“Doctor Of The Poor” Gave New Hope To Bangladesh

SALEEM SAMAD

My mindset was first awakened after reading the cover story Dr Zafarullah Chowdhury (popularly known as Zafar Bhai) and his dream hospital Gonoshastya Kendra in a defunct weekly Bichitra on 25 January 1974.

Later, on the first-page news photo in a defunct Dainik Bangla newspaper, dozens of women health workers of Gonoshastya Kendra (People’s Health Centre) from the outskirts of Dhaka, riding bicycles arrived at Central Martyrs Memorial in Dhaka to pay homage to the language martyrs on 21 February 1974.

I along with Nadira Majumder, correspondent of weekly Robbar and myself (The New Nation) regularly visited Gonoshastya Kendra in 1981 to understand Dr Zafarullah Chowdhury’s concept of his war against “drug imperialism” of the multinational companies in Bangladesh and health for all campaign.

The international drug producers were profiteering from third-world countries, like Bangladesh in over-invoicing imports of raw materials, over-pricing packaging materials and producing unnecessary medicaments.

We were doing serious research and interviews of the national committee headed by Dr Nurul Islam, Zafarullah and others when they were drafting the crucial National Drug Policy and a voluminous document reasoning for banning thousands of drugs and listing a hundred or so essential drugs which have to be produced under the generic name.

The drug policy completely knocked down the business of the multinational companies in Bangladesh. The drug policy for the first time was pinned on the world map for a pro-people initiative.

Despite the drug policy being severely criticised by drug producers and hundreds of doctors, the military dictator General HM Ershad went ahead with full steam to implement the policy.

Several ambassadors spoke to the government to delay the implementation, citing unemployment of hundreds and thousands of employees and the shortage of drugs in the market which will jeopardise the healthcare system in the country.

Zafarullah was confident and so was the Health Ministry admitting that there will be a shortage of drugs in the market and could be replenished from the competitive world market.

Gonoshastya Kendra believed in alternative healthcare which needs to reach the rural areas, where people cannot afford it and most importantly where rural people have never seen a doctor in their life.

The centre produced thousands of barefoot doctors mostly women, recruited from rural areas. They went to remote inaccessible regions to provide healthcare to pregnant women, children and treatment of elderly people.

The concept of barefoot healthcare medics encouraged the government to launch a nationwide primary healthcare programme. The best example is the nationwide child immunisation drive by the government by trained paramedics. Child immunisation was much higher than the World Health Organisation (WHO) target of 75% and Bangladesh attained between 93% and 98% every year since 2005.

Well, fearing the doctors and physicians will be posted in rural areas, away from the luxuries of city hospitals, the Bangladesh Medical Association vehemently opposed the national primary healthcare programme.

The medical doctors’ apex body criticising the programme said it takes several years to train a doctor and a couple of years for nurses (including internship), therefore the mobilisation of medics will be a major challenge.

Zafarullah scoffed at their criticism and said it is possible to train barefoot medics within six months, who can perform delivery of infants including obstructive births.

The world’s largest NGO, BRAC partnered with Gonoshastya Kendra to train thousands of medics to cover millions of the population in villages.

The drug policy buoyed the massive growth of home-grown medicament entrepreneurs who are presently producing drugs in Bangladesh and exporting to more than 150 countries worth US$163.83 million (2021-22).

No other medical colleges or para-medic training institutions in Bangladesh have compulsory field (rural) training experience, except for those under Gonoshastya Trust.

The 82-year-old doctor of the poor had the vision to reach the rural poor to ensure that the global ‘Health For All’ campaign was meaningful.

When the health message of smoking-related diseases was not known to many, his institution was a pioneer to announce job opportunities and even for students in medical college and para-medics, with a strict note in red letters that only non-smokers should apply.

The patient’s suffering, agony and pain caused by smoking-related disease is widespread. The government’s ban on smoking in public has not been able to deter people from smoking, ignoring the harms of nicotine and second-hand smoke.

Well, besides a series of successes, he has had a few failures in his life. He attempted to bring about a change in politicking and government, which he miserably failed. In 1981, he wanted to form a coalition of the left-leaning, muktijuddhas (liberation war veterans) and mainstream Awami League to support his candidate, a liberation war hero General MAG Osmany for the president.

The plan was scuttled and a major setback in the presidential campaign when Awami League nominated constitutional author Dr Kamal Hossain as their candidate for the election against Bangladesh Nationalist Party (BNP) candidate Justice Abdus Sattar who obviously won with a wide margin.

Zafarullah did not have any properties or business in his or his family’s name anywhere. All the institutions and establishments are under Gonoshastya Trust. He left behind the entire country to mourn his death but left behind his legacy of pro-people healthcare institutions.

First published in The News Times on April 13, 2023

Saleem Samad is an award-winning independent journalist, media rights defender, recipient of Ashoka Fellowship and Hellman-Hammett Award. He could be reached at <saleemsamad@hotmail.com>; Twitter @saleemsamad

Feeding the children in coronavirus pandemic

Children School Meal Policy/Photo: Latif Hossain

SALEEM SAMAD

The coronavirus pandemic severely dents free meal programme to help mitigate hunger and malnutrition amongst the most vulnerable school children

In 240 government and BRAC-run educational institutions for children in Trishal, Mymensingh, thousands of school students enjoyed attending classes as the authorities provided a free midday meal.

The cooked food ingredients include rice, lentils, and mixed vegetables -- in total 178 grams which costs Tk10.50. The school students’ nutritional intake of calories was 545 kcal and protein 11.46 gm. The hot cooked meal is culture-specific and nutrition-rich. Dietary diversity is ensured through a change in the recipe to maintain appetite.

The midday meal in rural and urban schools mitigates short-term hunger -- for most students, it was the only full meal.

A study by key civil servants in Bangladesh known as MATT (Managing at Top Team) showed that almost 60% of children go to school hungry. 

In the third year, the school attendance in urban areas in BRAC-operated midday meal projects increased from 55% (2011) to 81% (2013), and in rural areas, attendance increased from 64% (2011) to 92% (2013).

Basanta Kumar, Kar chief of Global Alliance for Improved Nutrition (GAIN) in Bangladesh pushed the idea of a midday meal in schools with the Bangladesh government in 2011 after Prime Minister Sheikh Hasina’s political pledge in Vision 2021 articulated a strong priority on primary school education and nutrition to ensure food security.

However, the Covid-19 crisis has contributed to a child rights crisis. For children, the costs of the pandemic were immediate.

In Bangladesh, like most developing countries, accessibility and affordability of food and nutrition become challenging, while keeping staple food distribution and local food markets is an uphill task for the governments amidst a lack of accountability and weak transparency.

The brunt of the suffering when it comes to access to adequate nutrition with depleting income sources falls on the children, adolescents, and women.

According to the Primary Education Census (2011), there are 20 million primary school-age children, of which 18.4 million children are enrolled in primary schools.

Various studies show that quality education in primary school is hindered by a high dropout rate caused by hunger and malnutrition and widespread micronutrient deficiencies.

The provision of nutritious food improves the cognitive and physical development of children, remarks Basanta. An estimated 20.9% have sub-clinical Vitamin-A deficiency, 19.1% are anaemic, and 40% are iodine deficient.

To ensure the sustainability of the free-midday meal in schools in Trishal, local government representatives, school committees, and participation of mothers of the students have ensured accountability of free mid-day meals in schools.

Unfortunately, after the departure of Basanta, the fruitful negotiations with development partners and international multilateral donors have become weak.

The pioneering program initiated by GAIN with development partners BRAC and Banchte Shekha emerged as a “game-changer.” Recently the government renewed commitment to replicate and scale up the school feeding model nation-wide in primary schools.

“It is critical to ensure food diversity and adequate nutrition, including key micronutrients and fortified staples,” Basanta said.

On Universal Children’s Day which is on November 20, the United Nations claims a definite impact has been found in investing in children. In response to the global nutrition crisis, school feeding programs can be adapted and scaled up to reach the most vulnerable children.

First published in the Dhaka Tribune on 17 November 2020

Saleem Samad is an independent journalist, media rights defender, recipient of Ashoka Fellowship and Hellman-Hammett Award. He can be reached at saleemsamad@hotmail.com. Twitter @saleemsamad

Dr Amartya Sen: What's happening in Bangladesh?

AMARTYA SEN

Self-assured commentators who saw Bangladesh as a “basket case” not many years ago could not have expected that the country would jump out of the basket and start sprinting ahead even as expressions of sympathy and pity were pouring in. This informative Lancet Series on Bangladesh helps to explain what happened—and why. It is important to understand how a country that was extremely poor a few decades ago, and is still very poor, can make such remarkable accomplishments particularly in the field of health, but also in social transformation in general.

The lessons are important for Bangladesh's own future, and for what The Lancet Bangladesh Team describe as the construction of “a second generation of health systems”. But the messages from Bangladesh's experience are also of great relevance for many other countries in the world that suffer from debilitating poverty. It might not be good manners for Bangladesh to start lecturing the world on what to do, so soon after jumping out of the basket to which it had been relegated, but the country's experience has important lessons for other developing countries across the globe.

These lucid and helpful papers discuss the main avenues of change on which Bangladesh has travelled. I will not summarise the findings: this has been nicely done in the introductory paper by Mushtaque Chowdhury and colleagues. Instead I will concentrate on a small number of striking features of the strategy followed by Bangladesh in moving rapidly towards health transition.

One direction of change is the emphasis that the country has placed on reducing gender inequality in some crucially important respects. The impetus for the change was linked in many different ways with the politics of liberation that made the issue of freedom, including the liberation of women, a part of the progressive agenda of what people wanted and were ready to fight for. There are inescapably complex issues to be addressed in order to explain more fully how exactly that happened. It can be argued that there were historical elements in the culture of Bengal, and particularly in the emergence of radical movements in various forms in that province throughout the first half of the 20th century, that leant them to include a serious concern for gender equity. But it was the nature of the struggle for independence of Bangladesh, particularly in focusing on the contrast with West Pakistan, that made it possible to make an effective political translation towards empowering women.

The causation of this move towards gender equity cannot but remain somewhat speculative, but its consequences are clear enough. Schools focused particularly on expanding the education of girls: Bangladesh is one of the few countries in the world where the number of girls in school now exceeds the number of boys. Public services, including school teaching, health care, and family planning, employ a much higher proportion of women workers than is the case in most developing economies, including in Bangladesh's neighbouring countries. Women have also entered the economic workforce in plentiful numbers, led by such industries as garment making that provided easy entry to female labourers, even though the neglect of safety at work has been a huge blot in the record of that industry, a serious deficiency that is only belatedly being addressed, and perhaps not yet strongly enough.

Women have also received special attention from Bangladesh's powerful non-governmental organisations (NGOs)—from large initiatives like BRAC and Grameen Bank to smaller organisations—and the mobilisation of the active agency of women has been a distinctive feature of the vision that has moved Bangladesh forward. And there has been a general determination in post-independence Bangladesh to target the elimination of female disadvantage in different fields of action, including maternal and child survival.

The removal of female disadvantage and the use of female agency have raised Bangladesh's record of achievement even on its own, but it is in fact the case that women's agency has also contributed greatly to the advancement of the lives and freedoms of all—men, women, and children. The unlocking of the power of women's active role in the society and in the economy has been an extremely productive move for Bangladesh and contrasts with what has happened in much of India. Bangladesh's powerful achievement in making much greater use of women's agency is a remarkable affirmation of the importance of what Mary Wollstonecraft called, in 1792, “the vindication of the rights of woman”. Indeed it turns out that the removal of the social shackles that restrain women has a crucial part to play in the progress of all people—of both sexes and of all ages.

A second striking feature of the Bangladesh story is the general acceptance of a multiplicity of instruments in the public and private sectors for rapid social advancement. Just as state initiatives have been seriously undertaken, NGOs and private enterprises have been forcefully supplementing the efforts of the public sector. As Syed Masud Ahmed and colleagues argue, the use of pluralism has allowed Bangladesh to get off to a quick start bringing the country a little closer to a health transition.

This is not to deny that the mixture of instruments that characterise Bangladesh's path of development will demand critical examination over time, since substantial overall advancement can coexist with persistent inefficiency and inequalities in the sharing of the benefits of health transition. These evaluative issues remain open to scrutiny and critical examination, but what has to be immediately—and firmly—recognised is that Bangladesh has been, in its own way, going ahead rapidly, rather than remaining paralysed by the slowness that is often entailed by the pursuit of “purity” in more ideologically oriented initiatives which favour either exclusive reliance on private enterprise or exclusive use of state-based programmes. The pragmatism that Bangladesh came to accept through a complex political and social process has yielded noticeable success, which has impressed—and to a considerable extent surprised—the world.

A third feature, closely related to the second, is the intelligent use of community-based approaches in the delivery of health services and medical care. As Shams El Arifeen and his coauthors outline, the mobilisation of community-based participation has many advantages, not only for the fostering of social cooperation, but also for extending the reach of the health initiatives and their impact. The innovations in health-service delivery from which Bangladeshis have benefited have been possible partly because of these participatory features in the process of social change. The importance of innovations is also discussed in the context of equity in the paper by Alayne Adams and colleagues.

A fourth feature, which demands particular attention in Bangladesh, is the country's improved ability to face natural disasters, such as storms, cyclones, floods, and droughts. These natural calamities have acted as a persistent drag on the country's progress. As the contributions by the Richard Cash and colleagues highlight, the deep vulnerability of the disaster-prone country to unruly forces of nature, which needed to be subdued, has indeed been, to a considerable extent, reduced. The elimination of these problems would, however, demand much more security-oriented progress in future years, especially if the threats for climate change become stronger.

I have pointed to a few of the special features in Bangladesh's progress towards a health transition, and many other features have been explored in this valuable Lancet Series. One very important aspect of this compendium of investigations is the continued focus on a call to action that nicely supplements the appreciation of what has been accomplished. Bangladesh has still a long way to go. This Lancet Series shows how Bangladesh has firmly placed itself on the way to that long journey (and has made an excellent beginning), but also points to further problems that have to be tackled as the journey proceeds. The key to Bangladesh's laudable success has been the avoidance of the twin dangers of inertia and smugness. The future will demand more from these virtues.

I declare that I have no conflicts of interest.

First published in The Lancet journal, 21 November 2013

Prof Amartya Sen, a Nobel laureate and professor of economics, Harvard University, Littauer Center, Cambridge, MA 02138, USA

Bangladesh: From 'basket case' to model

Lessons from the achievements--yes, really, the achievements--of Bangladesh

Photo Caption: In this Sept. 30, 2012 photo, Sathi Akhtar, a 29-year-old Bangladeshi woman known as Tattahakallayani or Info Lady shows a 15-minute video played in a laptop at one of their usual weekly meetings at Saghata, a remote impoverished farming village in Gaibandha district, 120 miles (192 kilometers) north of capital Dhaka, Bangladesh. Dozens of Info Ladies bike into remote Bangladeshi villages with laptops and Internet connections, helping tens of thousands of people - especially women - get everything from government services to chats with distant loved ones.

In 1976, five years after independence, a book appeared called "Bangladesh: The Test Case of Development."

It was a test, the authors claimed, because the country was such a disaster that if development could be made to work there, it could surely work anywhere. At the time, many people feared that Bangladesh would not survive as an independent state.

One famine, three military coups and four catastrophic floods later, the country that former U.S. Secretary of State Henry Kissinger once dismissed as "a basket case" is still a test. But no longer in the sense of being the bare minimum that others should seek to surpass. Now, Bangladesh has become a standard for others to live up to.

In the past 20 years, Bangladesh has made extraordinary improvements in almost every indicator of human welfare. The average Bangladeshi can now expect to live four years longer than the average Indian, though Indians are twice as rich. Girls' education has soared, and the country has hugely reduced the numbers of early deaths of infants, children and mothers.

Some of these changes are among the fastest social improvements ever seen. Remarkably, the country has achieved all this even though economic growth, until recently, has been sluggish and income has risen only modestly.

Bangladesh might seem like a special case. Because of its poverty, it has long been a recipient of vast amounts of aid. With around 150 million people crammed into a silted delta frequently swept by cyclones and devastating floods, it is the most densely populated country on Earth outside city-states. Hardly any part is isolated by distance, tradition or ethnicity, making it easier for antipoverty programs to reach everyone. Unusually, it has a culture that is distinct from its religion: although most Bangladeshis are Muslims, their culture and language are shared with the non-Muslim Indian state of West Bengal. Religious opposition to social change has been mild. Not many nationalities have so unusual a collection of traits.

The female factor

That said, the most important of the country's achievements can serve as a model for others. Bangladesh shows what happens if you take women seriously as agents of development. When the country became independent, population-control policies were all the rage (this was the period of China's one-child policy and India's forced sterilizations). Happily lacking the ability to impose such savage restrictions, the government embarked instead upon a program of voluntary family planning. It was stunningly successful. It not only halved the rate of fertility within a generation, but also increased women's influence within their own households. For the first time, wives controlled the size of families.

Later, the textile industry took off -- and four-fifths of its workers are female. Bangladesh was also the home of microcredit, tiny loans for the poorest. By design, these go to women. Thus, over the past two decades women have earned greater influence in the home and more financial autonomy.

And, as experience from around the world shows, women spend their money differently from men: typically, on their children's food, health and education. Child welfare has been underpinned by a quiet revolution in the role of women.

That is not all there was to it. Thanks to remittances from abroad and to the Green Revolution, Bangladesh has done better than most at reducing persistent rural poverty. It has maintained a broad consensus in favor of basic social spending despite military coups and a toxic politics dominated by the bitter infighting of the "battling begums" (the widow and daughter of former presidents, who lead the two main parties).

Bangladesh also has benefited by letting non-governmental organizations (NGOs) get on with what the state itself has been too weak or corrupt to do: experiment with different programs and scale up those that work. Much of its success is attributable to local NGOs like Grameen and BRAC.

Bangladesh has shown that countries can transform the lives of the poorest without having to wait for economic growth. But it does not show that growth is irrelevant. The country surely would have done better still if its economy had expanded faster.

As people's education and expectations rise further, it will be all the more important to provide new jobs and opportunities for advancement.

This article was first published in THE ECONOMIST, November 5, 2012