This article appeared in the January/February 1977 issue of Asian Action, the newsletter of the Asian Cultural Forum on Development (ACFOD), Room 201, 399/1 Soi Siri, Siom Road, Bangkok 5, Thailand.
This notable rural health program was started by Dr. Zafarullah Choudhry. Now Dr. Choudhry and the paramedics of this people's health centre bring health services to a complex of villages around Savar near Dacca. They are becoming well known for their innovations in rural health practices, and the way they are eroding the barriers against change in village tradition, official attitudes - and in western medical mystique. Moreover, Gonoshasthaya Kendra knows fully well that ultimately people's health can only improve if there is an overall improvement in the socio-economic environment in which they live.
As the war of liberation came to an end in 1971, Bangladesh Hospital "pulled up stakes", and headed home over the border. The work of assisting wounded civilian and freedom fighters was over, and a new challenge lay ahead. Now the returning workers faced the task of providing health care to a densely populated nation, sadly torn by war.
Ira, her sister Boro Gita, Choto Gita and Mosharaf, returned from their exile with the other hospital workers and set about meeting the crucial health problem of the countryside.
Sophisticated professionals, we have found, despite avowals to the opposite, are prone to regard with little seriousness, the arguments of the villager, poor, unsophisticated, uneducated. And this is at least one vital element missing from the success of a health programme. But it is hard to listen until you respect, and it is difficult to respect until you know. And knowing is near impossible if you do not go there, to the village where the people are.
The rural area of Bangladesh, where approximately 90% of the population lives, somehow failed to be effectively included in government plans for the development of the nation, receiving about 6% of the government's health service expenditure. So Bangladesh Hospital, renamed Gonoshasthaya Kendra, the Bangali for People's Health Centre, was relocated twenty miles to the north of Dacca city, in a rural area.
War Experience
Experience during the war had indicated that many real needs can be filled in the absence of professionally trained doctors and nurses. Thus, young men and women were drawn from the surrounding villages to assist in meeting the critical health needs. Mosharaf, Boro Gita, Ira, and Choto Gita, themselves villagers, were joined by others who set out to meet demands that doctors were unable, or unwilling to face.
The paramedic, who is at the core of the programme here at Gonoshasthaya Kendra, is a young person of 17 to 25 years of age, and is a member of the local community. He or she is trained at the centre for a period ranging from six months to a year in such areas as simple preventive and curative medicine, dressings, in-patient care, vaccination, post and ante natal care, hygiene/nutrition, simple pathology, some pharmacology, village work, and family planning with motivation, distribution of contraceptives, and followup. Theoretical classes are only given in the evening with the main part of the training taking place, right from the start, in the field.
In our family planning work we found that there were many women willing to have tubectomies, yet custom has made them shy to submit to having the operation done by a male surgeon. Runu, a paramedic, though she has yet to master the art of reading and writing, had been assisting in the operation theatre quite efficiently. Now she asked if it would not be possible for her to learn the technique of tubal ligation. It was not only possible, but proved to be a very wise step. The women preferred the young female surgeon to the professional physicians who were men. Now twelve girls and one boy are capable of performing the operation independently. Kanon has done over 600. All are truly professional skilled in carrying out the procedure which has become a regular part of the paramedic training.
The training programme is a continual experience, extending after the paramedic has become a member of the regular staff. Senior paramedics instruct newcomers and take charge of such departments as family planning, sick-room, and village work. However, among them there remains only one classification of staff, that is, the paramedic.
Advantages of Paramedics
As members of the local community, the paramedics have the advantage of being familiar with the real needs of those they are serving, and are able to communicate more readily at a meaningful level.
Furthermore, the paramedics are members of the local community not only by birth . Unlike trained physicians, they are not removed from the community by a prolonged and formal education. The physicians, though they might return to serve the people of their own village, have been made remote through an education geared to western needs and giving little recognition to the health problems of the countryside.
Few trained physicians will work in the rural areas. They opt rather for a private practice in the city, or to go abroad. Of those who do work in the countryside, few are equipped professionally, or psychologically, for the needs they meet. The paramedic, on the contrary, as he/she has not left his/her environment, either physically, psychologically, or intellectually, is equipped to meet these needs. His/her medical training has been molded out of the very health situation of the local community.
Village Midwife
The professional village midwife or 'dai' is also vital to our programme. After receiving a basic training at the centre in the areas of hygiene, post and ante natal care, she assumes work on a part-time basis while continuing with her regular household tasks. Family planning motivation, distribution of contraceptives, and follow-up are a major part of her role. She is aware that she has the support of the centre for backup and referral, and the programme in turn benefits from the considerable confidence that the villagers place in her.
Encouraging Aspects
Among the other aspects of the project which we feel to be essential to the health service is agriculture. The surrounding areas have been cultivated with all staff members, paramedics, guards, doctors, drivers, assisting the regular agricultural workers in the morning on rising, and again in the afternoon. Experimental crops such as soybean have been planted.
Recently, educated, upper-class women of Dacca city marched with placards demanding that the government import baby foods for the proper feeding and better health of their children, while knowledgeable and sophisticated journalists sympathized with them in front-page headline coverage.
Ira, later addressed some of these same women at a UNICEF sponsored nutrition workshop. What food had they been given as infants that had assured their reaching maturity, she asked. It was not imported baby food. Our country, she emphasized, will not and cannot overcome the crisis of malnutrition with foreign imports. It will only succeed if the needed food is grown here, in Bangladesh, by us. And breast milk will provide a far better diet for an infant than baby food. It would be sad to think that in order to preserve an attractive figure, a woman would sacrifice the better nourishment that her child would receive from breast milk. If this western fashion which has permeated our city, should reach the villages, the increase in infant mortality would be near overwhelming.
A woman's vocational centre was initiated in the hope of training women and equipping them for economic independence, thus releasing them from an inhuman subservience to their husbands' whims. During a morning "discussion" one woman told us, "We have no honour in our homes. Here we have honour".
A mechanic/carpentry shop, now in its initial stages, has combined with the woman's vocational programme and will eventually expand to include a functional school for the poorest among the young children. These three programmes: workshop, school, and women's vocational training, constitute a new, independent project with Boro Gita recently appointed as the Director.
The health service, family planning, and agriculture, form the original project, and operate from the Savar site along with Boro Gita's project. Independent, yet harmonized, the success of one programme depends directly and indirectly on the success of the other.
It was not long before experience indicated further needs for an effective programme. A strictly medical approach we realized, could not produce a healthy ·community. With few exceptions, the reasons for poor health were poverty and ignorance. The project evolved, therefore, into a true health project, that is, a community development programme dealing with sickness at the root, as well as in the later forms.
Now we hear such things as the words of an old man who answered our query as to what he thought of the project as a whole. "I don't know what medicine you are giving, but I do know that you have brought our women out of the house." In Muslim, conservative Bangladesh this is not a small work accomplished, as one great barrier to the development of the country has apparently begun to crumble
Clinics and Village Work
The main center of the project serves as a base for seven sub-centres where weekly clinics are held. These sub-centres are in the process of evolving into permanent bases for a team of paramedics. Eventually each sub-centre will have a clinic with facilities for a permanent staff of three to four workers. The doctor and team will continue their weekly visits to the sub-centres for referral cases, supervision, etc. All the sub-centres are accessible to the main centre, making regular referral and supervision possible.
Clinics are held on a weekly or twice weekly basis with the greatest effort being put into the village work. Surveys, vaccination programmes, nutrition/hygiene instruction, and family planning motivation , distribution of pills and injection, and follow-up, are all principally done through home visiting. At the main centre, limited bed space is provided for in-service care when this is needed.
Meanwhile, ninety miles to the north of Savar, a third project has taken root. Gonoshasthaya Kendra, Jamalpur started as a family planning, mother/child care centre and now has plans to expand into those community development works that will make the health care more effective. The director of this project is Choto Gita
Clarity and Keenness
It is not quite five years now since those young villagers, forced by an incredibly cruel war, left their homes and traveled on foot for some seven days, not only to save their own lives, but to somehow help in saving the lives of others
With the crisis of war behind them, they daily meet the more complex task of rendering health service in a difficult situation. Still without formal "degrees" but possessing a solid and practical education, an intelligence, keenness, and clarity wrought from experience, they attempt to enlighten the professionals responsible for the country's health system. Addressing with eloquence, born of conviction, both national and international gatherings, or pressing home their point during a personal meeting with a local government official, they defend in argument the work that they are simultaneously dedicated to developing.
Dr. A Oasem Chowdhury
Project Director
(The health workers in this programme reported, in December 1977, the murder of one of their paramedics, stating that evidence has shown that "Nizam was murdered by vested interests who found that the project was damaging their source of income and weakening their control over the local population).