain patient, ten to fifteen people gather around that patient’s bed. They expose the injured part of the patient as the professor demonstrates and examines the damage and talks about its clinical features and treatment plan. The other doctors and students also examine the patient. For the duration of their examination, patients remained passive and indifferent. It seems they do not know what to do. Some just keep their eyes closed while some stare at the roof. The women feel most embarrassed when a number of male doctors and students gather around her exposed body part for examination. Sometimes the patients just cover their face with their shari (woman’s robe) during the examination. If someone hesitates to co-operate with the doctor during the examination, s/he receives a vigorous scolding. As a result, most of the patients remain silent and passive during these rounds and allow others to examine their body.
Beds: for patients and relatives
Beds in this ward are not meant only for patients but also for their attending relatives. The presence of patients’ relatives in the ward is normal in Bangladeshi hospitals, as it is in many parts of the world. It is always possible to see one or more of the patient’s family members in and around the ward. Usually they bring the patient to the hospital. One of the relatives then becomes ‘attached’ to the patient during the whole period of the patient’s hospital stay, and plays an important role in caring for the patient. In fact, patients’ family members are crucial players in the overall functioning of the ward, as it is impossible for the limited number of nurses and ward boys to take care of the more than hundred admitted patients in the ward. Moreover, most staff are engaged in tasks other than the provision of patient care, such as paperwork and gate keeping. As a result, although relatives are not part of official organization of the hospital, the staff members heavily rely on them for much patient care. Therefore, relatives are essential actors in the informal organisation of the ward. They help the patient with feeding, washing and using the toilet. They take part in therapeutic processes by helping the patient to take medication and change their dressings. Relatives play an intermediary role between the patient and the ward staff and the patient and the world outside the hospital. They participate in various decisions concerning the treatment of the patient and also provide economic and emotional support to their sick relative.
As a result, family members occupy the ward, and even the beds, of the patients. They are, however, not allowed to stay in the ward during the morning round of the professor. Sometimes beds become a hiding place for an attending family member during this time. An excerpt from my field notes:
I was talking to Abdul Khaleque, an elderly man who had broken his right hand and right leg when a car hit him as he was crossing the highway near his village. He hardly ever came to the city, but now he is trapped in this big city hospital bed with two plastered limbs. As this is harvest season, his two sons are busy in the fields in the village. His wife is taking care of him in the hospital. He told me that his wife stays with him day and night and helps him with everything in the hospital. His sons sometimes come in the evening.
As Abdul Khaleque cannot move his hands, his wife had just finished feeding him breakfast. After a while it was time for the professor’s round. As usual the nurses, ward boys and cleaners all started to shout at the relatives of the patients, telling them to get out of the ward. One ward boy shouted at Abdul Khaleque’s wife to leave the ward quickly. I asked Khaleque where his wife waited during the professor’s round. Khaleque told me that usually she goes out and sits with other relatives in the corridor in front of the operation theatre, but today she is feeling too weak to go out because she could not sleep the night before. Khaleque was having pain in his leg and she remained awake to caress his head.
I left them there and joined the professor’s round. After the round I went back to them and asked Khaleque whether his wife was already back. Khaleque lowered his voice and asked: “Is the professor gone out of the hospital, or can he come again to the ward?” I told him that he was gone and there was no chance of him returning to the ward. Khaleque then whispered: “Actually she is just here beneath my bed. I told you that she was very weak; she didn’t go out.” I was surprised because I had been standing beside his bed for some time but had not noticed anything. Khaleque then asked his wife to come out from beneath the bed. She came crawling out from under the bed with a sigh of relief. Luckily, Khaleque’s bed was in a corner of the ward, so it was a good place for her to hide during the round.
Except for during the professor’s rounds, hospital beds are a meeting place for patients and their relatives. In the night, the relatives share the patients’ beds with the patients or use a spare mattress, if one is available. Sometimes family members make a separate bed under the patient’s bed. With a mosquito net neatly tied above and below the hospital bed, the single bed becomes a two-storey bed. The photographs [5, 6 and 7] show the involvement of relatives in ward activities and their sharing of beds.
Empty beds in the women’s ward
As seen in the pictures [8 and 9] most of the beds of the female ward remain empty. At any point in time, 90 to 95% beds of the ward were occupied by male patients. The empty beds in the female section of the ward reflect the gender conditions of the society. The restricted mobility of Bangladeshi women in the outside world probably explains this disparity. Bangladesh is a predominantly Muslim country where the concept of purdah (seclusion) for women prevails. Though Islamic rules are not strictly followed in everyday life, it is generally discouraged for women to work outside the home and there are few employment opportunities for women outside of their own domestic sphere. As the mobility of women outside the home is limited, they are not as exposed to the dangers that can cause orthopaedic causalities as men are. Most of the patients are young males, as they are the main work force in Bangladesh and have greater likelihood of becoming victims of orthopaedic injuries.
Literally purdah means ‘curtain’ or ‘veil’. It refers to the system of isolation of Muslim women from outsiders and the imposition of high standards of female modesty. The ideology of purdah serves to sanction and legitimate the separate and unequal worlds of women. It inhibits women from directly participating in activities carried out in public sphere.
The most striking characteristic of the agnatic emphasis in Bengali Muslim culture is that half of its population [46% of Bangladeshi population are women] those who retain an eminent role as life sustainers are defined by their absence. Unless thoroughly concealed, women are not to be seen at public events, in the street or on public transport (Katalova 1996:16).
It is also interesting to notice that the majority of the attendants in the ward are males. This is contradictory to the prevailing notion in Bangladeshi society that caregiving is female work. Patients gave various reasons for the absence of female family members from their bedside. It is often not possible for women to leave their household responsibilities to attend a patient in the hospital. It is also considered inappropriate for women to stay in a public place such as a hospital ward, with men lying in beds, and certainly not at night.
Although much change has taken place in women’s life in Bangladesh in last few decades due to urbanisation, an increase in female education, and interventions by NGOs in rural areas, the invisibility of women in the public sphere is still the characteristic feature of Bangladeshi society. As Mohammad Yunus, the founder of the internationally renowned Grameen Bank, a bank for the poor, once commented: “Bangladeshi women are like the other half of the moon, we know it is there but do not know much about it” (in Khan 2002:12).
Patients considered their hospital bed as a kind of prison. The average stay of a patient in the orthopaedic ward is two to four weeks, and some have to stay for months. Most of them are unable to walk and are confined to their beds. It is a great struggle for them to fight off the monotony of this confinement. As one patient said, “Sometimes I feel I am in a prison. As if the clock has stopped. A day seems a year.” Most of the patients spend their many hours either lying or sitting on a 7 foot by 5 foot bed. After their initial days of bewilderment, they develop a routine. In the morning they wash and eat their breakfast. Then the round of the doctors begins. During that period they do not have much to do except waiting for their turn to be examined. After the professor’s round and before the visiting hour, they have an hour or two when they are left alone and are relatively relaxed. Then, in the afternoon, the visiting hour starts and each patient typically has several visitors come. This is a pleasant break for the patients. However, again in the evening, after the visiting time is over, the patients return to their own lonely world.
A question that occupies patients is “Why has this happened to me?” A number of them told me that all day long while lying in bed they try to review their life. Some of them think that this ‘prison’ is their punishment for some sin or misdeed.
For some, the hospital bed was a prison in the literal sense of the word. Among the hundred patients admitted to the ward there are always one or two patients who are literally prisoners, temporarily shifted from the prison to the hospital for medical treatment. The patient in pictures 10 and 11 has been sentenced to lifetime imprisonment and tried to flee from the prison. He broke his leg while trying to climb over a high wall at night. He was arrested and then brought to the hospital. In the hospital he cannot flee. He is chained to the bed and two policemen guard him. One police constable attending a prisoner-patient said:
This is probably the most difficult duty I have as a policeman. It is a punishment to be here in this hospital. I have nothing to do, what should I talk about with this criminal? Fortunately two of us are here. We gossip, read newspapers and struggle to finish our eight-hour shift.
Hospital beds are different from other beds, and Bangladeshi hospital beds are different from other hospital beds. The bed in a tertiary level public hospital in Bangladesh has lost all its privacy. In this hospital where one hundred beds are placed in rows with a gap of only a few feet and without any bed curtains, the patients can hardly maintain any space for themselves. Even a bed sheet or a mattress placed on the floor has come to be considered a bed. Moreover, attending relatives are occupants of the patient’s hospital bed. Because the relatives are integral, albeit informal, part of hospital organization the hospital authorities allow the relatives to use hospital facilities including beds.
The lack of privacy explains why the situation is very different in the female ward. While the male section of the orthopedic ward is overcrowded, the smaller female section is relatively empty. Women of Bangladesh live a less public life. Their chances to become the victim of orthopedic injuries are also fewer. Women are also less visible as attending relatives. It is often not possible for women to leave their household responsibilities to attend a patient in the hospital. Moreover, it is not considered appropriate for women to stay in a public place such as a hospital ward.
At the same time, beds in this hospital ward are ‘prisons’. Patients think that God has imprisoned them in this bed due to some misdeed. Sometimes convicted prisoners are admitted to the ward who are literally chained in and to their bed.
Without a doubt, the bed takes on a specific ‘personality’ in a Bangladeshi hospital. It reflects the features of Bangladeshi society. It shows the poverty and social inequality in the country and the crucial role of family members in an individual’s life. It also reveals the invisibility of women in public sphere. It is my hope that an ordinary piece of furniture, the bed, has become a portrait of a society at large.
Shahaduz Zaman is associate professor and programme coordinator of the James. P. Grant School of Public Health, BRAC University, Bangladesh. He is a physician, medical anthropologist and writer and has a Ph.D. from University of Amsterdam.
2002 Discovery of Bangladesh: Exploration into dynamics of a hidden nation. Dhaka: University Press.
1996 Belonging to others: Cultural construction of womanhood in a village in Bangladesh. Dhaka: University Press.
1994 Bangladesh: Reflections on the water. Dhaka: University Press.
2005 Broken limbs, broken lives: Ethnography of a hospital ward in Bangladesh. Amsterdam: Het Spinhuis.