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Demographic Crisis

:
The Impact of the Bangladesh Civil War (1971)
on Births and Deaths in a Rural Area of
Bangladesh
GEORGE T. CURLI N, LINCOLN C. CHEN AND SAYED BABUR
HUSSAIN
Prior to the demographic transition in the now industrialized world, short-term fluctuations in
births and deaths due to disasters - famine, epidemic, war-were common events.^ In part
because of the introduction of new technologies in agriculture and public health, industrialized
societies today are characterized by stable food supplies and adequate containment of epi-
demics. But, these advantages of modernization are not shared by the rapidly growing popula-
tions of low-income countries. Over the past decade, there have been no less than ten major
disasters in these regions in the world as a whole. ^ In addition, the world-wide drought in 1972
marked the beginning of unprecedented international food scarcity.^ In that year, world food
production declined for the first time in two decades; foodgrain prices escalated and food
reserves became depleted. Hardest hit have been less developed countries with rapid population
growth and a chronic deficit of food. The possibility of Malthusian tragedies is a grim but real
prospect in the years ahead.
This paper presents the findings of an investigation into the impact of one recent crisis, the
1971 Bangladesh Civil War, on births and deaths in a population of approximately 120,000 in
rural Bangladesh. Data for the analysis come from a longitudinal vital registration system
maintained by the Cholera Research Laboratory (CRL) in Matlab Bazar thana (county),
Bangladesh.* Baseline trends of vital events for the years 1966-67 to 1970-71 are presented.
Short-term fluctuations in births and deaths during the disturbances of 1971-72 and in the two
subsequent years are analysed, and selected fertility and mortality rates are computed to
document the differential impact of the conflict on the population.
There are several reasons why research on the demographic consequences of disasters are
of interest. First, mortality is considered to be one of the most sensitive and reliable measures
of the extent and magnitude of a crisis. Famine, for example, has been defined as widespread
food shortage accompanied by an increase of deaths, and the death rate is considered as one
of the best indicators of the severity of famine.^ Secondly, studies of mortality differentials
facilitate identification of sub-groups in a population which are at high risk to the impact
of a disaster. Information on mortality differentials, therefore, has obvious relevance for
preventive and remedial programmes. Thirdly, short-term fluctuations in births and deaths have
longer-range demographic consequences, particularly on the age-sex composition of popula-
tions. Accurate assessment of short-term changes in vital rates, therefore, may assist in
^ E. A. Wrigley, Population and History, Weidenfeld & Nicolson, London, 1969, pp. 62-76.
* L. C. Chen (ed.). Disaster in Bangladesh: Health Crises in a Developing Nation (Oxford, New York, 1973).
' U.S. Department of Agriculture, The World Food Situation and Prospects to 1985. Economic Research
Service, Report No. 98, 1974.
* W. H. Mosley, A. K. M. A. Chowdhury and K. M. A. Aziz, Demographic Characteristics of a Population
Laboratory in Rural East Pakistan. Population Research, Center for Population Research, National Institute of
Child Health and Development, 1970.
' G. Blix, Y. Hofvander and B. Vahlquiet (eds.). Famine: A Symposium Dealing with Nutrition and Relief
Operations in Times of Disasters (Almquist & Wicksell, Stockholm, 1971).
87
Populatio
88 G. T. CURLIN, L. C. CHEN AND S. B. HUSSAIN
demographic analyses of population growth rates, population projections, and development
planning. Finally, investigations on the demographic characteristics of contemporary disasters
may offer insights to historical demographers in their study of pre-industrial populations.
Before the demographic transition, short-term fluctuations in vital rates, particularly death
rates, were the rule rather than the exception. There is a paucity of detailed information regard-
ing these historical processes, and studies of modern phenomena may provide clues to the
past.
THE BANGLADESH CIVIL WAR OF 1971
At the partition of British India in 1947, Bangladesh, then East Pakistan, joined West Pakistan,
a region five times its size but with a smaller population, to form the Islamic nation of Pakistan.
During 24 years of union, the two wings of Pakistan enjoyed an uneasy partnership marked by
intermittent regional economic, political, and cultural conflict. Tension reached its height after
the national elections of December, 1970 when one party from East Pakistan won an absolute
majority of seats in the National Assembly which had been apportioned on a population basis.
The military government, controlled by the West wing, however, refused to convene the
National Assembly, and in March 1971 tension escalated into a civil war.
March 1971, therefore, marked the beginning of the Bangladesh Civil War. In the early
part of that month, the urban workers in Bangladesh went on strike, many returning to their
village homes. On 25 March, armed conflict between the Pakistan army and Bengali civilians
erupted. Over the next nine months, a conventional army attempted to subdue a rebellious
civilian population. The conflict was not static. Initially the army held strategic positions in
urban and transport centres and made periodic expeditions into the countryside. By June-July,
however, a guerilla insurgency had developed and armed clashes in the countryside became
common.
These hostilities had a number of serious consequences. The fragile Bangladesh economy
ground to a standstill; transport and communication facilities were paralysed; and, most
important, the supply of foodgrain was seriously compromised. Agricultural production fell
sharply because of dislocation of supplies and services. Food marketing was disturbed, and
food imports, representing about 15 per cent of normal foodgrain consumption, were delayed
and could not be transported or distributed in the countryside.^ Bangladesh was threatened
with a major famine.
The severity of the food shortage was reflected by estimates of foodgrain (rice and wheat)
availabilities. These staples constituted about 85 per cent of the calorie content of an average
Bengali diet.^ In the 1960s, cereal consumption averaged about 15 ounces per head daily.
During 1971, consumption probably fell to a near starvation level of twelve ounces.® The severity
of the shortage was substantiated by a nationwide nutrition survey conducted in May 1972,
which showed that the proportion of severely malnourished children had nearly doubled
during the war year.^ Malnutrition was most acute in the autumn months, just before the main
rice harvest. Only the brevity of the conflict and the reduction in consumption following an
exodus of about 16 per cent of the population to India, prevented widespread famine.
The conflict also precipitated one of the largest short-term international migrations in
recent history. Over a nine-month period, ten million refugees fled to India. Most were Hindus,
* L. C. Chen and J. E. Rohde, 'Famine and Civil War in East Pakistan', Lancet 2, 1971, pp. 557-60.
' L. C. Chen, 'An Analysis of Per Capita Foodgrain Availability, Consumption, Requirements in Bangladesh:
A Systematic Approach to Food Planning', Bangladesh Development Studies 3, 3, 1975.
^ S. R. Bose, 'Foodgrain Availability and Possibilities of Famine in Bangladesh', Economic and Political
Weekly, 1, 1972, pp. 293-393.
' United Nations Relief Operations, Bangladesh National Nutritional Assessment. Information Paper No. 13.
(Dacca 1972).
BIRTHS AND DEATHS IN THE BANGLADESH CIVIL WAR 89
the religious minority in Bangladesh. The daily influx into India averaged 36,000 and during
the single month of May, there were nearly three million arrivals. The Indian government was
able to place most refugees in camps scattered along the India-Bangladesh border. Relief
programmes were instituted to shelter, clothe and feed the refugees, and while relief efforts were
massive, conditions in the camps were appalling by any standard.
The conflict eventually engulfed India as well, and on 16 December the Pakistani army
surrendered to a joint India-Bangladesh command. Recovery in Bangladesh was not immediate.
A new government was formed, but the industrial base and the transport and communication
infrastructure had been destroyed. By the end of February 1972, nearly all refugees had returned
to their Bangladesh homes, requiring large-scale resettlement assistance. Over the next several
years, Bangladesh embarked on a massive rehabilitation effort with international assistance.
THE STUDY AREA
Matlab Bazar thana is an administrative unit in central Bangladesh. The area is situated on a
fiat deltaic plain intersected by numerous rivers and canals, and is characterized by land
which tends to be deeply flooded during the monsoon season. Only recently has a dry-weather
road been opened, linking the region with the district headquarters at Comilla. The climate is
sub-tropical with three seasons: the monsoon (June-September), the cool-dry (October-
February), and the hot-dry (March-May). Agriculture is the dominant economic activity and
fishing is the second most common occupation. There are three harvests annually; the aman
crop, yielding over half the annual rice production in November and December, and smaller
crops are harvested at the end of the boro (March-April) and aus (June-July) seasons.
The population density exceeds 2,000 people per square mile, making Matlab Bazar one
of the most densely settled rural regions in the world. Villages average about 1,000 people living
in separate housing compounds called baris, which usually consist of patrilineally-related
residents. A family on average consists of about six persons, who usually live in a one- or two-
room hut with mud floors, jute stick walls, and thatch grass or galvanized iron roofing. The
people in Matlab Bazar thana are nearly all indigenous Bengalis; about 85 per cent are Muslims
and 15 per cent are Hindus, reflecting the religious composition of the nation as a whole.
The war in Matlab Bazar followed the chronology of the national conflict. During the
March 1971 disturbances, many labourers returned to their village homes in Matlab Bazar.
The army made its first appearance in the area in April with an expedition to Chandpur, an
inland port about 13 miles south of Matlab Bazar. In June, the thana headquarters were raided
by the army, and in July the army instituted periodic counter-insurgency operations in the
area. This precipitated out-migrations from the thana. As the confiict progressed, the insurgents
grew in strength and the intensity of the hostilities increased. By November, insurgents con-
trolled the entire thana. As with the rest of Bangladesh, independence marked the return of
many refugees to Matlab and the beginning of a difficult period of rehabilitation.
DATA COLLECTION AND METHODS
The CRL began a field research programme in Matlab Bazar thana in 1963, with the basic
aim of field-testing cholera vaccines. A small diarrhoea treatment unit was established in the
thana headquarters and a fleet of small speedboats maintained to transport patients and to
support the fieldwork. Approximately 2,500 patients are treated annually in the treatment
centre.
In 1966, the study area was expanded to cover 112,000 persons residing in 132 villages. To
keep the population under surveillance, a census was taken and registration of births, deaths,
and migrations was instituted. While an additional 101 villages were added to the registration
90 G. T. CURLIN, L. C. CHEN AND S. B. HUSSAIN
system in 1968, this study confines itself to the 1966 census population to permit a longer
observation period for baseline trends.
Vital registration is conducted by several tiers of trained fieldworkers. In each village, a
local female (often illiterate) resident visits each household daily to inquire about births, deaths
and migrations. A high-school educated male field assistant, who supervises three to five
female fieldworkers, visits each family weekly. He records all vital events on standard registra-
tion forms. Male fieldworkers are supervised in turn by male sanitary inspectors who visit
each household twice a month to check on the completeness and accuracy of registration. The
entire field staff is supervised by the field surveillance supervisor and his deputy who are
responsible for the co-ordination of the fieldwork.
From 1966-67 to 1970-71 the registration system was believed to be reasonably complete.
However, the system suffered setbacks during the 1971 war. The speedboats were withdrawn in
April, and in July the treatment unit was closed temporarily. In response to an unusually
severe cholera epidemic the unit was re-opened in September and remained active, although
below complement, until the situation returned to normal in January 1972. In the field, many
male field assistants failed to make regular visits to households during the conflict. Some staff
members temporarily moved away, and supervision at the sanitary inspection level was spora-
dic. Most female fieldworkers, however, stayed in their villages and continued to record vital
events (with the assistance of village literates).
After the cessation of hostilities, the CRL launched a drive to correct the defective registra-
tion system. In July 1972, a new census was taken in 45 villages to estimate the errors which
had accrued in the vital events registration system during the disruption. This survey demon-
strated underregistration during 1971 as follows: births 2-7 per cent; deaths 4-9 per cent; in-
migration 17-7 per cent; and out-migration 32-4 per cent. The major defects appeared in the
migration data, and another drive was instituted to catch up on missed events. By July 1973,
supervisors were of the view that any future efforts to register omitted events would prove
fruitless.
The study population included only regular residents of the Matlab Bazar surveillance
area. Visitors, guests and residents who lived elsewhere but who returned home less than once a
month were excluded from the base population. Only births, deaths, and migrations which
occurred to regular residents were recorded, irrespective of the place of occurrence. The calen-
dar year of registration ran from 1 May to 30 April of the subsequent year, and the mid-year
population estimate related to 1 November. All population estimates were based on the 1966
Census and subsequent vital registration. The study year from 1 May 1971 to 30 April 1972
almost coincided with the war and for the purposes of this analysis, 1971-72 was considered as
the war year.
RESULTS
Fluctuations in Crude Rates
Table 1 presents a summary of the vital rates in Matlab Bazar thana for eight complete years,
from 1 May 1966 to 30 April 1974.^° Over the five base years (1966-67 to 1970-71) the crude
birth rate averaged 45-0. During the year of the conflict (1971-72) there was no detectable
change in the birth rate. A small but significant decline of the rate to 41-8 (seven per cent
' ° The CRL registration data included in this report were processed in Bangladesh by counter-sorter. The
data are currently being transferred to magnetic tape for more sophisticated computer processing. The trans-
fer necessarily entails editing, consistency checks, and cleaning of the data. Findings from subsequent ana-
lyses, therefore, may differ in minor respects from the results in this report. Any differences are likely to be
small and would not affect the conclusions of this analysis substantially. The 1973-74 crude rates in Table 1
were obtained by hand count. Subsequent tables do not include this year, because 1973-74 data were not
ready for counter-sorter processing at the time of this analysis.
BIRTHS AND DEATHS IN THE BANGLADESH CIVIL WAR 91
lower than the base level) was recorded in the year following the disturbance. By 1973-74 the
birth rate had recovered fully; that year's level, in fact, exceeded those of the four previous years.
In contrast to the modest changes in the birth rate, the crude death rate fluctuated
markedly and simultaneously with the conflict. During the base years, the death rate displayed
remarkable stability at about 15-0 per 1,000; an exception was 1967-68 when Bangladesh ex-
perienced an epidemic of smallpox. In the war year, the death rate climbed sharply to 21 -0 per
1,000, 37 per cent higher than the five-year average. By 1972-73, a significant recovery was
noted (16-2 per 1,000), although the rate remained above normal levels. Full recovery was
observed in 1973-74, two years after the conflict.
Over a seven-year period the study population increased from 112,711 to 132,797. This is
equivalent to an average annual growth rate of 23-7 per 1,000, which is less than the average
crude rate of natural increase during the base years (30-3). This diflerence is attributed in
part to two abnormal years (1971-72 and 1972-73) when the rate of natural increase declined.
In the earlier year the decline was due to an abnormally high death rate, and in the latter both
to a slightly lower birth rate and a modestly higher death rate. The major portion of the difler-
ence, however, is attributable to net out-migration from the Matlab Bazar study area. During
the five base years, the net out-migration rate averaged 4-9 per 1,000.
TABLE 1. Mid-year population, crude birth rate, crude death rate, and crude rate of natural
increase {per 1,000) in Matlab Bazar thana (1966-67 to 1973-74)
Mid-year
population
Crude birth rate
Crude death rate
Crude rate of
1966-67
112,771
47-1
150
natural increase 32-1
1967-68
114,561
45-4
166
28-8
1968-69
116,909
46-6
150
316
1969-70
120,217
45-3
149
304
1970-71
124,082
43-5
148
28^7
Five-year
average
(1966-71)
45-6
153
303
(War)
1971-72
127,840
445
210
235
1972-73
130,218
418
162
25-6
1973-74
132,797
456
142
314
Figure 1 was constructed to show in detail the response of births and deaths to the war.
In this figure the ranges of the lowest and highest quarterly birth and death rates for the five base
years are plotted. Superimposed upon these are quarterly birth and death rates during 1971-72
and 1972-73. Quarterly rates are computed simply by dividing the registration year (May to
April) into four three-month segments. The basic population of the denominator of the
quarterly rates is computed by assuming a linear change from one mid-year population to the next.
The base birth curve in Figure 1 displays a marked seasonal swing. Theoretically, this
could be due to either a corresponding variation in conceptions nine months earlier or to a
seasonal variation in foetal wastage. Previous research has demonstrated that the seasonal
pattern of births is due to variations in the monthly conception rate.^' The factors responsible
for this fluctuation are, however, unknown. Noteworthy in Figure 1 nevertheless are the
amplitude of quarterly variations during the base period and the comparatively narrow range
of extreme values over five consecutive years. In May-July and August-October 1971 quarterly
birth rates lay within the range of the five previous years, but the rate for November 1971-
January 1972 exceeded the upper limit. Thereafter, the rate fell and two quarterly rates in 1972
were below the lower limit. By the end of 1972 and early 1973 the rate had returned to within
normal limits.
The decline in 1972 was not unexpected, presumably reflecting a reduction in conceptions
*' L. C. Chen, S. Ahmed, M. Gesche and W. H. Mosley, *A Prospective Study of Birth Interval Dynamics in
Rural Bangladesh', Population Studies, 28,1974, pp. 277-297.
G. T. CURLIN, L. C. CHEN AND S. B. HUSSAIN
70 -
60
50
40
30
8
o
Births
WAR
20
10 J_
_L
_L
_L _L
May Aug
1971
Nov Feb May
1972
Aug Nov Feb May
1973
F I G URE 1. Lowest and highest quarterly birth and death rates (per 1,000) in Matlab Bazar
ihana during five baseline years (1966-67 to 1970-71) and quarterly rates in 1971-72
and 1972-73.
Births
1. Base years: mean
highest value
lowest value
2. 1970-72
3. 1972-73
Deaths
1. Base years: mean
highest value
lowest value
2. 1971-72
3. 1972-73
First
(May-July)
314
391
27-6
289
23-5
13-2
148
122
17-5
15-4
Quarters
Second
(Aug-Oct)
499
52-6
470
514
446
15'7
17-2
150
24-3
148
(months)
Third
(Nov-Jan)
644
695
584
73-1
60 6
188
199
180
250
18-7
Quarter
(Feb-April)
410
44-7
361
38-4
388
139
166
12-4
178
163
BIRTHS AND DEATHS IN THE BANGLADESH CIVIL WAR 93
during the conflict in the previous year. Births between May and October 1972 corresponded to
conceptions nine months earlier, between August 1971 and January 1972. Disruption in
Matlab Bazar thana, as in Bangladesh as a whole, was at its most severe during this period. The
reduction in conceptions could be attributed to numerous social and biological factors. Coital
frequency may have been reduced because of voluntary (fear, anxiety) or involuntary (separa-
tion) factors. A desire to avoid pregnancy at a time of crisis could have resulted in a modifica-
tion of reproductive behaviour. In addition, there was the possibility of biological impairment
of reproduction due to malnutrition and disease.
Less readily explainable was the increase of the quarterly birth rate for November 1971-
January 1972. This may be due to errors of registration since this was the period of weakest
field staff performance. A more likely explanation, however, is that this rise was real and reflect-
ed an increase in conceptions between February and April 1971. From the month before the
onset of the conflict in March, civil disturbances were common and, as was noted earlier, many
urban workers went on strike and returned to their village homes. This situation continued into
the early months of the conflict, when rural areas had not yet been reached by the army. In
Matlab Bazar thana, an area about 30 miles from Dacca, a significant proportion of the adult
male population were urban or industrial workers. As the proportion of cohabiting couples in
the villages increased, this could have resulted in increased coital frequency, more conceptions,
and more births nine months later.
While the baseline curve of deaths also exhibited seasonal variations, the swings were less
pronounced. Nevertheless, the quarterly death rates during and immediately after the conflict
fluctuated considerably. The quarterly death rate for May-July, 1971 was already high. It
continued to climb throughout 1971, paralleling the conflict. The fall began with the cessation
of hostilities, and by May-July 1972, the quarterly death rate had returned to normal limits.
Thereafter, the rate remained within normal limits until the end of the observation period.
The death rate therefore appeared to be very sensitive to the disturbances. In fact, the
fluctuation in the death rate in 1971-72 ran parallel with the severity of the conflict and its
associated civil strife and food shortage. While the overall increase in the annual death rate in
1971-72 was 40 per cent above base value; during the conflict itself the quarterly rates were
higher. In August-October 1971, for example, the quarterly rate was 55 per cent above base value.
Fertility Rates
Table 2 presents various fertility and reproduction rates of the study population from 1966-67
to 1972-73. In the five-year base period, the general and total fertility rates averaged 206-3 and
6-3, respectively. The gross and net reproduction rates were computed as 3-1 and 2-2 respective-
ly. An interesting feature of the data in Table 2 was the trend of these rates during the base
period. In each case the rate showed a consistent decline over time. Between 1966-67 and
1970-71 the general fertility rate fell from 223-7 to 191-1 per 1,000 (15 per cent) and the total
fertility rate declined from 6-7 to 5-9 births per woman (twelve per cent). Similarly, the reproduc-
tion rates declined by 12 to 17 per cent over the same period.
This is the first instance in which Bangladesh's recent fertility decline has been docu-
mented by longitudinal observation. Several previous studies have reported, on the basis of
retrospective data, a decline of fertility in Bangladesh during the 1950s and 1960s.^^ The
decline is apparently not entirely due to the impact of the national family planning programme,
which was intensified in 1965, since the National Impact Survey conducted in 1968-69 found
only 3-7 per cent of eligible women currently using contraception.^^
^^ Paul T. Schultz, 'Retrospective Evidence of a Decline of Fertility and Child Mortality in Bangladesh',
Demography, 9,1972, pp. 415-430; John Stoeckel and Moqbul A. Chowdhury, 'The Impact of Family Planning
on Fertility in a Rural Area of East Pakistan,' Demography, 4,3,1967.
^' I. Sirageldin, M. Hossain and M. Cain, 'Family Planning in Bangladesh: An Empirical Investigation'.
Bangladesh Development Studies, 3, 2, 1975.
94
G. T. CURLIN, L. C. CHEN AND S. B, HUSSAIN
An analysis of the causes of this trend lies beyond the scope of this paper. The relevant
finding is that the decline in fertility appeared to have been arrested in the war year. There is,
in fact, suggestive evidence that the level of fertility may have increased slightly during the war
year, consistently with the findings shown in Figure 1. A significant decline was observed,
however, in 1972-73 the year after the war.
The gross reproduction rate closely followed the trend of general and total fertility rates
during and after the war. Interestingly, the net reproduction rate fell sharply in 1971-72; this
occurred despite reasonably stable fertility levels. The cause of the decline obviously was
poorer survivorship, particularly of children. During the base period, about 72 per cent of
live-born children survived to age 27-5 years. In 1971-72, however, only 63 per cent lived to this
age. The low net reproduction rate in 1972-73, the year after the war, reflected both a decline
in fertility and an incomplete recovery in the mortality rate.
TABLE 2. General fertility rate, total fertility rate, gross reproduction rate, and net reproduction
rate in Matlab Bazar thana (1966-67 to 1972-73)
1966-67 1967-68 1968-69 1969-70 1970-71
Five-year
average
(1966-71)
(War)
1971-72 1972-73
General fertility rate*
Total fertility rate
Gross reproduction rate
Net reproduction ratef
223-7
6-7
3-3
2-4
214-5
6-3
3-1
2-2
212-4
6-3
3-1
2-2
193-7
6-1
3-0
2-1
191-1
5-9
2-9
2-0
206-3
6-3
31
2-2
196-4
6-0
2-9
1-7
181-2
5-5
2-7
1-8
* Births per 1,000 women ages 10-49 years.
t Computed by applying five-year mortality schedule to annual fertility schedules
TABLE 3. Age-specific fertility rates (per 1,000) in Matlab Bazar thana (1966-67 to
1972-73)
Age-group
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
1966-67
8-6
238-6
331-4
306-9
248-8
138-5
50-0
15-4
1967-68
8-6
232-3
333-6
297-3
204-3
127-9
44-2
19-3
1968-69
20-9
204-2
357-9
292-3
227-3
101-3
40-0
12-4
1969-70
25-3
205-8
302-9
320-3
197-6
117-7
30-9
9-9
1970-71
18-7
199-1
275-2
280-9
192-2
142-2
53-4
14-9
Five-year
average
16-4
216-0
300-2
299-5
214-0
125-5
43-7
14-4
(War)
1971-72
4-6
192-0
260-0
318-8
207-1
159-4
47-9
14-6
1972-73
5-5
139-0
282-8
276-7
220-7
117-9
53-3
8-8
In Table 3 we show the trend of age-specific fertility rates during the study period. During
the pre-war base period most age groups experienced a modest, though unsteady fertility
decline. Some of the inconsistencies in age-specific trends are probably due to faulty age data.
The most consistent and marked declines were observed in the age groups under 25 years,
suggesting that age at marriage may have been one important factor responsible for fertility
decline. Changes in age-specific fertility rates during and after the year of the conflict followed
those of general and total fertility rates. In 1971-72, no appreciable changes were noted. The
decline in 1972-73 appeared to be shared by all age groups. This presumably reflected a general
reduction in marital fertility. There was, however, a reduction of 30 per cent in the fertility rate
BIRTHS AND DEATHS IN THE BANGLADESH CIVIL WAR 95
of the youngest two age groups (under 20 years). One explanatory factor may be relevant: the
postponement of marriage during periods of social disruption, a phenomenon reported in
previous studies of historical populations.^'^ A post-war survey conducted in Matlab Bazar
found that during the conflict deferment of marriage was common, which, in turn, led to a
marked increase of marriages during the year following the war.^^
Mortality Rates
The stillbirth ratio and infant mortality rates during the study period are shown in Table 4. For
a closer scrutiny of the age group under one year, the infant mortality rate has been further
sub-divided into neo-natal (0-29 days) and post-neo-natal (30 days-11 months) rates. Before
examining the fluctuations in these rates, two aspects of the base infant mortality rates deserve
comment. First, the ratio of neo-natal to post-neo-natal deaths in this population was high;
neo-natal deaths in Bangladesh constituted about 68 per cent of all infant deaths during the
last three years of the base period. In a developing country with this level of mortality a
preponderance of post-neo-natal infant deaths due to the effects of poverty, malnutrition, and
infectious diseases could normally be expected. ^^ Neo-natal deaths are believed to be primarily
related to the quality of maternity care and biological variables, and as such are not as
responsive to malnutrition and infection. Stoeckel and Chowdhury have previously reported
TABLE 4. Stillbirth ratio, infant mortality rate {including neo-natal and post-neo-natal
rates) in Matlab Bazar thana (1966-67 to 1972-73)
Stillbirth ratio*
Infant mortality
rate*
neo-natal
1966-67
330
1107
595
post-neo-natal 51 2
1967-68
42-6
125-4
67-8
57-6
1968-69
39-6
123-8
82-9
40-9
1969-70
35-4
127-5
87-5
40-0
1970-71
33-2
131-3
89-9
41-4
Five-year
average
(1966-71)
37-6
127-5t
86-8t
40-8t
(War)
1971-72
37-8
146-6
86-9
59-7
1972-73
40-6
127-7
ll-l
56-0
* Per 1,000 live births.
t Average of 3 base years (1968-69 to 1970-71),
this unusual observation in the Matlab Bazar population and postulated that disproportionate
underreporting of neo-natal deaths could in part explain the weaknesses of some previous
research. ^^ Whatever the cause of this high ratio, the relevant aspect of this relationship to this
investigation is a relatively greater contribution of neo-natal deaths (nearly double) than of
post-neo-natal deaths to overall infant mortality. Secondly, there is evidence of registration
errors in the first two years, when fieldwork had just begun. The infant mortality rate of 110-7
per 1,000 live births in the first year (1966-67) was lower than in any other study year. More-
over, in both the first (1966-67) and second (1967-68) years, the ratio of neo-natal to post-
neo-natal deaths was less than during the last three years of the base period. With newly trained
fieldworkers, it is possible that some neo-natal deaths could have been misreported as post-
** E. A. Wrigley, op. cit. in footnote 1.
^' K. M. A. Aziz, private communication to the authors.
' * United Nations, Department of Social Affairs, Population Division. Foetal, Infant and Early Childhood
Mortality, 1954, p. 35.
^•^ John Stoeckel and A. K. M. A. Chowdhury, 'Neo-natal and Post-neo-natal Mortality in a Rural Area of
Bangladesh'. Population Studies, 26,1972, pp. 113-120.
96 G. T. CURLIN, L. C. CHEN AND S. B. HUSSAIN
neo-natal during those first two years. This suggests that a more reliable base period for com-
parison would be the last three years of the base period (1966-69 to 1970-71) when neo-natal and
post-neo-natal rates exhibited consistent levels and ratios.
During the year of the war, the infant mortality rate rose to 146-6, 15 per cent above the
three-year base average. By 1972-73, the rate had returned to essentially pre-war levels. When
mortality in the first year of life was examined for neo-natal and post-neo-natal periods separate-
ly, it became clear that the fluctuation was due entirely to an increase in the post-neo-natal
component. The neo-natal rate in 1971-72 closely approximated that of the base, while post-
neo-natal mortality at 59-7 per 1,000 live births in 1971-72 was 46 per cent higher than the base
average. In the base years the stillbirth ratio averaged 37-6 per 1,000 live births. No significant
fluctuation in this ratio was observed in the war year and though the ratio rose slightly in
1972-73, it continued to remain within the range of base levels.
Previous reports indicate marked increases in stillbirths and neo-natal deaths (or peri-natal
deaths) during periods of severe food deprivation and social unrest.^® Yet, in the Bangladesh
crisis such a response was absent. This is due to several factors. As noted earlier, the deter-
minants of these early death rates are either primarily biological or related to the quality of
maternity care. In this impoverished population modern maternity care did not exist before
the war, and the situation was not changed by the conflict. The most important biological
variable is probably nutrition. The nutritional status of women before pregnancy, weight gain
during pregnancy, and the subsequent birth weight of the infant are all known to be independent
variables afl"ecting pregnancy outcome and neo-natal survival. ^^ While pockets of severe
huiiger deepened and malnutrition increased during the conflict, as noted earlier it was never-
theless believed that a major famine had been averted. There was an exodus of ten million
refugees to India, and these emigrants are estimated to have reduced the demand for food
within Bangladesh by over six per cent.^° A more important explanation is the comparatively
brief duration of actual hardship. The war began in March and ended in December; moreover,
during the first three months, civil disturbances and food shortages were localized and limited.
Thus, the vulnerable period was brief.
The stable stillbirth ratio and neo-natal rate contrast with the fluctuation in the post-
neonatal rate which increased by 46 per cent from the base level. The post-neo-natal rate could
be expected to be more responsive to short-term disruptions, as it is determined largely by
socio-economic, nutritional, and sanitary factors. The most vulnerable post-neo-natal group
would consist of completely weaned infants or those receiving food supplements (normally
starting at about nine months of age in Bangladesh) who are susceptible to the diarrhoea-
malnutrition complex of diseases.^^
Following the post-neo-natal rate, the age-specific death rates in the 1-4 and 5-9 year age
groups also exhibited marked fluctuations in the war year. As shown in Table 5, the death
rate at ages 1-4 during the war year was 43 per cent higher at 36-9 than the base level. By
1972-73, it had returned to normal. By far the largest relative rise in age-specific rates was
recorded in the 5-9 year age group. From a base of 3-7 per 1,000 the rate climbed to 11-4
in 1971-72, representing an increase of 208 per cent. In 1972-73, the year after the war,
this rate rose even further to 14-1 per 1,000 which was 281 per cent above base levels. A con-
tinued rise of rates in 1972-73 was also noted in the 10-14 age group. From a base of 1-6
1^ C. Smith, 'Effects of Maternal Undernutrition Upon New-Born Infants in Holland', 1944-45, Journal of
Pediatrics, 30, 1917; A. Antonov. 'Children Born during the Siege of Leningrad in 1942', Journal of Pediatrics,
30, 1947, p. 250.
^' National Academy of Science, National Research Council, Food and Nutrition Board, Committee on
Maternal Nutrition, Maternal Nutrition and the Course of Pregnancy (U.S. Government Printing Office), 1970.
2° L. C. Chen and J. E. Rohde (1971) be. cit. in footnote 6.
2^ N. S. Scrimshaw, C. E. Taylor and J. E. Gordon, Interactions of Nutrition and Infection, WHO Monograph
Series No. 57 (Geneva, 1968).
BIRTHS AND DEATHS IN THE BANGLADESH CIVIL WAR
97
deaths per 1,000, the death rate at these ages increased to 2-2 and 2-0 in 1971-72 and 1972-73
respectively. The persistent rise in the death rate in 1972-73 in these age groups was due to
post-conflict epidemics of smallpox and dysentery.
The fluctuations in death rates in the 15-44 and 45-64 year age groups paralleled the
conflict and they returned to normal levels in 1972-73. In the 15^4 year age group, the death
rate increased by 38 per cent and in the 45-64 year age group it remained unchanged. In the
very elderly age group (65 and over) the rate increased by 63 per cent in the war year and
remained high in 1972-73.
The differential impact of the war on sex-specific death rates is also shown in Table 5. Sex
differentials were apparent in most rates during the base period. Infant mortality rates were
higher among males but higher death rates in most other age groups were observed among
females. This pattern is typical of most Asian populations; the higher male rate in infancy
TABLE 5. Age-specific death rates {per 1,000) in Matlab Bazar thana il966-67 to
1972-73)
Age
Under
1
1-4
5-9
10-14
15-44
45-64
65 +
All
ages
Sex
Males*
Females
Total
Males
Females
Total
Males
Females
Total
Males
Females
Total
Males
Females
Total
Males
Females
Total
Males
Females
Total
Males
Females
Total
1966-67
1175
1041
1107
200
299
24-9
3-7
45
41
12
2-3
1-7
39
4-2
41
150
15-7
15-3
598
806
679
145
15-5
15 0
1967-68
1271
123-8
1254
24-6
33-5
294
50
51
50
16
26
21
4-2
4-6
4-4
18-0
17-7
17-9
77-9
81-4
79-3
16-5
16-7
16-6
Study year
1968-69
134-3
113-7
123-8
22-5
25-2
23-8
4-0
3-7
3-9
1-6
1-9
1-7
3-0
4-4
3-7
15-6
19-7
17-4
68-8
83-4
74-4
15-1
14-9
15-0
1969-70
137-2
117-4
127-5
18-6
21-1
23-1
3-0
3-6
3-3
0-8
1-3
1-0
3-7
4-0
3-8
16-9
19-2
17-9
68-2
75-4
71-1
15-0
14-8
14-9
1970-71
134-7
127-9
131-3
21-2
34-9
27-9
1-4
3-3
2-3
1-5
1-1
1-3
2-1
3-2
2-7
15-8
12-7
14-4
63-8
86-4
72-9
13-9
15-7
14-8
Five-year
average
135-4
119-7
127-5
21-4
30-2
25-8
3-4
4-0
3-7
1-3
1-8
1-6
3-4
4-1
3-7
15-1
17-0
16-6
67-7
81-4
73-1
15-0
15-5
15-3
(War)
1971-72
149-3
143-8
146-6
28-9
45-3
36-9
9-4
13-4
11-4
2-0
2-5
2-2
5-2
4-9
5-1
23-0
16.3
20-0
112-6
128-6
119-1
20-7
21-3
21-0
1972-73
126-3
129-2
127-7
17-3
28-5
22-7
12-7
15-5
14-1
1-7
2-4
2-0
2-1
3-6
2-9
16-1
13-0
14-7
92-5
102-2
96-5
15-6
17-0
16-2
* Infant deaths per 1,000 live births.
reflects the universally higher biological risk of new-born males and the relatively higher
female rate in childhood presumably reflects differential parental concern and greater care of
sons. In the reproductive ages, maternal mortality would be expected to lead to higher female
death rates.^^
During the year of the conflict, sex differentials remained intact in most age groups. A
notable exception was in the 1-4 year range where the increase in the female rate was dispro-
portionately greater. This probably demonstrated a heightening of parental concern in the care
of sons at times of stress and crisis.
The effect of the differential fluctuations in age-sex-specific death rates on the absolute
^^ L. C. Chen, M. Gesche, S. Ahmed, A. I. Chowdhury and W. H. Mosley, 'Maternal Mortality in Rural
Bangladesh', Studies in Family Planning, 5, 1974, pp. 334-341.
98 G. T. CURLIN, L. C. CHEN AND S. B. HUSSAIN
number of deaths is projected in Table 6. In this table the average age-sex specific death rates
for the five base years are computed. Multiplying these rates by the mid-year population during
during the war year provided an estimate of the anticipated or projected number of deaths by
age and sex. These figures, when compared with actual deaths, provide a crude estimate of
excess deaths.
Overall, the actual number of deaths (2,688) in 1971-72 exceeded the projected number
(1,820) by 868. This excess was equally shared by the two sexes, but the impact varied at
different ages. Particularly striking was the larger number of deaths among female children
aged 1-4; there were nearly twice as many female deaths in this age group as of males. Counter-
balancing this predominance of female deaths was the larger number of male deaths in the age
group 45-64 years, and 65 years and over. In these two age groups combined, there were 162
male excess deaths compared with only 68 excess female deaths.
TABLE 6. Projected, actual and excess number of deaths in Matlab
Bazar thana by age and sex during the year of the Bangladesh Civil
War {1971-72)
Sex/Age
Males
Under 1
1 ^
5-9
10-14
15^4
45-64
65 +
all males
Females
Under 1
1-4
5-9
10-14
15-44
45-64
65 +
all females
All
Five-year average
(1966-71) death rate
135.4
214
34
1-3
3-4
15-1
67-7

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

Other gastro-intestinal causes
2-5
5-2
0-4
1-7
1-8
6-2
0-3
1-6
3-4
5-8
0-5
1-3
3-2
6-3
0-2
1-7
(War)
1971-72
4-6
1-9
0-7
6-7
15-5
2-6
3-3
1972-73
2-3
1-7
0-2
5-9
7-8
2-2
2-3
BIRTHS AND DEATHS IN THE BANGLADESH CIVIL WAR
IOI
WAR
1-4
MEASLES AND SMALLPOX
66-67 67-68 68-69 69-70 70-71 71-72 72-73
FI GURE 3. Age-specific death rates (per 1,000) due to measles and smallpox in
Matlab Bazar thana (1966-67 to 1972-73).
Age group
Under 1
1 ^
5-14
15 +
All ages
1966-67
2-7
2-2
0-2
0-5
0-5
1967-68
5-3
5^7
0-7
0-4
13
Study year
1968-69
1-8
2-3
0-2
0-2
0-5
1969-70
04
1-4

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.