The prevalence of naturally acquired swimming ability among children in Bangladesh

Unlike in high-income countries, most children in Bangladesh learn to swim without undertaking formal swimming lessons. They learn from their friends and family in open water, such as ponds and rivers. This is usually done while undertaking daily activities, such as bathing or washing clothes.

And yet, drowning is still the leading cause of childhood death in Bangladesh.

Why? Well, those children who are not lucky enough to learn swimming still have to bath, and still have to wash their clothes. Their risk of drowning while undertaking these activities is extremely high.

Recent research suggests that learning how to swim is the equivalent of receiving a vaccination against drowning (in fact, few vaccines achieve the same efficacy as learning how to swim).

Unlike most vaccination programmes, this study suggests that the leading cause of childhood death in Bangladesh could be immediately reduced by targeting a minority of children.

The ‘topping up’ of the prevalence of swimming in Bangladesh could and should be achieved as part of a national drowning prevention programme.

Interested to see the results from this review, good work Francene and team!

Full Text Reports...

Development of a Systematic Review of Public Health Interventions to Prevent Children Drowning
Source: Open Journal of Preventive Medicine

Drowning is the leading cause of death from unintended injury in children globally. Drowning is preventable, and mechanisms exist which can reduce its impact, however the peer-reviewed literature to guide public health interventions is lacking. This paper describes a protocol for a review of drowning prevention interventions for children. Electronic searching will identify relevant peer-reviewed literature describing interventions to prevent child drowning worldwide. Outcome measures will include: drowning rates, water safety behaviour change, knowledge and/or attitude change, water safety policy and legislation, changes to environment and water safety skills. Quality appraisal and data extraction will be independently completed by two researchers using standardised forms recording descriptive and outcome data for each included article. Data analysis and presentation of results will occur after data have been extracted. This review will map the…

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Posted by: tommecrow | November 20, 2013

Great CPR video by the WHO in Bangladesh

A nice CPR education film from the World Health Organisation and Government in Bangladesh….

Have you seen this on TV?

Posted by: tommecrow | November 8, 2013

Liberalisation, Income and Health

It is commonly argued that the world has undergone fundamental transformations over the past twenty years as ‘places’ and people become amalgamated into a world system of flows. Information, disease, and commodities (including people) are crossing boarders with relative freedom, providing the stimulus for global corporations and international non-governmental organisations to expand into previously disregarded spaces .

 Many academics have argued that this interconnectivity has eroded state boundaries, and is increasingly challenging the role of the state as a territorial entity. The push by international financial organisations for countries to adopt stringent neoliberal policies and ‘roll back’ state spending in favour of privatization has added further questions to the new roll of the state in the modern world system.”

Continue reading, download….Liberalisation Income and Health – 2013.

Posted by: tommecrow | November 4, 2013

Simple Water Safety Messaging

For the past few months I’ve been working with the Royal National Lifeboat Institution (RNLI) to project manage the develop an ‘Aquatic Survival’ programme for low resource settings.

Based on the premise that 97% of drowning deaths occur in low and middle income countries, my aim has been to produce a simple set of resources that organisations can used to educate their communities about how to be safe around water.

Part of the programme has been to develop some simple ‘Water Safety Messages’ that are contextually appropriate for a low resource environment.

The first starting point was to look at the Open Water Guidelines that have already been developed by Dr Linda Quann, Elizabeth Bennett and their team and ‘context check’ them against the rural environments in which we planned to work (Uganda and Tanzania). We noted that a few of the messages would have to be modified to make them culturally and environmentally appropriate.

We coordinated a UK stakeholder group of drowning prevention and development experts (RLSS, RNLI, Nile Swimmers, and Plan UK) to ensure that our modifications were in line with current best practice, and liaised with partners in Uganda and Tanzania to ‘sense check’.

The following 10 Key Water Safety Messages were adapted by the group…


1) Know water and weather conditions before entering the water

2) Always test water depth before entering the water

3) Be aware of animals


4) Never enter the water alone

5) Obey all safety signs and warning flags

6) Know how and when to use a lifejacket

7) Always tell someone where and when you’re going swimming


8) Learn safe rescue techniques

9) Always supervise children in and around water

10) Keep your home safe

For each message we also highlighted ‘Why‘ the message was important, and a the ‘take home message‘ we wanted the learner to have. An illustration was also developed for each message and flash cards were created for ease of teaching.

We have since worked with our local partners (the Panje Project) to pilot the messages in schools in rural Zanzibar to make sure they were culturally and environmentally appropriate. We worked with local teachers to identify the best way to deliver the messages, and trained 10 local instructors. During a five day pilot in October 2013 approximately 2,300 children received the messages through a combination of song, drama, pictures and story telling.

Local and RNLI Aquatic Survival Project team with

The programme went very smoothly and initial feedback has been positive! Our next step is to modify the messages based on feedback from our partners, and then to conduct research into the best methods of delivery. Of particular interest is the retention of knowledge of the children using different delivery methods.

I’ll keep you posted of any developments!

Posted by: tommecrow | May 23, 2012

Lifeguard training in Bangladesh

I’ve been in Cox’s Bazar for the past few months working with the Cox’s Bazar Surfing and Lifesaving Club to help them develop a beach lifeguard service. They’re a great bunch, and really keen for new/old equipment. Ramjan Mia is their communication man, and can be contact at

Here’s some news from the beach…..

Setting up a voluntary patrol

In April the Centre for Injury Prevention and Research Bangladesh (CIPRB) teamed up with the Royal National Lifeboat Institution (RNLI) from the UK to deliver a beach lifeguard training course to 15 members of the Cox’s Bazar Surfing and Lifesaving Club in Bangladesh.

Although many different private company’s claim to employ ‘lifeguards’ along the beach, few have received any formal training and many are poor swimmers. Most lifeguard stations make money from advertising, and struggle to build the skills of the lifeguards. This leaves the beach and its swimmers inadequately supervised.

Drowning is a leading cause of death in Bangladesh (the leading cause of death in children aged 1-17). Each year many tourists unaccustomed to the dangers of the sea get into difficulty in the treacherous currents on the beaches of Cox’s Bazar.  In recent years a number of high-profile drowning deaths have highlighted such dangers. 

The 10 day lifeguard training course provided by CIPRB and the RNLI taught participants how to identify a drowning casualty, bring them to the shore, and provide appropriate after-care (including resuscitation).

Fortunately, Green World lifeguard Mohammed Abdul Sukkur – who is also a member of the Surfing and Lifesaving Club – attended the training course.


Abdul, 28, was conducting a regular patrol in Cox’s Bazar a few weeks ago when he noticed a swimmer in difficulty in a rip current off Kolatoli Beach. Reacting quickly Abdul ran into the water and swam out to help the swimmer.

“I was watching him while I was swimming. He was getting more and more tired in the water, then his face went down in the water” says Abdul.

By the time Abdul arrived at the scene the casualty was unconscious.

“I remembered the lifeguard training that we did recently. I towed the person into the beach and the other lifeguards helped me bring him up the sand” he recalls.

“I checked for breathing, he was still breathing so I put him in the recovery position. He was vomiting lots of water, but the recovery position stopped him from chocking”.

After 15 minutes the victim – a 25 year old male tourist from Dhaka – regained consciousness and was sent to the local hospital by rickshaw.

“He wouldn’t give me his name,” says Abdul smiling, “he said he did not want to be identified in the local papers because he would be in trouble from his family in Dhaka”.

The incident highlights the need for professional training for all lifeguards currently working on the beaches of Bangladesh. CIPRB and the RNLI are in the process of organising training for more lifeguards in October, and are confident they can train master trainers in Bangladesh to continue the work.

However there continues to be uncertainty from current lifeguard services surrounding the benefits of investing in training, despite the obvious – and now demonstrated – benefits to beach users.

“The private lifeguard services in Bangladesh don’t want to spend money on training lifeguards because then they will have to pay them more” says one of the lifeguards on duty who wishes to remain anonymous.

CIPRB and the RNLI hope that the newly trained lifeguards will create demand for extra training as they continue to save lives, and hope to work in partnership with the companies currently funding lifeguard services in the future.

“We are looking forward to working with the beach lifeguard providers to provide appropriate training to the lifeguards in Bangladesh,” says Dr Aminur Rahman, technical director of CIPRB. 

Abdul is pleased with the training he received, stating, “I have been working as a lifeguard for 7 years. Before I didn’t know how to rescue, but now I am proud of my new skills.”

Swimming is a skill that most people – particularly those in high resource societies – are taught from an early age. To many it is considered a ‘life skill’, or even a ‘life saving’ skill that can protect you from drowning.

Globally, drowning is a leading cause of childhood death. In some low-resource countries it is the leading cause of childhood death in children over the age of one year.

Yet in most low-resource countries a high proportion of children do not learn how to swim, and those that do learn through an often dangerous informal process of copying friends or family.

A number of organisations are currently working to introduce formal swimming lessons rural communities. The International Drowning Research Centre in Bangladesh (who have trained approximately 200,000 children how to swim as part of their research) have noted a huge (over 95%) decrease in drowning rates among their swimming cohort compared with their control groups.

Yet despite the growing evidence from low-income countries that learning how to swim does provide protection against drowning, there remain a number of academics skeptical of the link. Their main argument stems from the moral hazard conundrum often associated with car-insurance; if you learn how to swim you become more risk averse when it comes to water-safety, and therefore could put yourself at higher risk of drowning.

This argument keeps popping up in public health debates about drowning prevention and may be hampering the roll-out of large scale swimming projects. However, the argument lacks an understanding of the context in which drowning deaths happen in low resource environments (where the World Health Organisation estimate over 96% of drowning deaths occur).

In high-resource countries water is predominantly used for recreation. Drowning deaths usually occur while the victim is undertaking water based recreational activities, for example boating or swimming. In low-resource environments water is used for basic ‘essential’ tasks, such a washing, cleaning clothes, cooking, drinking, fishing…. they are activities which people must undertake, regardless of their swimming ability. People generally don’t swim for recreational purposes like in high-resource countries.


Evidence from South East Asia has shown that the majority of drowning victims can’t swim. The victim accidentally steps into an area too deep to stand while cleaning their clothes, or gets pulled away by the current of a river while trying to fill a water container. In such situations a knowledge of swimming would certainly increase their chances of survival.

It’s true that after learning how to swim a small number of children may undertake more recreation swimming. However such speculation must be seen in the context of the environment and the scale of the drowning problem (18,000 children drowning every year in Bangladesh alone). Those children will still have collect water for drinking and cooking, still have to wash, and still have to fish… but they will be much safer when doing so.

Posted by: tommecrow | August 20, 2011

Nile Swimmers

After a fair amount of work I’ve updated the Nile Swimmers website.

This is a program I have been involved with in Sudan since 2007. Our new development, The Nile Swimmers Alliance is aimed at bringing together organisations and individuals who have an interest in reducing rates of drowning on the River Nile.

Anyway,  you can find out lots more at:

Still needs some work doing, but it’s mostly there!

Posted by: tommecrow | August 20, 2011

Drowning in Bangladesh

So after being here for a year, and with only a few months left in Bangladesh, I thought it would be a good idea to tell people what I do here (because some people still don’t have a clue).

Drowning is the leading cause of childhood death in Bangladesh (between the ages of 1-17). My Dhaka friends are a bit sick of me telling them this, but it’s still a hugely under-recognised problem.

So we (my organisation, the Centre for Injury Prevention and Research Bangladesh) are looking at interventions to reduce the high rate of fatal drowning (death rate currently approximately 85/100,000 in children aged 1-4).

In children over the age of 5 we’re looking at teaching survival swimming skills as an intervention.  Prior to the studies done in Bangladesh there had been no studies conducted looking at the association between swimming and drowning. In fact, it was suggested that teaching someone how to swim might actually increase their risk of drowning due to ‘moral hazard’; they might be more inclined to undertake risky swimming behaviour  due to increased confidence in the water. In some states in the US the moral hazard worry actually led to the suspension of a state wide swimming program because public health experts in the government were so worried they might inadvertently increase drowning rates.

In most high-income countries it would be impossible to study the association between swimming ability and drowning because there are so few drownings that take place. In Bangladesh over 18,000 children drown each year, and there are many children who are unable to swim. The Centre for Injury Prevention and Research Bangladesh (CIPRB) have trained over 100,000 children how to swim since 2005. They have been following all the children they have trained and have been monitoring their rate of drowning. For each child that can swim they have control children matched by age and sex.

Results have shown that rates of drowning in SwimSafe swimmers are 95% lower than in the control groups.  This is the first ever research to draw causation between swimming ability and drowning.

One of the research projects I’m doing at the moment is a follow up from this study. We now know that children who can swim are less likely to drown than children who can’t swim. But what about those children who can already swim? A large proportion of children in Bangladesh learn swimming ‘naturally’ from their peers. By giving them extra swimming skills could inadvertently we be putting them at extra risk? It’s the whole Moral Hazard question all over again. If they are put at extra risk (even if this risk is small) then this could have a huge impact on the numbers of children drowning if swimming lessons were to be rolled out nationally.

I’ve been involved in running and analysing data from a study of  over 25,000 children in Bangladesh, looking at their swimming ability and their number of entries into water over the previous 48 hours. I’ve just finished the analysis and it looks like there is no difference in risk taking behaviours between children who have learnt how to swim in the SwimSafe program and those who have learnt naturally from their peers. We’ll be publishing the results soon, but in our small drowning community this is big stuff. It shows that by rolling out a national swimming program to all children over the age of 4 we could reduce drowning rates in this age group by 95%. This would have a huge impact on Bangladesh reaching it’s millennium development goals in reducing childhood mortality.

In children under the age of 5 we have shown that by introducing a simple day-care scheme between the peak drowning hours of 9am-1pm (when mothers are cleaning and preparing food for the day) rates of drowning can be reduced by 85%. Not only this, but it also has a significant effect on all other types of injury, and even seems to have an effect on reducing communicable disease!

Both interventions have had an independent cost effectiveness analysis done on them. Both are considered to be ‘very cost effective’ by WHO guidelines.

I’m also working on the rollout of a community based First Responder program. There has been no evidence of the effectiveness of CPR in developing countries, or even the feasibility of introducing community based responder schemes. We’re training 2,400 people in CPR and First Aid.

One of the biggest problems we’re finding is the cultural acceptance of CPR. In a conservative Muslim country like Bangladesh it’s difficult to convince someone to do ‘mouth to mouth’ on someone, particularly if they are of the opposite sex. We’ve been asking questions on peoples perception of CPR, their willingness to perform it, and the retention period of their skills. We’re about 1/2 way through the program now, and are currently entering the data for the past 6 months into a database for analysis.

I’m also doing some other stuff with portable swimming pools. I’ll tell you about that next time because my fingers hurt.

Posted by: tommecrow | November 27, 2010

Surfing Bangladesh

It’s 444km from Dhaka, the capital of Bangladesh, to Cox Bazar. So, with a 5 day holiday for Eid I thought it would be a good idea to attempt to do it by Bicycle. I managed to convince someone equally as stupid as me, a fellow expat, but American,  to come with me. A few weeks before the trip we went into the super busy streets of Old Dhaka and picked up a couple of old bikes. I managed to hunt down an old 1940’s style Indian bike, and Garrett found an old racer hidden amongst a pile of junk in a shop. They were lacking a few minor components, including brakes, but we were convinced we would find the time and the bits to fix them back together.

Alas, we were too lazy, and struggled to find the parts we needed. So on Eid eve morning we set off at 5am with two quality bikes ready to make the 110km journey to our first check-point, Comilla. Despite the early start the traffic in Dhaka was very heavy; the day before Eid is the most busy day on the roads. I noticed Garrett wasn’t keeping up so wellwhen we first got into centre the city. His total lack of brakes usually meant he was up in front, but this day he was lagging behind. Eventually we hit the main bus station in the centre of the city – on our route out of the city. The number of people and busses was unimaginable. The fumes were intollerable. Our bikes were crushed between hundreds of busses and we had to inch ourselves forward millimetres at a time. Despite all this people kept asking the usual questions:

“What your country? What your name?”

At this point Garrett lost total control and vomited all over the place. But still the people kept asking us questions. He continued to vomit for the next couple of hours as we tried to get out of the city into the countryside, but after a only a few kilometers (it tool us nearly 3 hours to cross the centre of Dhaka) we pulled over and called it a day. With Garrett nearly passing out, and time running out due to the traffic there was no way we were going to make it 110km before sundown. So, we headed back home.

Garrett slept most of the day whilst I continued to plan an escape from Dhaka. I biked to the train station and found an overnight sleeper train that left at 11pm and arrived at 6am into Chittagong – from there it’s a 3 1/2 hour bus journey to Cox Bazar. I booked a couple of tickets in the hope that Garrett would stay alive long enough to make the trip.

Garrett did survive, and we made it to Cox Baxar. The train ride was incredible. We had an Air Conditioned sleeper cabin and 1.5l of Scotch Whisky; it was like a hotel on wheels, squeeky clean (except the toilet) and very confortable. When we got on the bus there was an Australian girl in front of us. A couple of hours into the journey she turned round and started chatting to us. Turned out she was going to Cox Bazar to surf with some friends at an Eco-Lodge just outside town. Given that we had no plans (having only booked the train ticket a few hours before we left) and nowhere to stay she invited us to come with her. And we, luckily, said ok…

When we arrived we met up with her friends and went to the house of the head of the Bangladesh Surf Club. The guy was something of a local legend. His house was full of boards donated to him over the years. Long boards, short boards, you name it, there must have been at least 50. There was also a guy there who had walked to Cox Bazar from Germany!!! It had taken him 3 years. Amazing. Actually, it kind of made me glad we didn’t bike. I thought people would be impressed by our effort, but to arrive and find someone had walked there.. from Germany… would have been something of a kick in the balls!

So, after picking up some surf boards we made our way out of town to the ‘Eco-Lodge’. It was a nice place right on the beach, with NO PEOPLE (something you don’t get often in Bangladesh). Coxs Bazar is the longest beach in the world! We surfed all day for the next four days before heading back to Dhaka. Perfect!

Having been stuck in the bustling traffic and fumes of Dhaka for nearly two months it was such a relief to find out I could get away from everything so easily, sit out in the sea in total silence. I remember when I was in London I used to have to get out every few weeks to stop me going crazy. This has made living and working in Bangladesh so so much easier.

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