The 1985 Ramon Magsaysay Award for Community Leadership

BIOGRAPHY of Zafrullah Chowdhury

The eldest of ten children, ZAFRULLAH was born December 27, 1941 in Quepara, a village outside Chittagong in East Bengal, India (present-day Bangladesh). His mother, Hasina Begum Chowdhury, was a highly intelligent woman, but as she came from a strict Muslim family, had only five years of schooling. His father, H. M. Chowdhury, had excelled in sports as a youth and was an All-India hockey and football player. He had been recruited by the police to play on their teams and eventually joined the force and served as an officer in the Calcutta Metropolitan Police until 1947 when the sub-continent was partitioned and Bengal was divided between India and Pakistan. At that time he transferred to Dhaka, the capital of the eastern province of the newly formed state of Pakistan.

Young ZAFRULLAH entered school in Dhaka in 1949, and except for one year when his father served as officer-in-charge in the subdistrict of Mysensingh (1952-53), he spent his primary and high school years in the capital. He was a good student and, like his father, an accomplished athlete. Nevertheless, his athletic interests were secondary to his pride in his scholastic achievements; the year a young uncle surpassed him in class, he abandoned sports completely. He blames this impetuous decision on his temperament. "I was an angry person," he recalls, and quickly adds, "I am still an angry person." But now it is social injustice that disturbs him.

On merit scholarships throughout his school years, ZAFRULLAH CHOWDHURY was readily accepted at Dacca Medical College when he

decided to take his mother's advice and become a doctor. He graduated from medical school in 1964 and completed one year of internship before he left for England where he continued his surgical training in various British hospitals and studied to become a Fellow in the Royal College of Surgeons (FRCS). In spite of pressures of surgical training, he had time and funds to indulge his taste for fine living, including Savile Row suits, fast cars and flying.

The young surgeon-playboy never achieved his advanced degree, however, for within a week of his final examination fighting broke out in East Pakistan and his immediate concern was for his homeland. He decided to forego both the FRCS for which he had worked so long, and his life of pleasure.

The decision was in character. During his student days CHOWDHURY had been politically active, organizing protests against social injustice and agitating for educational reform and increased political power for East Bengal. When the country was under martial law in 1962 he had helped organize a doctors' strike. It was suppressed by the government and CHOWDHURY and other leaders were incarcerated for several days in the Dhaka Central Jail. Though not a card carrying member, he was ideologically committed to the leftist wing of the Awami (People) League and espoused socialism.

During his London years CHOWDHURY maintained contact with doctors, university professors, union leaders and other Bengalis, both at home and in England, who were seeking to end martial law in Pakistan and to achieve economic parity for East Pakistan (vis-a-vis West Pakistan), where 55 percent of the population lived and 60 percent of the country's foreign exchange was earned, but to which only 30 percent of the national budget was allocated. The independence of East Pakistan from West Pakistan, although implied, was not a stated goal.

The December 1970 Pakistan election, conducted by the outgoing military regime of General Yahya Khan, brought into sharp focus the conflict between the two regions. In that contest virtually all the political parties in East Pakistan supported Sheik Mujib Rahman and the Awami League, whose six-point program called for greater regional autonomy at the expense of the central government. The Awami League captured more than half the National Assembly seats; the remainder were shared by 10 West Pakistani parties, including the Pakistan People's Party headed by Zulfikar Ali Bhutto.

Mujib should have become Prime Minister following what observers attest was a free and fair election. On the basis of Mujib's demands a period of 120 days was set to frame a new constitution. During that period Khan and Bhutto insisted Mujib modify his six points, but negotiations over the shape and nature of the new government bogged down and Mujib on March 23, 1971 presented a plan for dividing the country. Four days later Yahya Khan undertook military action. Army tanks attacked Dhaka University and sprayed the two largest dormitories with rifle and machine gun fire. Street riots and civil war followed.

In England CHOWDHURY threw himself into the war effort. He, like many of the other Muslim Bengalis living in London, had been hoping for an open break. Together with a dozen or more of his friends, he formed a committee to raise money and sway British and world opinion—writing, lecturing and providing the press background on the conflict—to support the newly declared government of Bangladesh. Funds came readily from the more than 150,000 Bengalis in England, and from sympathetic British citizens, one of whom, Marietta Procope, donated a house for their headquarters. A Pakistani judge, Abu Sayeed Chowdhury (no relation), who was on a European speaking tour, was drafted as the group's leader.

As battlefield casualties rapidly mounted, CHOWDHURY became dissatisfied with his supportive role in London. There were few trained surgeons in the field to administer to the injured and, he reasoned, each untreated casualty could demoralize scores of healthy soldiers. He conveyed his concern to fellow doctor Mohammad Abdul Mobin who shared his views, and the two decided to leave immediately for the front. As the heaviest fighting was along the eastern border between Bangladesh and India, they offered their services to the commanders there. But the generals' priority was arms and the two doctors were urged to return to England and raise more funds.

Discouraged but determined, the two appealed to Abu Sayeed in London and the Bangladesh Provisional Government in Calcutta for funds to set up a small field hospital, but they met with red tape and procrastination. Impatient with the bureaucratic delays, the two sold their automobiles and other possessions in England, and with the proceeds built a makeshift hospital on the Indian side of the border near the Bangladeshi town of Comilla. The hospital was a collection of tents and thatched structures. Tree branches tied together with rope and covered with bamboo served as beds. The staff of 12 comprised Bangladeshi doctors recruited from England and army surgeons including a woman, Captain Sitara. Their limited medical supplies were generously augmented by donations of medicines and equipment from the British medical profession and other private supporters in Great Britain.

The lack of trained assistants was an early obstacle. As few Bangladeshi nurses were available, CHOWDHURY sought to recruit British nurses, but the Provisional Government refused to permit them in the border area. Since time was as much an enemy as the Pakistani soldiers, and nurses' training takes years, CHOWDHURY had to be innovative. He had followed with interest China's successful experiment with "barefoot doctors"—illiterate villagers skilled in treating common diseases and administering emergency aid to accident victims. The nearby refugee camps were teeming with young women eager to assist in the war effort, so the doctors decided to draw upon this pool and train their own "barefoot" nurses and paramedics. There were many volunteers. Not only did the young women learn quickly, they were tireless workers; after all the soldiers had been treated, they would attend to the refugees and the nearby rural poor. The hospital eventually expanded to 480 beds, with outlying centers to treat refugees and villagers.

The war ended abruptly in December 1971 following intervention by the Indian Army. Bangladesh had gained independence, but the new country was in disarray—the economy shattered, the Provisional Government disorganized, and many of the new officials were as corrupt as those of the past. Mobin returned to England disillusioned. CHOWDHURY, unsure of continued government support, prepared to dismantle the Comilla operation and advised his young village helpers to return home and go to school. Many, especially the girls, having contributed to liberation and having accepted responsibility and experienced the thrill of meaningful work, were unwilling to return to traditional roles. They chose to remain.

Although the other field hospital doctors resumed their careers, CHOWDHURY decided not to return to England to sit for the FRCS; he realized that an advanced surgical degree was not necessary for the work that needed to be done in Bangladesh. The war had brought him face to face with realities that had formerly been mere statistics. Bangladesh, among the world's poorest nations, was also among the most densely populated. Its citizenry was predominantly rural, illiterate and conservative. Existing health facilities were still inadequate both in quantity and quality. Modern hospitals and medical personnel were concentrated in the urban areas and accessible to only the privileged few. In the countryside malaria, tuberculosis, smallpox, diptheria, tetanus and whooping cough were chronic and malnutrition among children was routine.

Soon after cessation of hostilities CHOWDHURY began, through seminars and lectures, to explain his ideas for rural health to Bangladeshi government and non-government organizations and to the World Health Organization (WHO) of the United Nations. He advocated a campaign of massive inoculations and of instruction in family planning techniques, employing young veterans of the liberation struggle as paramedics. He proposed delaying reopening the universities for one year so the nation could profit from the current surge of patriotism, arguing that the young, like his 14-year-old brother who had helped blow up a bridge, could hardly be expected to become schoolboys again overnight. Instead he suggested they be asked to rebuild the country, for "only then will the young realize that reconstruction is more difficult than destruction."

The government rejected CHOWDHURY's radical ideas, but made a house in Dhaka available to him as a hospital and he, Captain Sitara and two other Bengali doctors moved in. Some 40 young people who had been acting as nurses and paramedics joined them. He realized that the capital was not the place to start implementing his ideas, but the building enabled him to keep the staff and equipment together and allowed him time to organize for the eventual shift to the countryside. There was no money for salaries, but the group was supplied with food by friends, and medical supplies were still coming in from Britain.

Two months later the parents and uncle of Dr. Mahmuder Rahman, a family friend and CHOWDHURY's teacher in medical school, donated two acres—later increased to nine—of land in Savar, 40 kilometers north of Dhaka. The location was ideal for a pilot rural health project: there was no hospital in the population area of 170,000, the literacy rate was low and the site was near the capital. The last point was important; for a demonstration facility to be effective it must be accessible to decision makers.

CHOWDHURY moved the hospital to Savar in April and registered it with the Bangladesh government as a nongovernmental charitable trust and a voluntary organization dedicated to the promotion of rural health and community development. He initially held meetings with the villagers to determine the best method of bringing medical services to them, and eventually adopted the idea of a referral center and a number of sub-centers.

He called the hospital Gonoshasthaya Kendra (GK) which means People's Health Center. The name has an intentional socialist ring to it for

CHOWDURY did not want to found just another rural health program or philanthropic enterprise, but a project whose underlying philosophy emphasized human equality, individual worth and the dignity of labor. Equality was to be a precept for guiding all undertakings.

CHOWDHURY's ideas were sound and his faith in the good sense and integrity of the common man rewarded. Gonoshasthaya Kendra prospered and grew. Today GK employs over two hundred workers and includes a hospital, a medical outreach program, an insurance plan, a school, a farm, living quarters for workers and vocational training centers. The complex is managed by a board of directors, but major issues are decided by workers at monthly meetings presided over by an elected chairman.

The 20-bed hospital staffed by eight doctors, two of whom were trained in the U.S. and one in England, is the heart of the complex. The beds are reserved for serious cases or emergencies. GK has resisted the urge to enlarge the hospital because the project emphasizes outpatient treatment which is less costly. And CHOWDHURY insists that the patient recovers faster at home where the diet is familiar and the care more personal. The hospital, equipped with a modern operating theater and sophisticated diagnostic instruments, is home base for the five health centers that service the rural area of 250,000 people. Each center has a five-bed ward and is headquarters for GK paramedics in the region. GK doctors take turns staffing these centers, but a senior paramedic is in charge of each clinic and some 120 paramedics, divided between Savar and the centers, bear the burden of the medical work. The paramedics are actually better trained for the simple medical and surgical work they do than the doctors—who have learned more theory than practical medicine practice—and they have more rapport with their village patients.

Most of the paramedics are women. To afford women the opportunity to earn a living and to prove his theory that the Bangladesh economy will develop only with their participation, CHOWDURY gives women employment preference at GK "When you talk of poverty," he contends, "you are talking about women. In this country, poor women are twice oppressed: first because they are poor and second because they are women." He was convinced that progress would come only if tradition, both the cruel cause and the tragic result of this waste of female talent, could be broken.

The hold of tradition, however, is strong. A survey in 1974 among Bangladeshi farmers revealed that the majority advocated female marriage before age fifteen as a deterrent to sexual offenses. But the reality for girls of such an early union was a quarter century of fertility and the threat of abandonment of them and their daughters should they fail to produce a male heir. Since women were discouraged from acquiring technical skills, their opportunities for earning an income sufficient to support themselves were negligible. As CHOWDHURY says: "Once divorced a woman would not be accepted by her parents to whom she would only be another mouth to feed. Neither could she find employment to support herself. She could choose. As a beggar she could go to town and there discard the last shred of any human dignity she may have had, or she could take the more attractive way of insecticide poisoning." Should a husband die or become infirm, his wife's fate would be equally gloomy.

In keeping with his concern for women, therefore, the paramedics trained at GK are mostly young rural girls between the ages of 17 and 25. Their greatest strength is their closeness to village life. They live and work in areas where 70 percent die without a doctor, where potable water may be a distant walk and where human waste is excreted in a corner of the family plot.

Not all aides receive full paramedic training. The most elementary course is given to the dai (midwives), village women, usually illiterate, who have learned their craft as apprentices. Their instruction, lasting only one week, is designed to fill gaps in their knowledge. For example, CHOWDHURY says: "I ask them, 'When do you wash your hands?' 'After holding the baby and cutting the cord,' they answer. I tell them that for half a million taka (US$1,250) I learned in medical school to wash my hands before and to put the thread and blade into hot water." After covering basic hygiene he teaches them to treat common ailments and introduces them to family planning techniques. They receive a monthly GK supplement of Tk. 50.

The second group, also illiterate, is trained by GK for the government. The women receive one month of instructions on the treatment of common ailments such as diarrhea, skin diseases, intestinal parasites, burns, shock and poisoning, and they attend lectures where family planning is fully discussed. After they return to their villages they will be evaluated by a GK doctor or advanced paramedic and will come to Savar for further training twice within the next 18 months. The government gives them a stipend of Tk. 100 a month.

The third category consists of GK's own paramedics. With rare exception they are required to have five years of schooling and be literate.

Their training lasts from six months to a year. Lectures stressing the relationship between poverty and disease "take a big chunk out of our curriculum," CHOWDHURY laments, abut these things, they must understand. " They are taught to treat the most prevalent diseases (70 percent of the village caseload), how to do blood, urine, sputum and stool tests, and how to perform female sterilization.

The preferred method of female sterilization is the minilaparotomy, an operation introduced by Dr. Vittoon Osathanondh, a Thai population expert. The method is so simple that the paramedics have performed over 7,000 successful operations, with an infection rate lower than in similar operations performed by physicians—probably because the more complicated cases are handled by the doctors.

CHOWDHURY was early discouraged from attempts to popularize family planning in the rural areas by a friendly government official who advised him to warn his paramedics against pursuing the program vigorously "This is an orthodox Muslim country and they will be [physically] beaten," he cautioned. But a chance encounter with village women proved the bureaucrat wrong and dispelled CHOWDHURY's fears for his young helpers' safety. The villagers were seeking "the doctor from England" who they thought "might know how to stop having babies." From that day on the promotion of family planning has been a major function of each paramedic.

In CHOWDHURY's view early government attempts at curbing the birth rate—largely financed and influenced by foreign aid organizations—were misdirected and inadequate. Contraceptive pills or devices were given without adequate instructions; when pills were consumed in improper doses and caused harmful side effects women stopped taking them. Foreign supported clinics also offered cash or rice to women who accepted sterilization. CHOWDHURY views this "bribing" of unsophisticated and illiterate women as forced sterilization, and a real threat to their well-being. GK paramedics charge a small fee for contraceptives so that they will not be taken carelessly or wasted, and not only charge for sterilization, but refuse to sterilize women unless they have at least two sons, because a woman is in danger of divorce or abandonment if her only son dies and she cannot produce another.

Villages visited by paramedics are often distant from Savar or the sub-centers. Although the male paramedics shortened their journeys by bicycling, a taboo against girls' biking forced the latter to walk. Obviously if girls also rode, CHOWDHURY reasoned, their efficiency would increase, but no amount of urging on his part induced them to break the taboo. One day a break came. A failing student who was about to be expelled begged for one more chance. "Only if you learn to ride a bicycle," CHOWDHURY responded. She agreed and soon was pedaling around the compound. Other girls, envious of her skill, learned also, yet none of the riders were ready to venture outside the GK gates for fear of harassment.

But the day finally came when four girls, confident of their skill, rode to work. Their route was through an orthodox Muslim village where they were seen by the horrified townfolk. The men, incensed at this breach of propriety, accosted CHOWDHURY saying: "Doctor, you did a very bad thing. Girls on bicycles! God will not forgive them, and we will catch them on their way back and punish them." Instead of answering the men directly CHOWDHURY, turning to the headman, inquired about his mother's eye operation in Dhaka: "How did she go, did she walk?" "Oh, you must be joking, Doctor. You cannot walk 40 kilometers. We took a bus," he said amused. "Was the bus empty?" CHOWDHURY asked. "Oh no, it was quite full," he admitted. Feigning alarm CHOWDHURY exclaimed, "Do not tell me, Haji Sahib, that your mother went in a crowded bus with men touching her on all sides? At least girls on bicycles are not touched by men." Henceforth women paramedics visited their patients on bicycles with few onlookers daring to criticize.

The following year one girl suggested they celebrate May Day by cycling to Dhaka. Twenty-three agreed. The press was alerted and a reception awaited them when they pedaled into the capital. Their exploit made newspaper headlines and caught the eye of President Zia ur Rahman who asked to meet these enterprising young women. Because the president was a veteran of the War of Liberation he knew how women had worked shoulder-to-shoulder with men, and how wasteful taboos against women were to society. Impressed by the zeal of these young paramedics, he ordered bicycles for all government health workers, and the GK project later became a blueprint for the government's rural health program.

The salaries of paramedics, like those of every other GK employee, are decided at mass meetings, where voting is by show of hands and the majority rules. They also receive fringe benefits in the familiar industrial sense: housing, schooling for children, subsidized dining facilities and medical insurance.

The medical insurance scheme is a pioneering feature of GK. An applicant for insurance is placed in one of three categories. Category A

is for the poorest, a family defined as one which foregoes a few meals during any part of the year. Category B is for those who, although poor, never starve, and Category C for the rich, i.e., farmers with a surplus. Those in Category A pay no membership fee, but one taka (US$.04) for each consultation. This covers the cost of all subsequent treatment and prescription drugs. Members of Category B pay an annual membership fee of Tk. 10 and Tk. 2 per head per consultation. The consultation fee includes medicine, but should x-rays or an operation be necessary additional fees are charged. Category C members pay Tk. 20 per year, Tk. 5 per visit and higher fees for other services. Everyone regardless of category is charged for family planning devices and abortions. When hospitalization is unavoidable, those in Category A pay one taka per day, in B, Tk. 3, and in C,Tk. 5. Currently 60,000 are enrolled at Savar alone. Subscription fees and consultation charges cover from S0 to 60 percent of the operating costs of the hospital. In the past bank loans and grants from Nederlandse Organisatie voor Ontwikkelingssamenwerking (NOVIB) covered the deficit. Now profits from Gonoshasthaya Pharmaceuticals are expected to make up the difference.

Although not all GK employees, especially the doctors, enroll their children, CHOWDHURY operates a five-year school within the complex. Like most GK projects it is experimental and a radical departure from tradition.

A 1976 survey in Bangladesh revealed that only 54 percent of the nation's children attended school. Of those who did, only 14 percent of the girls and 33 percent of the boys completed five grades, the minimum for literacy. Many peasants found education a drawback. A literate boy could be lost as a farmhand, thereby increasing the burden of the rest of the family. And it was difficult to find a husband for an educated girl: no unschooled boy would want her and dowries for literate bridegrooms were costly. Moreover, many parents felt they could not spare their children from routine rural chores. Although peasants consider education a luxury, it is in reality a necessity if the villager hopes to avoid exploitation: every peasant who signs a contract or loan with his thumbprint is in danger of being cheated.

CHOWDHURY therefore fashioned his school to fit the demands of the villagers. Since children are needed for the harvest the GK school is closed at such times. As farm children must also care for siblings and tend animals, students are allowed to bring their younger brothers and sisters into the classroom and to graze their animals with the GK herd. Since children of the poorest families are often sent out as servants or other menials, teachers point out to parents that the small wage lost by attending school instead of working is partially compensated for by the

free meal provided to each student. (Food, the school's biggest budget item, is provided for by Australian Community Aid Abroad and by rice donations from the local government.)

The GK curriculum emphasizes reading and writing Bengali, and introduces a few useful English words and some basic mathematics. An innovation is the pupil-teacher program. Quick learners are assigned to tutor slower ones or to teach literacy classes in the afternoon in the village to adults or school dropouts. The young tutors are not compensated for their work; their incentive is pride. In the vicinity of Savar there are now 15 such afternoon classes—meeting in a courtyard or under a tree—where children teach their elders. The GK classroom is not much more elaborate. It is of bamboo and mud construction like village houses, and the students sit on the mud floor.

The success of the school has been impressive. The normal retention rate is 90 percent compared to 15 percent in government schools, and 30 percent of the most recent graduates have gone on to high school. Functional literacy classes, primarily for women, are also taught. These emphasize learning to read simple directions and measurements, and understanding the economics of production.

From the schoolhouse windows one looks directly onto the 20- acre GK farm. CHOWDHURY insisted that a small farm be an integral part of the complex since Bangladesh is an agricultural country (70 percent of the GNP comes from agriculture) and likely to remain so. The country cannot be understood or its problems solved unless agriculture is considered sympathetically, he insists, therefore everyone, without exception, begins each work day with one hour of agricultural activity. In this way all, regardless of background, gain an appreciation of farm problems and of the rural poor. The benefit of regular physical activity is a happy by-product.

Not all appreciate this policy and mandatory labor is one reason staff leave. Farm work has also been a source of friction between the workers and the professional staff. A complaint often heard at monthly meetings is that doctors shirk their vegetable patch chores, even though they (including CHOWDHURY) are given "simple jobs" such as planting and weeding. The complicated agricultural tasks are left to expert farmers. Women are involved in the fields, as well as in traditional agricultural occupations that usually take place within a family compound, in order to refute the notion that women do not participate in agricultural output. Milk cattle, chickens and ducks are raised, besides fruits, vegetables and rice. The produce is bought for use in the communal dining hall; when there is a surplus it is sold in the village. The land is so fertile that five crops a year can be grown.

Apartments are provided rent-free for GK workers. Dining hall meals, electricity and other amenities are charged on a sliding scale. Those earning more, pay more. CHOWDHURY, as a physician, earns 3,000 taka per month. As others in his wage category, he pays 400 each for himself and his wife Susan, a West German volunteer at his field hospital whom he married in 1972, and 200 for their eight-year-old daughter Brishti. A paramedic who earns 600 taka pays only 150. Housing is allotted strictly on the basis of family size. Even though he is Project Coordinator CHOWDHURY has a one bedroom apartment for his family of three. A mechanic with four children, on the other hand, would have three bedrooms.

Within the compound are more than a dozen small manufacturing shops producing a variety of goods. All make money, but profit is not the principal motive. They were set up as vocational training centers so villagers could learn skills such as welding, carpentry, weaving and baking to augment the family income. Once trained it is easy for them to find jobs, CHOWDHURY observes.

The complex also has a small printing plant that publishes Mashik Gonoshasthaya (People's Health Monthly) which sells for five taka and has a circulation of 20,000 throughout Bangladesh and Bengali-speaking districts across the Indian border. This popular journal has feature articles on family problems, women's issues and various aspects of exploitation. The plant has printed six books, one a national best seller initially serialized in Mashik Gonoshasthaya. A Bengali translation of Where There is No Doctor by American biologist David Warner it, like the others, has been sold by mail order. CHOWDHURY does not place any of his publications in book stores because, he says, "the middlemen always cheat you."

Partly in consequence of CHOWDHURY's urging, President Zia in 1980 created a Women's Commission to study the problems of women and recommend some solutions. Membership consists of CHOWDHURY, two other men and two women, although CHOWDHURY argued for greater representation of women and the rural poor. So far the results have been few. The quota for female primary school teachers has been increased to 50 percent, and enrollment in medical schools to one third. In 1984 CHOWDHURY went outside the commission in an attempt to raise women's consciousness and organized a national conference under GK sponsorship. The agenda covered all aspects of women's plight. One observer described the gathering of 5,000 as an achievement in itself, something that had never been done before in Bangladesh. "I saw how the women participated. One would tell her story and another would say, 'Your story is not any worse than mine.' It was truly amazing they spoke up because that is not usual here."

CHOWDHURY has also been involved in a long standing attack on the high cost and proliferation of drugs, marketed primarily by multinational pharmaceutical companies. Ironically, poor nations and individuals pay proportionately more for medicines than the rich. In Bangladesh, for example, about 40 percent of the total health budget is spent on drugs; in contrast Britain spends only 10 percent. In the case of individuals, where doctors are few the poor rely heavily on over-the-counter remedies. Drug dealers, seldom qualified, push expensive medication; and misleading advertisements by drug companies lure the unsophisticated into wasting money on useless medication which can often be harmful if taken incorrectly.

About one-third of the drugs marketed by multinationals in Bangladesh and other developing countries are vitamins and tonics. Another 15 percent have been banned in some developed nations. Vitamins, tonics and elixirs rarely kill people, but can be addictive; one popular vitamin tonic, for example, contains 27.5 percent alcohol. Improper drug consumption is particularly prevalent in Bangladesh where women are in seclusion and fathers buy remedies for family ailments by merely describing their wives' or children's symptoms to shopkeepers who recommend whatever they feel appropriate and within the purchaser's budget.

In 1977 WHO published The Selection of Essential Drugs, which was updated and re-released in 1982. It advised Third World countries to restrict the import, manufacture and use of drugs to about 225. Although heart attacks, cancer and strokes are major causes of death in rich nations, dysenteric illnesses, tetanus, malaria and respiratory infections are the major killers in poor states. Most of the latter deaths are needless for these Third World diseases can be reduced with the introduction of clean water, sanitation and good nutrition and treated with a few simple drugs. As Director General of WHO, Dr. Haltdan Mahler estimated that "for the villager and urban slum dweller great miracles can be achieved with fewer than 30 well-chosen drugs." Yet in 1980 in Bangladesh over 4,000 drugs were on pharmacy shelves or on peddlers' mats.

Interested in the problem of medicines CHOWDHURY, in consultation with Dutch friend Jan Willem van der Eb and aided by grants from NOVIB, OXFAM and Christian Aid, had built a factory at Savar in 1979 to produce low cost generic drugs. Gonoshasthaya Pharmaceuticals Ltd. is organized as other manufacturing companies, but with two major differences. It has no individual shareholders but is 100 percent owned by the Gonoshasthaya Kendra Charitable Trust; and its charter requires that 50 percent of its profits be invested in factory expansion, and the balance used to finance other GK projects and programs.

The company is pledged to producing essential and high quality drugs at reasonable prices and operates on the following four principles: keeping the public up-to-date concerning the harmful effects and possible misuse of medication; opposing drug sales on credit because it encourages unnecessary purchases; never allowing a few distributors to monopolize Gonoshasthaya products; and never forcing slow moving items on customers.

Skepticism initially greeted the new enterprise, but CHOWDHURY and his colleagues never doubted its success. Once they started production they realized that drug prices could be very, very low. For example, they could make a five milligram tablet of Diajapam (Valium) for three paisa (20th of a taka), sell it at five and make a 20 percent profit. The same tablet was being sold by others for one taka. CHOWDHURY proved the accuracy of his pricing and the quality of his product by inviting the Minister of Health to the factory to look at his books and inspect the plant; the minister, himself a doctor and professor, was astounded. The company takes a lower profit on essential drugs and a higher one on those less critical, but its overall profit is 15 percent after costs, depreciation and taxes.

Gonoshasthaya Pharmaceuticals is a fully modern plant, among Bangladesh's largest with 42,000 square feet of floor space. Quality control, equipment maintenance, airconditioning and humidity control all meet international standards. Superficially there is little to distinguish it from other well-run factories. But unlike its capitalistic counterparts, the plant operates on the worker-oriented philosophy common to all GK projects: women are given preference, training is provided the rural poor, daily agricultural work is mandatory and profit is not the primary motive. For example, although the plant has a highspeed machine capable of packing several thousand capsules per hour, it is seldom used because it would displace several workers. The preferred machine is an older, slower one which requires four women to operate. The modern machine is on hand only to fill government orders which are usually large and urgently needed.

In 1982 Gonoshasthaya Pharmaceuticals was producing affordable quality drugs, but 10 multinationals still controlled 75 percent of the market and still sold medicines the World Health Organization deemed nonessential. The rural poor still bought packaged preparations from illiterate and even blind peddlers. A national policy controlling the import and sale of drugs was clearly needed—as CHOWDHURY had tried to prove to every government since 1974.

To his surprise, within days of the March 24, 1982 coup by Lieutenant-General Hossain Mohammad Ershad, he was asked by a government official to help formulate a new drug policy. As he was a doctor, ran a successful pharmaceutical firm, understood the medical needs of rural Bangladesh, and had long written, lectured and lobbied for such a change, the government's choice was logical. But CHOWDHURY at first refused to believe that a military government, in debt to foreign donors, could pioneer the radical measures that he advocated; only a socialist government could implement such a policy he maintained. Finally convinced of the government's sincerity, he agreed, despite misgivings and the warning of his friends.

One month and three days after the coup, therefore, CHOWDHURY joined seven other experts on the newly-formed Drug (Control) Committee, appointed to draw up policy recommendations. The multinationals complained to the government that they were not represented, and objected to the inclusion of a former employee known for his strong support of the WHO position. Their objections were ignored and the group began its deliberations.

The committee worked in secret, often 18 hours a day, and produced a report the second week in May. One month later, on June 12, 1982, the government promulgated the committee's recommendations as the Drug (Control) Ordinance.

The committee's report argued that drugs are essential tools for health care, so must be treated differently from other commercial products. It recommended that 1,700 unnecessary drugs, of the more than 4,000 on the market, be banned in a phased manner. And it proposed safeguarding and promoting the local drug industry by prohibiting multinationals from manufacturing or importing products locally available or those of simple formulation which required no special machinery or technical expertise.

The report recommended drugs (by generic name) for the three levels of the government's health program: 12 basic drugs were listed for

the village level, an additional 33 for the sub-centers and another 105 for the central health clinics. A supplemental list of 100 drugs was suggested for use by specialists.

Reaction as expected was mixed. Many governments, organizations and individuals worldwide wrote or cabled their congratulations. The Asian Development Bank called the recommendations "steps in the right direction." But home governments of multinationals, notably the United States, the United Kingdom and West Germany, all important aid donors, urged the government to reconsider.

The Bangladesh Medical Association, many of whose members were Western-trained, initially criticized the policy as precipitous, but later reversed itself and gave support. The multinationals, on the other hand, launched an advertising campaign accusing CHOWDHURY, War on Want and OXFAM of conspiracy. Other than agreeing to form a Review Committee which suggested some modifications that were accepted, the government remained steadfast in the face of the controversy which raged for months.

Eventually the success of the policy muted opposition. The English-language Bangladesh Observer in March 1985 reported: "With the implementation of the new drug policy 1,707 harmful and unnecessary drugs have been banned. The new drug policy has saved taka 30 crore (US$1,106,000) in foreign exchange and encouraged local pharmaceutical companies to meet the country's requirements."

Ideologically CHOWDHURY is still a dedicated socialist but he belongs to no political organization. "I wish I could be a Marxist," he says, "but to my mind a Marxist. . . cannot have any human weaknesses. I still like a few luxuries, after-shave for instance. . . . And should you invite me to a fine dinner and I have the time, I will come. I enjoy good food."

Two books about China have influenced his work: Away With All Pests, by Joshua Horn, a professor of orthopedic surgery at Cambridge University, which describes China's health system and experiment with barefoot doctors, and Iron Oxen, a sympathetic treatment of China's agricultural experiments by the American William Hinton. However, it is his own brand of down-to-earth socialism that gave birth to the GK philosophy and is the magnet which pulls professional and management staff to Savar.

Recognition of CHOWDHURY’s accomplishments came first from Europe where in 1974 he received the Swedish Youth Prize. Four years later Bangladesh conferred on him its most prestigious honor, the Independence Day Award, and in 1981 he received the Maulana Bhasani Award for his efforts in health and family planning.

A meeting with CHOWDHURY can make one self-conscious. One feels he would rather be elsewhere, doing something more useful than relating past successes, and that the complexities and potential of a future project are replacing the topic at hand in his consciousness. One would probably be right, for he is still far from satisfied with the Bangladesh health system, and ways to improve it are very much on his mind: he wants a law passed that would require the use of generic names on the 45 essential drugs marketed, and he is agitating for a regulation to force multinationals to engage in the transfer of technology.

A radical academy of medicine dedicated to rural health is another preoccupation. Two international workshops to formulate guidelines have already been held, and negotiations are underway with Nagar University (near Savar) to establish there a medical school "where doctors will be trained for health, not for disease." CHOWDHURY's hope is to have the institution, a pilot model like all GK projects, operational within six years. The Magsaysay Award monies have been earmarked for that purpose.

September 1985
Manila

REFERENCES:

Chowdhury, Zafrullah. "Affordable and Effective Rural Community Health Service." Presentation made to Group Discussion. Ramon Magsaysay Award Foundation, Manila. September 3,1985. (Typewritten transcript.)

______. "Basic Service Delivery in 'Underdeveloping Countries': A View from Gonoshasthaya Kendra." Working paper for United Nations Children's Fund Special Meeting on the Situation of Children in Asia with Emphasis on Basic Services. May 4, 1977.

______. "Research: A Method of Colonization," Bangladesh Times. January 13, 14, 1977.

"Drug Policy Saves Taka 30 Crore," Bangladesh Observer. March 24, 1985.

Gonoshasthaya Pharmaceuticals. Brochure. Savar, Bangladesh: Gonoshasthaya Pharmaceuticals. N.d.

Rolt, Francis. Pills, Policies and Profits. London: War on Want 1985.

Thomas, Winbum T., ed. "An Evaluative Study of People's Health Center's Health Plan (Gonoshasthaya Kendra)." Dhaka, Bangladesh: International Voluntary Services, Inc. June 1, 1974.

Interviews with Zafrullah Chowdhury and persons acquainted with his work.