The revolutionary who transformed health care

ZAFRULLAH Chowdhury draws inspiration as much from Hippocrates as from Mao Zedong. To the first, he owes his medical ideals and to the second, his taking up a rifle to fight in Bangladesh's war of liberation in 1971. Bangladesh owes a lot to Chowdhury, whose diligence made his country the first in Asia to adopt a comprehensive drug policy based on the needs of the poor. He is also responsible for setting up the Gonoshasthya Kendra, an ideal health programme for the benefit of the rural population. The world has honoured him and the kendra with the Magsaysay Award in 1984 and the Right Livelihood Award in 1992, but in Bangladesh, Chowdhury tells Down To Earth, opposition to him and his drug policy is mounting. Excerpts from his interview:

 
By Amit Mitra
Last Updated: Saturday 04 July 2015

What was it that led you to abandon a lucrative career abroad and return to your country? Was it your rural roots?
No, though I was born on December 27, 1941, in Uttarpara village of Chittagong district, I had hardly any rural connections. I was schooled in Calcutta, then at the Dhaka medical college and finally in England. The turning point came in 1971, when I returned to fight in Bangladesh's liberation war. After the war, I stayed on, motivated by the peasants who had faced the butchery of the Pakistani army to save us. How could I desert these great people?

What led to the foundation of the Gonoshasthya Kendra?
In June 1971, I saw the appalling condition of the people in Savar, a village 40 km from Dhaka. After the war, we decided to start a project in Savar, which was so near the capital and yet so backward -- only 1.2 per cent of the women and 8 per cent of the men were literate. We began by talking to the villagers to understand what they wanted and founded the kendra on April 24, 1972.

Why did you chose Savar?
A friend donated land in Savar for the experiment. Besides, Savar was ideally located as we didn't want to be too far away from the city. Our objective was to set an example for society and to change society if possible. We wanted to make the village independent. We decided to develop the kendra and the village with our own resources and the help of the villagers.

With aid flowing in, especially from the US after it recognised Bangladesh, wasn't it difficult for you to stay away from it?
Self-reliance was important because accepting aid, especially in the formative years, would sooner or later lead to compromising the right to exercise our choice. Staying with the villagers, sharing their lifestyle -- our work was, initially, totally voluntary. We welcomed young people, especially doctors and nurses. Our people's health care programme was the only one of its kind. Smallpox was eradicated in our area long before anywhere else in Bangladesh or in India. We succeeded because the people took over the health care system.

How did you ensure that people were taking care of their health?
In 1972, we started a people's health insurance scheme. We grouped households according to incomes and fixed the premium at two takas (Rs ??) a month for a poor family. The consultation, pathological examination and medicines were free, but it wasn't charity -- one had to join the scheme first to get benefits.

How has the movement spread?
We work in 150 villages now and intend moving into urban areas. We have different rates for the rich and the poor, but they are much lower than market rates. This will enable us to recover 45 per cent of our costs. The average infant mortality rate is nearly 140 per 1,000 in Bangladesh, but in the areas where our kendra operates, it is only 65. The maternal mortality rates in these areas are 1-2 per 1,000, compared to 65 in India; the population growth rate is 1.5 per cent, compared to the national rate of 2.4 per cent.

Given this background, how and when did you formulate your country's drug policy?
The drug policy arose from our concern that the poor did not get the medicines they needed. In those days, a day's medicines for tuberculosis cost a poor person two days' wages. And, the treatment lasts one-and-a-half years! How can the poor afford it? All the anti-tuberculosis drugs had to be imported and multinationals (MNCs) like Squibb, May and Baker, Pfizer, Glaxo and Organon really exploited this.

What exactly did you do?
Something very simple. MNCs were producing tonics without any therapeutic value instead of the drugs that the poor actually needed, on the excuse that they were introducing sophisticated technology. But what is the sophistication required to produce a bottle of syrup? Making a chappati requires more skill. But the people didn't understand this and accepted high technology as a justification for high prices. So in 1974, I wrote using various pseudonyms against the drug industry and a story on drug imperialism shook the country. Simultaneously, we mobilised popular opinion on the need for a drug policy. I spoke to Mujibur Rahman and Ziaur Rehman, but in vain.

But how did you calculate the country's requirements?
It's like Tolstoy's story, How much land does a man need? As a member of the committee looking into the issue, I proposed eminent physicians should be asked to list all the medicines they prescribed in the previous three months. The list of the dean of faculty of medicine in Dhaka medical college, Nurul Islam, who was also chairperson of the committee, did not exceed 100.

The committee felt that 250 drugs were sufficient, though 5,000 concoctions were available in the market. A list of 150 essential drugs and another 100 to be reviewed every 6 months was made. We also included price controls, though this was opposed a lot. I was asked what will happen to profits? I offered 15-20 per cent and calculated the price. Why should different manufacturers charge different prices for the same medicine? In this, India's Hathi committee report has been our guiding spirit. It's a pity that it was not accepted in India. (The Hathi committee report said drug producers were profiteering at the cost of patients and drug prices were unjustifiably high. It also accused the producers of bribing doctors to prescribe specific medicines.)

Why did H M Ershad, then president of Bangladesh, accept the drug policy? Was it because you were his man?
Ershad read about our work and of our drug factory at Savar and he understood MNCs were corrupt. He wanted a drug policy, but complained we only talk big and couldn't do anything when it was required. I took up this challenge and on April 27, 1982, a committee was formed to evolve the policy and it was declared on June 1 the same year. Ershad must have got the shock of his life when US ambassador Jane Cuhn (spelling being checked) told him the same morning that the policy was not acceptable to Washington. We had learnt from Sri Lanka's experience what US pressure could be like and from the fate of the Hathi committee report, we knew the medical profession would not accept our proposal.

Our friends were the people. The policy survived because as soon as it was proclaimed, Ershad got congratulatory letters and wires from all over the world. Reagan asked him to revise the report, but American scientists supported the policy. Ershad realised the US government was against us, but not the American people. But this also meant that we had to keep up continuous pressure. Our six-page report was very simply written, so that everybody could understand it. We also made sure that no bureaucrats were involved.

Why were doctors opposed to the policy?
Globally, there is a connection between drug companies and doctors. The Bangladesh Medical Association (BMA) openly opposed the drug policy, but its links with the MNCs are well-known. Its general secretary, Salar Ali, was Pfizer's medical director. Besides, BMA journals as well as foreign trips for its members are funded by MNCs. These doctors are part of a corrupt society and they considered me a threat. They have attacked me many times and our units at Savar have been burnt down. But we have built up public opinion and we can't be faulted on medical grounds, either.

Is the drug policy under threat?
Not exactly, but we have not been able to make our doctors accountable to the people. The present government has reversed all of Ershad's policies, but not the drug policy. In the last decade, prices of every commodity, except drugs, have gone up. Drug prices have remained low, despite the devaluation of the taka from 18 to the dollar to 40. Drugs are being taxed now and we have to import raw materials because we don't produce any. Despite all this, our drug prices are cheaper.

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