DRUG SITUATION IN BANGLADESH
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- Title
- DRUG SITUATION IN BANGLADESH
- extracted text
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RF_DR_19_SUDHA
qp
(a Bangladesh case study)
A reference file on Gonoshasthya Kendra3
GK Pharmaceuticals and the Bangladesh
Drug Policy .
Background resource material prepared
for Dr Zaf arullah Chowdhury rs visit to
Bangalore on 1st December 1983o
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CONTENTS
1
Introd notion
2
Gonoshasthaya Kendra
• Z Chovvdhury
3o The Paramedics of Savar
4o Learning from the Savar
Project
5 • Go no shasthay a
Pharm accutic als
6 <. Essential Drugs for the
PooriMyth and Reality in
Bangladesh
• Abhay Bang
• Z & S Chovdhury
Z 6c S Chowdhury
7. The Bangladesh Ban on
Hazardous and Irrational
Drug s--its r cview and
present status
5 Mira Shiva
b- Curbing Drug MultiNationals -“Will India
follow Bang la example
9O
10
Bang 1 ad e s h .Po 1 icy und er
US pressure
s Sumanta Banerjee
•Tv Parasuram
Reading list on Drug
Issues
11 o Drug Action Netvjork News
12o
Oxfam publication on
Drug Issues
so urc e s
No 0 2
Toward s a .People’s Science Movement (KSSP publication 3
1979)
No o 3
Development Dialogue 197d5 No • 1 6c mfc Bulletin
No o 57 9 September 19b0
No o 4
mfc Bulletin No 5o 9 October 19dU
No o 5
Health for the Millions (VHAl)9 V0I0V.III5 No o 6 5
December 19 d 2»
No .6
Ecodevelopment News5 Paris? MSH-CIRED9
Nd o 23 9 December 19d2c (a'bi? id. gad.)
No o?
Handout of Lox-v Cost Drugs and Rational
Therapeutics Cell9 VHAIo
No od
Deccan Herald 9 Septumber 16 5 19o2o
NO a 9
Indian Express? August 219 19d2.
Tntroci ucEi orT
Dear Friend s5
The v/ork of the Gonoshasthaya Kendra (People fs Health
Centre) of Bangladesh under the leadership of
Dr Zafarullah Chowdhury is well known» Soon after independence
the Gonoshasthaya Kendra was established in Bangladesh and
it went ahead step by stepto organise the Community Health
Program5 the. Women’s vocational Centre (Nari Kendra) 5 the
People ‘s Workstop (Gono shilpalaya)5 the People’s Shoe
Factory (Gono Paduka)9 the People’s School (Gano Patshala)9
the People’s Farm (Gono Krrshi Khamar) and the now famous
Gonoshasthaya Kendra Pharmaceuticals» During these years 9
the Kendra also organised training programmes for the
para-medics of Savar9 and health workers (IRDP
UNICEF) and.
field programmes for undergraduate medical students and post
graduate doctors® Since 19829 the GK Project has been exploring
the possibilities of evolving an alternative medical curriculum
more suited to the health9 socio-political and cultural
realities of countries like Bangladesh® In March 19b39 there
was a special conference held in Dacca entitled “People and
Health11 organised by the Kendra and Jehangir Nagar University
ple and
(Bangladesh) at which recommendations for a more peo
people
health oriented curriculum were made.
1982 has also witnessed in Bangladesh the government’s
bold decision to ban 1707 hazardous and irrational drugs 9
fix. fees for doctors 9 stop construction of' eight new medical
colleges and enforce a five year compulsory rural work
before permanent registration of doctors--all these steps
hopefully towards a more people-oriented health service®
Dr Zafarullah Chowdhury will be visiting India (Pune9
Bombay 9 Trivandrum 9 Bangalore 9 Delhi and Culcutta)
from 24 Nov to 4 Dec 19o3 in response to invitations by
the Inc ian z^cademy of Paediatrics9 voluntary Health
Association of India9 Medico Friend Circle9 Lok vidnyan
Sang hat an a (Maharashtra) 9 Kerala Sastra sanitya Parishad 9
NISTADS9 FMRAI and other organizations®
He will be in Bangalore on 1st Dec 198 3 and will deliver
two public lectures here (St John’s Medical College
9 am to 9.45 am) and Indian Institute of Science (3.30 pm
to 4® 30 pm) apart from having group discussions with
medical teachers and health and development activists and
trainer So This file Jias been prepared as a background
resource material for all those who are keen to know
more about the GK Project3 the GK Pharmaceuticals and
the Bangladesh Drug PolicyWe are grateful to OXFAM
So ut h Ind i a Of f ic for their assistance in preparing
this fileo
Materials and information here may be reproduced
freely in media/handouts for public awareness giving *
specific -sources (mentioned in each article) due
acknowledgemento we hope this file will help in focussing
the relevance of such effort for the Indian situation as
well e
medico friend circle
Indian Social Institute
Science Circle (Indian Institute of science)
Bangalore
I
GONOSHASTHAYA KENDRA
(PEOPLE’S HEALTH CENTRE)
DACCA, BANGLADESH
OBJECTIVES
1.
To provide adequate health service in the rural area of
Savarthana
2.
to increase the independence and bargaining power of
women, and
*
to bring about a change in the infrastructure and thereby
allow for the economic and social development of poor
villagers, i.e., 90 percent of the population of Bangladesh-
ACTIVITIES
1.
2.
A health programme which encompasses
a.
training of paramedical workers, basic health workers,
medical students and doctors in rural health care
delivery,
b.
curative care through a system of sub-centres which
are staffed by paramedical workers and backed by a
main centre which is staffed by doctors, technicians
and paramedics, and which offers OT, sick-room,
pathology, x-ray, and dental care facilities,
c,
preventive care including immunization programmes,
mother/child clinics, pre-, and post-natal care,
nutrition, hygiene, and basic health education carried
out through regular programme of vV^age visiting,
da
family planning which provides contraceptives (pills
and injection), sterilizations, and abortions, while
carrying out a programme of motivation and follow-up,
e.
an insurance scheme for users of the health care services;
f*
pharmaceutical plant which manufactures drugs under
their generic names (this is in the initial stages
of operation), and
g-
publication and distribution of literature to assist
medical practitioners in effective health care delivery
in rural areas.
A vocational training programme for villagers in which both
men and women are instructed and employed in all of the
following areas:
a.
b.
c.
agriculture,
jute handicraft manufacture for export,
shoe manufacture and sale,
.../2
2
d.
e.
fo
3.
4
metal work including welding, etc.,
woodworking and finishing, and
management of canteen which caters to a sizable
public clientele ,
Education
a.
classes in literacy and conscience-raising for village
women and staff members, and
bo
experimental school for children of landless combining
practical training with formal study.
Credit unions providing loans for marginal■and landless
farmers 6
CRITICAL ANALYSIS
1. Health Programme, "Some success of the primary service
have been ascertained by surveys of sample villages and also
by more random observation of disease incidence. Thus, there
has been a dramatic fall in incidence of serious diarrhoea
with dehydration. This is probably due to our intensive
teaching of oral fluid therapy to mothers of small children,
who now give the ’shorthut' to their infants as soon as they
notice the first symptoms of diarrhoea. Since diarrhoea in
children is still the commonest cause of death in Bangladesh
as a whole, our success with preventing serious cases may
well account for the lower overall death rate in our area
which has been established b}^ a sample survey (12/1,000 as
opposed to the national average of 17/1,000)c There has also
been a marked decrease in scabies and other forms of skin
diseases. Care of at-risk pregnancies, especially of women
with symptoms of pre-eclampyxa, has resulted in nil maternity
deaths for the last year in the area fully covered by our service V
2. Women., "Out of a total project staff (including subcentres)
of 114, forty six are female; and on the health sidd, women
outnumber men. Apart from nightguard duty, there is no single
taa< which women have not been engaged in on equal terms and
on equal pay with their male colleagues, it the daily
agricultural labour, health work, welding in the technical
workshop, teaching, or office work. In the vocational
training programme women are taught blacksmithing, carpentry,
whitewashing, and varnishing .,..
”A much talked-about event occurred on May 1, 1977, when 23
women from the project cycled all the way to Dacca to demons
trate solidarity with women's movement all over the world ...
"While behavioural changes and increased self-confidence made
possible by economic independence and experience of work out
side the home is most striking in the women closely connected
with the project, there has also been a discernible change
in the attitudes of women in our area in general. Burkas
(veils) have almost vanished from sight among patients both at
.../3
the main centre and the subcentres, recruitment of female workers
for those types of work and training which do not require much
school education, no longer poses a problem; indeed, we have
to send many home for lack of places, and during our recent
processioiT to~the Shimulia subcentre to commemorate the first
death anniversary of Nizam (see below), many village women,
as well as men, joined the ranks of the project staff.
’’Nationwide, our work with women has contributed to Government
decisions to recruit women for village work in family planning
and as female primary school teachers.h
”22
However, though as individuals there is a noticeable liberation
among women, with certain barriers having come down, as a group,
they yet remain unorganized.
3. Infrastructure. ’’Nizam was 25 years old. He had been with
the project as a paramedic since its inception, and when a
paramedic subcentre was to be set up at Shimulia he was the
one arranging the final details of the land. He knew the coming
of the centre to Shimulia would threaten the fraudulent practices
of a good many people, including illegal possession of government
lands, smuggling and selling health centre drugs. Among those
involved in the illegal activities was the only qualified
physician in the area, who was making a handsome profit by
over-charging patients. Nizam did not realize just how great
a threat the new centre was. In collaboration with local
officials, i.e., the union chairman and a union member, the
physician hired a group of thugs to have Nizam murdered, confident
that he could make the .necessary payments to the proper people,
allowing him to continue his illegal work, along with his cohorts ?
and ensuring that the centre would not become a permanent fixture
in Shimulia. Nizam lost his life, and now an almost incredible
struggled or simple justice seems to be availing nothing.
We have come face to face with the village. We have reached,
it seems, our limit. Do we carry on with our small struggle or
are we sustaining a system that would (and should) crumble,
sooner without our gallant efforts. And even if we choose to
work on, can Gonoshasthaya Kendra last in its present form?
How viable can a body remain when it is alien to thesystem in
which it operates?”3
REFERENCES
1.
G-onoshasthaya Kendra Progress Report No. 6. Pec., 1977,
p. 8, par. 2.
2.
G-onoshasthaya Kendra Progress Report No.6. p. 1, par. 3 9
and 4, p.2? par. 2 and 3.
3.1 Basic Service Delivery in "Underdeveloping” Countries: A
View FrommG-onoshasthaya Kendra, by Dr Azfrullah Chowdhury,
published by UNICEF.
SOURCE
Towards a People’s Science Movement
Kerala. Sastrasahitya Parishad
***************
..</4
II
THE PARAMEDICS OF SAVAR: AN EXPERIMENT IN
COMMUNITY HEALTH IN BANGLA DESK
INTRODUCTION
The People’s Health Centre (Gonoshasthaya Kendra) is situated
at Savar, some 30 miles from Dacca. The centre at Savar has
gained an international reputation as an example of integrated
development; none of the familiar problems (health, family
planning, food, even poverty) are dealt with ^an isolation.
Health, however, dominates the activities of the Centre. Most
of the Centre's 44 paramedics are women. One of the Centre’s
founders was Dr Zafrullah Chowdhury., Chowdhury's team has
achieved remarkable success as well as deserved recognition.
But it has not been without its setbacks. In 1976, a key
paramedic was murdered in one of the local villages - illus
trating the kind of opposition to pioneering health that exists
among the wealthy elite, not least among the quack doctors,
in the villages. Here Dr Zafrullah Chowdhury describes the
work of the Centre.
The poor health in our rural areas is a consequence of under
development, Malnutrition is a problem not for the physician,
but for the agronomist, the teacher and the community organizer.
A strictly medical approach cannot produce a healthy community,
and without the involvement of the community, anything that is
produced will have a questionable value.
Originally, the Bangladesh Hospital came into being during the
war of liberation in 1971. At the close of the war it moved
into the rural area of Savar thana, which had no health centre.
Health services for the heavily populated rural areas are
virtually non-existent. It was on remedying this that the
BangladesL Hospital, now name! Gonoshasthaya Kendra, set ite sighRi
When we came to Savar in 1972, we held numerous meetings both
with villagers and students in the area, to try to determine
the best methods for bringing service to the people. We
decided upon a centre base, which would act as referral point
for a number of subcentres. Initially we recruited 100 parttime volunteers from among the students, to carry out the
vaccination and health education programmes.
From the beginning, we made efforts to ensure that Gonoshasthaya
Kendra would be a People’s Health Centre, rather than a
'community death and disease centre o' Preventive programmes
were emphasized and integrated with other areas of life that had
a bearing on health, such as nutrition, agriculture and family
planning.
THE PARAMEDIC:
In time, we discovered that the part-time volunteer workers
were not able to fulfil the demands that the project work was
making on them. We came to realize that a full-time paid
worker was needed.
. . ./5
- 5
It was at this time, in 1973, that we developed the concept
of the paramedic. This has continued to evolve, although we
still define the paramedic as ’a worker who brings community
development services to his own village.’ From the beginning,
wemrealiz^d that a majority of girls would be needed if we were
to reach uue women of the aieci,. The paramedics are drawn from
the area which the project serves, so they are working in a
familiar locality where communications are at their best. They
range from 17 to 25 years. Their training is carried out in
the field, where they take part in the delivery of services,
carefully supervised and supported by the doctors. Some
theoretical classes are given in the evenings, but the greatest
strength of the paramedic is his or her closeness to the village,
its unspoken needs, its wisdom and its ways»
Paramedics must show understanding and sensivity to the life
of the village. They do not preach vitamin A capsules, hut
rather local green vegetables. They do not ask the mothers to
go (usually some distance) to a tubewell for bathing, but they
are pleased if the tubewell water is used for cooking and
drinking. Unlike the docvox who doled out two to six large
piperazing tablets to be taken at home, the paramedic had the
child take the required treatment in front of her. She is aware
that a mother would hesitate to give a large dose of medicine to
a child at one time.
It was also the paramedics who questioned the wisdom of the
antenatal clinics. Among the people being served in one sub
centre area (15,000 to 20,000) there would be approximately
800 pregnancies in a year. Out of this number, no more than
15 to 20 percent would he ’risk’ pregnancies. Gathering all
the women and having them sit unnecessarily was neither an
efficient use of their time nor of the clinic’s. An alternative,
was to ha^e the paramedics par regular visits to those
pregnant ’^men wh^ are most likely to have difficult labour
or other pregnancy problems, and give them the necessary
examination and instruction. The result is that we have had
no maternal deaths in the area.
The. selection of the paramedics involves the villagers, which
leads to a greater responsibility for the programme on both
sides. Members of the community chosen to interview the new
recruits are older villagers, ■but from among the poorer class.
If the delivery of the service, distance is always a problem.
We sought to overcome it by the use of bicycles. Though quite
acceptable for boys, girls on bicycles was a revolutionary step*
It took little time to win over the villagers, but the more
‘educated1 and Religious ’ leaders balked at the idea. Never
theless, the plan went ahead - and'not only does it solve the
problem of transportation, but it is also a definite step
forward in the liberation of the women.
The degraded social position of the women in the villages was
what first moved us into the field of education. We felt that
if they could receive some training which would provide them
with a marketable skill, they would eventually gain a certain
. ../6
economic independence and respect.
FAMILY PLANNING:
smd 0bstruction
When we oucirted our project, we became aware That demand for
family planning services existed in the villages. The source
of supply was lacking. So we began to offer a family planning
service, but always within an integrated programme. Without
real efforts at assuring parents that their young children would
xeacn adulthood, we felt we could not with justice deny them
right to sons and daughters of their own.
own. The programme
has therefore made efforts to provide the
the needed
needed health
health care,
educating the parents in birth control methods and family
planning to motivate them properly. C
Once the method has been
chosen, clients are visited at home regularly.
The dai has also been successfully incorporated into our
programme. Remainingin the village, she works on a part-time
basis, distributing pills, checking for side-effects, assisting
where possible and referring to the centre or sub-centre where
neeaeci. Sne is also taught to spot pre-eclamptic patients and
2^her g?sslble labour and birth difficulties and to instruct
the mothers in regard to child care. Because the dais are
vixlage based, their drop-out rate is lower than that of the
paramedics.
Since the
beginning —
of the
.
utxj programme in 1972, we have noticed
a :
.ll?rn 0^ c^-ieribs moving towards a more permanent
method of contraception ; once family planning has been 5^
accepted, In
7 1974' we began to offer female sterlization
performed by the paramedics, aand found that a relatively large
demand existed for this method
The sterilizations are per
formed under local anaesthesir
Paramedics, having been trained
to perform. -'These onere.ticngl '' e proved themselves to be quite
skilled. r”
The- villagers prefer the
female
-t
dl„ to the male <
1_ f
-- le paramedic
physicians,; iand' it
’ ' Jias_ been noted that the infection
u rate for
the paramedics is lower- than
‘
-- 1 that
of the doctors
The reason
for this may be that the doctor is usually an
„„ occasional
operator,
is doubtless a tendency for him to> assume
the more difficult
0
—1_—.-K — j
CA.SCSc
Advice on^ menstrual regulation and abortion are offered at the
clinic p
More advanced stages of abortion are performed by the
doctors, but the government attitude to abortion is somewhat
ambiguous° A survey conducted in Bangla Resh
Desh regarding
attitudes towards legalization
found that,
that,^wi
th
------ —- — --a of abortion found
with
the exception of engineers.
■
engineers, physicians
were the most conservative.
_•
_.£traen^ OJ- the physicians surveyed opposed the
legalizing , of abortion, Being far from the village reality,
they cannot or will not, accept it.
THE' WATER:
^M^Z2bl£IL of^Pumps
Lesh. At whim they rise
n° kinS> the
bhe rivers of Bangla Desh.
- ■
and. tail,, and
and <carry the fate
of 80 million people in their
drought’ dehydrated bodies,
course. They bring destruction, drought,
disease m a myriad forms,, to green fields,
fields fish, fertile soil.
’• •/?
- 7
Water is the first authority in the land to whom poor and rich
alike make their appeal. For want of water, or because of flood 9
the lands lie idle, yielding nothing.
However, this need not be, Bangla Desh has a farm labour force
of approximately 19 million men, but only 12 million of them
are employed. If land was used to its maximum advantage,
rather than only producing just over one crop a year, there
would be shortage of labour. Sixty seven percent of the land
in Bangla Desh, however, requires irrigation. One deep tube
well irrigates an area of atleast 100 acres.
Yet there are numerous instances where four of. five such wells
are installed within the radius of a mile. Often, this results
in too rapid use of ground water and local handpump wells go dry.
UNICEF has also paid attention to the problem of water, and
admirably put in efforts into supplying handpump tubewells.
But generally the pump has been situated close to, or within,
the compound of the wealthy mar. the man with power and influenee • UNICEF’s aim has been to supply one pump for every 200
people. Our suggestion was to make an initial payment of 25
paisa for each person using the pump. This would ensure that
it was placed in a position advantageous to all members of the
village. UNICEF did alter its original scheme, and decided
after three years to make a charge for the pumps ... 250
taka for each pump installed, with no further payment required.
Any one individual could make this payment of 250 taka. So,
now the rich man could establish his full rights over the water
Nofc'only installation but also real availability of water and
latrines for general use will contribute to the better health of
the community, cutting down intestinal and diarrhoeal diseases
and skin conditions« The inc-udence of disease is decreased by
the provision of water, irrespective of the quality, and an
uncared for latrine has no appreciable effect on community
health. What we need is a simple construction, that can be
cared for as necessary and is convenient for use.
(courtsey ~ Development Dialogue 1978, No. 1)
mfc bulletin : September 1980
** -m- -jh ^ ********** #
,../8
III
LEARNING FROM THE SAVAR PROJECT
Athay Bang
(The last issue contained a 1brief
' ~ overview of the Savar-project.
This one gives a more detailed information from close quarters
and.raises very interesting iuestions.)
As the car was passing from Dacca airport to the G-onoshasthya
Kendra of Savar
-- ?, the landscape of Bangla Desh was unfolding
before me. A decade ago while working as a medical volunteer
in the refugee camps during the liberation war, I had seen a
few glimpses of Bangla Desh by occasional infiltration,. My
interest in Bangla Desh dates back to that experience, The
news of political upheavals and natural disasters kept on
disturbing one- about Bangla Desh for last one decade, but at
the same time some interesting, rather sensational news of the
community health work started in Bangla Desh by a group of young
doctors
doctors.led by Dr Zafrullah Chowdhary, their paramedic programme.
paramedics doing tubectomies etc. had created a curiosity in my
mind, And here was I today heading towards the famous G-onoshasthya Kendra (G0 K.)y passing through the main land of
Bangla Desh, seeing both her beauty and ugliness.
BEAUTIFUL AND UGLY
Beautiful because of the natural greennery and abundance of water.
Ugly because of the poverty, the worst I have ever seen. The
per capita^ yearly income for Bangla Desh is 560 Rs; one of the
lowest in tne world. There is gross disparity even in this
small average income and the lower 50$ of the population has
per capita yearly income of Rs.225 or less. Population
density in this country of 85 millions is one of the highest
in the world (1375 persons per sq.mile). 91% of the population
lives in the rural area. 50% of the total population has either
no land or less than half acre of land. Literacy rate is 20%,
but for women it is less than 10%.
A passage from Dacca to G. Ko offers sights of sharp contrast;
tall buildings of American architect mushrooming on the expansive
periphery of Dacca juxtaposed to and even engulfing the
collapsing huts of the surrounding villages. It must be
mentioned^here that the $ost vulgur display of affluence is not
only by the plethora of ’ad’ agencies UN , World Food, US Aid
and so on.
9
But as we moved away from Dacca the poverty of the rural area
started showing and soon the car turned to the right to enter
into the headquarters of G-. K. The first to strike you are the
buildings-two-storey hospital cum office building and a fourstorey hostel residence for paramedics and other staff of the
G-o Ko Total buildings cost in GK is 9 lac Rs. ’’Was it so
essential?” one starts questioning in the mind. But same is
the feeling of Zafrullah Choudhary, who later on said, ’’For
initial Ij -year we were living in tents and temporary shades.
Had no money for buildings. An armed robbery, heavy rains^nd
inconvenience to the patients and the staff created a need for
buildings. Therefore, when we received generous foreign aid
offers for buildings, we were enamoured. We did the mistake 'of
accepting the offer and within next two years these incongruous
• • -A
9
edifices stood up.”
But what is more impressive is the simplicity and the austerity
of the living style of the staff and the equality in relation
ship. I rust admi/t that when I met Choudhar'. for the first time 9
I mistook him for a PA or typist of Zafrullah. Except for a
few families with children, all other workers live in the same
building in similar accommodation. From the gate keeper to
Zafrullah, all take the same, very ordinary food in a common
mess. G-. K. has a novel rule-reminding me of Gandhi Ji’s Ashram
in his time (not now)-everybody in the project works for li hour
in the’morning on the farm. ’’This not only helps us to become
self-sufficient in our food requirements, but also builds up
a healthy equal relationship among us, an identification with
the manual labourers of rural areas and also helps to screen
and eliminate the elitists among the new rec’Gits. ” All these
things must have contributed in the creation of the warm,
friendly and family relationship which exists in the whole team
of G-. K.
I shall not describe the history and all the activities of O.K.
as these things have already been published in the MFC Bulletin
(Paramedic of Savar: issue No 57) Instead, after a brief
description of the activities , I shall try to discuss some
questions and inferences from their experiences and some of the
recent experiments at G- Ko
THE PARAMEDICS
G-.K. started in 1972. With only 2500 doctors working for the 75
million people in the rural area of Bangla Desh (1 doctor for
50,000 population) and with only 700 trained nurses in the whole
country, the Western health model was irrelevent. ’’The purpose
of our project is to evolve some system by which the medical
care of-the whole population of a particular area can be undertaken efficiently and effectively with the minimum benefit , with
the employment of limited medical manpower.” (from the original
project proposal, Feb. 1972)
In the last eight years, G-. K. has been able to develop such
a system with the paramedic as its main health workers. There
is a central 50 bedded hospital withi.X’ray, pathology find
operative facilities. Office and training centre'is attached to
this hospital. The headquarters and its‘4 subcentres together'
try to deliver primary health care to the 91,000 population of
100 villages of Savar thana.
There are in total 4 doctors and 64 paramedics at present
(59 females and 25 males) - 16 paramedics in the headquarters
hospital and clinic, 15 stay at the headquarters and cover the
surrounding 40 villages, moving on bicycles. (Because of the
high population density a large number of villages are packed
in small area). Other 20 stay at 4 subcentres (5 at each) and
each subcentre covers 15 villages. 15 paramedics (mostly
males) are village based-living, in their own villages and
serving them.
Each paramedic (except village based) cover about 2500 population
(2 to 5 villages-depending up on the size of the villages.) .x-The9
..../io
The sub-centres have a weekly OPD when a doctor from the head
quarters visits but offers emergency services all the seven
dayse Some subcentres, managed entirely by paramedics, have
small indoor also. The head quarter hospital runs twice a week
OPD. T"
”
Most‘ of~ the
cp,ses are seen and treated- b~r the paramedics,
Doctors mainly work as a referral persons, as trainers
miners and as
administrators,
A paramedic is usually 7th standard to SSC pass unmarried girl
almost all recruited from the outside area because of the lack
of educated vzomen in the Savur area. They are given about one
year's inservice training, contents being similiar to AM training
in India
They are full time workers of GK.Drop out rate is 50%
Salama, the paramedic with whom I went to a village on bicycle to
see her routine village visit covers 4 villages. So she visits
each village about once a week, sometimes twice; goes house to
house, covering about 25 houses in one visit, thus usually the
same house is again visi^ted once in a month. The main assigned
jobs are 1) Treatment of minor illnesses. 2) Immunisation - BCG,
Triple to all children and tetanus tozoid to all the women in
child bearing ages. 5) ANC check up. 4) motivation for PP and
distribution of oral pills 5) Health education 6) Detection and
referring complicated cases, specially among pregnant women and
children to the doctor at subcentre OPD or at head quarters.
The sincerity and the efforts put by Salama were worth seeing;
out the response of the people and the health status didn't seem
good. The causes of low health status were also obvious in the
village - terrible poverty, poor sanitation (water, mud and flies
everywhere), ignorance and a resultant apathy< The paramedic was
struggling against these odds with her small health kit and fighting
spirit.. Of course, the pictures of health might have been still
worse without GK or without Salama.
I accompanied. Dr Kamal, to a subcentre. That was the OPD dayfor
the subcentre, J girls and 2 boys paramedics, all unmarried,
stayed.at that subcentre - must be a sensation in the rural Muslimcommunity of Bangla Desh. The OPD was overflowing with patients •
One could observe that neither the subcentre paramedics nor the
doctor were overusing antibiotics or the injections. Same
experience at the OPD at the headquarters.
GK has innovated some unorthodox methods. Diarrhoea and cholera
are^very common in Bangala Desh. When Cholera Research laboratory
(CRD) of Dacca evolved oral rehydration therapy with the
electrolyte mixture, GK field workers, while applying it in the
field conditions, modified it to "Lobon-Gur" that is salt and
Jaggery mixture.
Jaggery is easily available in every house,
it is cheap, and provides sucrose and potassium. CRD later on did
field trials on this "Lobon-Gur" mixture and found it almost
equally effective.
Paramedics doing tubectomies at GK is famous, and now about 85%
of the tubectomies are done by the paramedics with very low
complication rate. Even more bold is the OPD method of tubectomy.
.../Il
1
Patient is discharged within two hours and spends the post
operative period at home. This has been found to be safe and
also prefered by the patients who apprehended and avoided
tubectomies because of 7 days, hospitalisation.
WHAT DO PEOPLE WANT?
The study of the coverage and health impact of G. K. activities
raises some questions which offer useful lessons.
What is the coverage of the population by the project?
The total visits by patients to the curative services offered by
G. Ko are about 60,000 in a year. It has been estimated that if
cost and distance are not the barriers, each individual seeks
curative service on an average 5 times a year. So the 1,000,00
population in the project area should be seeking help 5,000,00
times. It means that 60,000 visits cover 20% of the total
curative requirements of the population. Remaining 80% are
either unmet or met by other health agencies (Quacks’ mostly)
what is the reason for this behaviour of the people?
But even more interesting is the analysis of these 60,000 visits.
In the year 1975-76 the OPDs (at headquarter and subcentres)
treated 48,000 patients while the paramedics in their village
rounds treated only 6000 cases.
We all speak hoarse on behalf of the ’dumb’ poor people of the
villages and advocate a decentralised, simplified, deprofesionalised, cheap medical care, for them. But in the G-K experience
when a fairly well trained (approx. 1 year) woman paramedic is
going to the door step only few people are availing her curative
services and the majority are preferring to walk a longer distance
to the subcentre or to the headquarter.
There are 2 possible reasons which could be discovered during
the discussion 1) People still felt that the curative services
offered at subcentre or headquarters are superior to the services
of paramedic. The mystification about doctors, indoor buildings
and injections influences their choice. 2) Paramedics are all
ill-equiped in their curative powers. They don’t have chemoth
erapy beyond sulfas. This has acted as an impediment in her
showing good curative results to the village people which in turn
diminishes their co-operation to her in the preventive activities.
These lessons should help others in planning the curative services
and understanding what people want.
THUS FAR AND NO FURTHER
What is the impact of Gstatus of the people?
K. health activities on the health
Though comprehensive statistic^s are not available, the one
offered by G. K. shows that the infant mortality rate in UK
area is about 120 as against 140 in Bangla Desh and the birth
rate is 29 as against 44 in Bangla Desh. The impact is definitely
.../12
12
there but a point of stagnation has come, beyond which further
improvement in health indices has become difficult.
I felt that whatever improvement G. K.
Ko could achieve is mainly
because of cheap, effective, 'idely availabl curative services,
A cure at an early stage is a major preventive force. Some
improvement is attributable to lower birth rate because of
family planning, oral rehydration therapy in the cases of de
hydration and tetanus toxid to mothers. But probably all these
measures have reached their saturation point. Some further
improvement might occur if the curative powers of the paramedic
are increased and if her acceptibility increases. But poor
paying capacity of the people will limit their utilisation of
curative services at some point. Further significant improvement
will notu (occur unless poverty, illiteracy and poor environmental
factors
are changed.
T.
~ - Improving-environmental factors is. a
difficult thing in Bangla Besh , where- most of the land is under
water for 6 months
in an
r- year. Huge inputs will be necessary
-- ‘-1^ -In
situation which people can’t afford.
to change this situation,
So GK offers a good case, fItiiioiis bj_-a ting to what extent the health
status can be improved by the health measures alone and then how
an^impasse comes because of socio-economic factors acting as
bottle neck. Su.ch conclusions are possible because though GK
has a comprehensive vision and has economic and educational
programmes also, they are too small to effectively influence the
whole population and hence the main force is still the health
activity.
WHAT ABOUT PEOPLES PARTICIPATION?
In GKs experience it is very difficult to achieve active community
participation for health purpose. The health volunteers from
the villages were inadequate. The health co^miittees formed in
the villages almost never funuuloned effectively. The villages
are factioned and health is not the priority. The paramedics of
GK mostly.are recruited from outside the GK area and being un
married girls, they stay together in the dojmitary rather than in
the villages. The community health programme of GK is in the
Director Dr Qasem’s words
-- Is, ’’village oriented but not village
based.”
In Jamkhed (MFC Bulletin No 49, Jan. 1980) VHWS are from the
same villages. But what about the apparent active participation
by the villagers in the programmes at Jamkhed. the respect and the
response the VHW seems to get there in her preventive and
educative activities as compared to the not so active co-opera
tion by the villagers to the G-K paramedic? Probably the peoples
co-operation at Jamkhed is not because of the health work (in
fact GK paramedics are better trained than Jamkhed VHWs) but
because of the massive feeding programme and the food for the
work programme. If these big economic inputs are eliminated
probably people won’t have much enthusiasm to participate only
for ’a health programme’ at Jamkhed also.
Go K,
• - - to
■
tried,
achieve economic self reliance by a health
insurance
---- scheme
--- ♦ . But the maximum they have been able to
]has
...13
13
achieve is 50$ economic self reliance, This was in spite of the
fact that the project got vaccines and FP supplements at no
cost
cost. The main impediments are poverty and hence the poor
paying capacity of the people (specially in Bangla Desh) and
the project not adopting unethical curative measures to satisfy
people and complete with the quacks.
Some of the conclusions thus drawn may seem negative. But these
are the hard facts of community health work and anybody jumping
into this field would better learn these lessons from the G-. K.
experiences rather than having illusions about massive people’s
mobilisation through health work, economic, self reliance and
improving health by health measures alone. I have found friends
at G-K very open and honest in accepting and discussing their
limitations also. This is a rare quality in a successful pfojecb
and this increases the educative value of G-K very much.
(To le concluded)
mfc bulletin: October 198
.../14
14
IV
ESSENTIAL DRUGS EOR THE POOR : MYTH AND REALITY
IN BANGLADESH*
ty
Z. & .S. CHOWDHURY
scene (controversy) has been headline news in BanglacoJntSliVfnV17 five
• The supply of medicine in this
country has for years been characterised by high prices, making'
arugs uwvallatle to the poor, by the aaleUf unnweSry aS 8
as l YY ~lY,!h,,i
c™tin»eii marketing of drugs identified
as narmlul and banned elsewhere..
Most people would agree that WHO'ss list^of
“' '
essential drugs (1)
covers most diseases afflicting the ‘world"
\ but the fact remains
3„®®?_?re,.not ■®e dru®s being produced in quantity - in
Bangladesh or elsewhere in the Third World
JitaSins’ "bUf+u
rUS U
Cdrlng aS
. big drug
producing
as Wel1
well as consuining nation, lu..
tonics,
restoratives" and
!
hich ore health
^.-stcratives"
enzyme digestives (most of
thiee-ouarS^
PreParations), n"spin" money and account for
for "eLen + i oi H i drug Production there,
there leaving scant resources
hU-i-i
druf® I2)‘ with -tuberculosis and leprosy major
GofULU
Vat country, the ' Indian Council of Social
?$ti-tn^S,Cr ?
report in 1981 that the production of
while that ofaUUUfS wa!.onk one-third the minimal requirement,
9
An excellent example of deman being stimula;ed for non-essential
drugs in poor countries is 11
case of Vitam_Lii B12. Used in
developed countries for the treatment of pernicious anaemia and
similar B12 deficiencies ? in Bangladesh the same B12 is advertised
to doctors by Glaxo (UK) as use±ul in a wide range of treatments
including "poor appetite",- "poor growth” and ’’sterility” (6).
While 8 formulations <containing B12_are listed in the UK MIMS
126 o'n
’’i- ^1
on the Brazilian market (7).
SOOoLEbnHnY1"*10"8
in Brazil range in dose from
2,uuu to ?O,000 micrograms per milllitre (2 of these formulations
are sold by British"Glaxo) o In Britain, the highest recommended
dose of injectable B12 is 1?000 micrograms per mililitre (8).
druLtpvpfW?rld countrl,es are no;/ doubling their expenditure on
Uwbf!
f
y6^3 while their Gross National Product (GNP)
double^ only every 16 years and, according to WHO, "... for
tUtr°aVg+C0Un'tries; iffiPortation of pharmaceuticals is one of
he iastest growing drains on hard foreign currency” (9),
*The article is the abridged version of one part of a paper
presented by the authors
1 — j at the Primary Health Care Symposium
No. 3 in Liverpool, UK in April 1982.
.../15
15
The Bangladesh scene before June 1982 and the new policy guidelines:- A waste of resources
In 1981 Bangladesh spent an estimated 1250 million taka on
allopathic drugs (approximately 63 million LS dollars). Only
a negligible portion of this was available free of cost at
Government Health Centres. The rest was sold commercially, In
a country with one of the lowest per capital incomes in the
world (70 US dollars per year), this means that after food,
clothing and shelter, medicines are a major part of the re
maining expenditure. Often a little medicine is bought in
extreme need, but not enough to cure the illness. The public
are left in ignorance as to the detrimental effects of breaking
off treatment prematurely and the drug companies thrive on the '
need for repeated prescriptions. Most important, due to poverty
and the high cost of drugs, only 15% of the population at a
maximum estimate, are able to buy modern medicine.
Inadequate information and the common habit of self-prescription
(because doctors are unavailable or too expensive and all drugs
can be easily bought over the counter) have led to a situation
where 70% of the annual drugs sales are on drugs described as
useless or therpeutically insignificant by the British National
Formulary, the National Research Council (USA) or the Federal
Drug Administration (USA). An apt example is seen in two
British companies manufacturing in Bangladesh - Glaxo and Fisons.
The Glaxo Bangladesh Limited Medical Reference List of March
1980 listed 51 products, of which only 17 are available in
Britain according to the UK MIMS of February 1980. Only onethird of Glaxo’s products on the market in Bangladesh appear on
WHO’s list of essential drugs. In the UK MIMS of January 1982,
Fisons had only five drugs listed out of the 31 products available
in Bangladesh and 17 of* these 31 were combinations of vitamins
and miner ils. The ’’hottest” item of the We^t German manufacturers.
Merck on the local market has been Neuobion ( a combination of
vitamins Bl, B6 and B12). This one item alone accounted for over
68% of the total 'market in neuro-tropic preparations and their
1980 Marketing Plan stated: ”0ur objective will be to achieve
at least 75% of the market share by intensifying our promotional
effort". They were also concerned that Government could prove
•a threat and so instructed their company in Bangladesh to ”....
maintain a very good relations with Government officials in
Health and Commerce Ministry to guarantee importability of our
products" (11).
Drugs worth an average of 150'million taka are imported
annualy into Bangladesh by local firms as well as voluntary and
UN organizations. The remaining medicines, worth about 1100
million taka are produced in the country. 890 million taka
worth, or 80% of the drugs produced in Bangladesh are manufact
ured by 8 multinational companies. The-rest is shared by.22 of
the larger local companies, with or without third party licens
ing' arrf.&gements with multinationals.
The Expert Committee, set up by the Government on 27th April
1982 to evaluate all the registered/licensed pharmaceuticals
then available in the country, found about 4170 brand name drugs
.../16
16
containing over 150 different active ingredients. Only about 250
of these (less than 1%) are therapeutically significant or
essential. The rest have been promoted solely^for the purpose of
financial gain. In a country like Bangladesh the situation is
acute because it diverts desperately scarce ■’'’esources and many
people will deny themselves ..fo^d in the hope that some aggress
ively advertised, but useless tonic will do them more good. But
it is not only a confidence trick - substances which have actually
been identified as harmful and banned in developed countries
have continued to be manufactured and marketed in Bangladesh.
Mr A Wahid, Managing Director of Pisons (Bangladesh), sums
up well when.he says, "we are businessmen first. First of all
° ‘ ‘ we are 0ver3ensitive about reports from
Restrictions on drugs and pesticides imposed in the US and
Canada should not be.applied in our country because our people'
are euhmcally and biologically different from others” (15).
(15).
Quality Controx and_p_rice Fixa,tion
Up to this point in time, manufacture and marketing of medicine
has L-een regulated by the Ministry of Commerce and Industries
try of Health- Drug Administration, a department
o the M_nistry of Health, tests the quality and composition of
drugs produced.and imported. Each drug and its price has to be
approved by.this body. On paper this sounds very good and this
iormal machinery is.cited by drug companies to argue that nothing
muon ca.n be wrong with their practice under such "stringent" a
system. However, to perform their vast task, which includes testng every drug on the market in Bangladesh as well as inspecting
x .marmaccuuicalCompanies and thousands of registered and unregrsberea pharmacies and 7 inspectors. It is clear that
supervision and
and.control of manufacturers and retailers can exist
with a system of this sort. In this connection,
ihe Expert Committee which, alter reviewing the drug market
iOrmulateo. tne new drug policy, recommended, that the Directora.e of Drug Administration be expanded and adequately staffed
with experts in medical and pharmaceutical sciences. They furthei
ecommenaed that all drug control laboratories be brought' under
ther?0?'tr°^ Of
Administration and that a properly ■
staffed-, and., equipped National Drug Laboratory with appellate
lacilibues oe set up as soon as possible.
The maximum retail price (MRP) of each drug is fixed by the
M^TC^Or G3n5<ral of prices> Supplier and Market Intelligence,
nistry o Commerce at about 200% of the cost and freight (C & F)
0^-, ' c
v/hich includes the value of raw and packaging
materials. This mar-up on C & P price includes 20% for
insurance, bank charges, etc
30% for distributors and
retailers and only about 15/20% rrofiT for the manufacturer.
117 13 estimated that the real profit has been
ji-bween /0/100%. One manner of obtaining this excessive profit
raw at Prices higher than international
competitive rates. Pfizer, for example has a binding clause
l
agreement with Government-that its head office in the
S will have to approve of any raw materials that it purchases,
1 1uS
pp?zer (Bangladesh) to buy raw materials at
exhorbitant prices from its sister companies abroad and thereby
.../17
17
transfer profit out of Bangladesh in the name of production
costs. Many other companies have similar clauses in one form
or another. Nationals as well as multinationals are out for
table profit. Two local as well as the transnational company
G-laxo are all buying from the same source, yet all quote
different prices. It is interesting that 3 years later (1982;,
in spite of tremendous inflation, GPL was able to buy from a
West German firm at a price less than that paid, by any other
company in Bangladesh. It would also be false to claim that
Pliva Pharmaceuticals (Yugoslavia) is of questionable quality
since Pliva products have been approved by Federal Food and Drug
Authority of the US as being of standard quality and usuable
in the US.
Packaging to increase profit:
The mystique of the name is supported cy other promotional
features, especially packaging. Consumers naturally tend to
identify brand name tablets, capsules and syrups by their dist
inctive bottle or packeting. Packaging is promoted with reference
to better hygiene and customer appeal. Foil-wrapped products
offer much more to visual perception than the same product which
comes out of a bulk tin and is wrapped in a twist of paper or
non-descript container. In a country like Bangladesh where
something like foil must be imported, there is a ready-made .excuse
for increasing the price of the product, since the MRP allowed
by the Government is two and one-half times the cost of raw
and packaging materials.
Fortunately the new drug policy has taken steps to curb these
practices also. All manufacturing companies must now
purchase their raw materials at competitive international prices
so this will automatically bring down the prices in.this area
for a number of companies. The mark-up price, previously hone
on a basis of 100/150% on raw materials and packaging should be
curtailed so that the mark-up is only the price of the raw .
materialsand no mark-up allowed on the actual cost of packaging
materials. The immediate effect of this would be a much more
even-scale price range for similar products manufactured by
different companies. ,
***************
.../18
Xb
GOKOStlASTHAYA PHARMACEUTICALS
G-onoshasthaya Kendra (People’s Health) Charitable Trust original
objective of establishing a preventive and primary health care
service in a rural area of Bangladesh gradually developed into
a broader community development programme and not surprisingly,
we began to consider how to provide our service area with quality
and inexpensive medicine.
A project of the Gonoshasthaya Kendra Charitable Trust (G-onoshas*thaya Pharmaceuticals Ltd), GPL is designed to supply 15-20%
of the present Bangladesh market in essential drugs. It aims to
produce high quality, essential and generic drugs only, at the
lowest possible price through responsible marketing practices.
GPL is registered with the Joint Stock Companies under the
Companies Act of 1913 and as such, is subject like any other
company, to the usual customs, taxes and other duties. Unlike
other companies, however, there are no private shareholders.
The entire stock is owned by the Trust which, by its charter,
limits profits to 10-*15% after payment of duties and bank charges
About 50% of the profits must be ploughed back into the factory
and 50% spent for research and charitable purposes.
The Board of directors has nine members - five from GK Trust
and the rest representatives from the Ministry of Health,
Directorate of Industries, Bangladesh Shilpa (Industrial) Bank
and NOVIB, a Dutch non-government organisation. This structure
was adopted with the hope that GPL would combine -the advantages
of private industry with its freedom of decision making for
management with the character of a public enterprise oriented
to the consumer and avoiding profit motives.
Funding came in good part through foreign voluntary organisation
donations directly to the G-K Trust for this (GPL) project, A
break-down is shown at the end of the second column.
Technical expertise was provided by the Internaational Dispensary
Association (Holland) who helped to organise additional training
for managers and procured machinery and raw materials♦ Professor
J Polderman, Expert Committee Chairman of the European Pharmacope^
has been sponsored by NOVIB as our Producting Advisor. All
managers of the factory are Bangladeshi.
Establishment of GPL, needless to say, met with problem areas.
The first of these was infrastructure. Any attempt to establish
a high technology project in an underdeveloped country will
suffer from lack of infrastructure and problems arising from
having to import much of the necessary equipments Our main
problems here were in the lines of architecture, electrical
supply and assembling and maintenance of machines/equipment.
The second area of concern was personnel. Skilled workers in
all categories, but especially maintenance technicians are
extremely diffi'cult to hold in Bangladesh due to migration to
the Middle East where wages are much higher. Unskilled labourers,
we were determined to recruit from among the really needy, main
taining the emphasis of the whole of Gonoshasthaya Kendra on
developing women’s skills. Since this was our objective, a good
deal of basic functional education was necessary before the
.../19
- 19
women could begin working in factory. For mcst of our recruits,
it, meant functional literacy classes as well as learning
pharmaceutical terminology and familiarisation with the machinery
they would he using.
NOVIB (Holland)
US
OXFAM (UK)
n
CHRISTIAN AID (UK)
2.62
million
n
0.33
n
H
H
0.22
H
COWIUNITY AID ABROAD
(Australia)
n
t;
0.05
n
EUROPEAN ECONOMIC COMMUNITY
(through Novih)
I!
n
0.20
ii
ii
1.50
i?
Bangladesh Shilpa Bank, OK Trust
and Others
(this is strictly a loan to GPL)
US
dollars
4..92
million
The social and political climate cannot he ignored either, when
beginning a new industry in a country like Bangladesh. The
government’s policy is to encourage industrial development,
especially in such a thing as essential drugs. However, anyone
who intends to produce or market in Bangladesh has to cope with
the corrurt practices which pervade the industrial and commercial
life of the country. Dor those who have been in the business,
GPL’s conditions for doing business come as a surprise which they
often cannot fully understand, since everyone knows bribery is
part and parcel of the way of life in this country.
Then of course, there is the problem of moving into an already
well-established market. Considering that our aim is to supply
quality drugs at the lowest possible price, we knew trouble
would be waiting - just how much trouble has only come in bits
and pieces, but it has come, especially in the field of pricing
and marketing.
We believe that for the proper information -of the consumer, all
pharmaceuticals should be obliged to give details of their pric
ing policy. The table ’’Contrast in Drugs Prices” though not a
break-down in details of pricing, compares some of GPL’s prices
with those of similar products being manufactured and marketed
in Bangladesh.
It should he noted that as new company, as well as due to our
insistence on very high quality control and social benefits for
our workers, our overheads are very high. Older companies whose
machines are fully depreciated will have much lower overheads.
We intentionally make higher profits on drugs we consider less
. . ./20
20 -
CONTRAST IN NRUGS PRICES
Company Name
1
Capsule, 'Tablet
price
Syrup/Liquid
Price
Penbritin
Amblosin
Ampicin
Amplin
Ampicil
Aldapen
G~hmpicillin
Tk. 1.69/cap*
1.80
1.70
1.70
1.70
1.30
1.00
Tk. 23.80/60mls
23.80
21.00
23.80
21.00
Amoxil
Amolin
G-Amoxicillin
J.OO/cap
2.47
2.25
32.00/60mls
25.00
Ampicillin
Pisons
Hoechst
Square
K.D.H.
Pioneer
Albert David
G.P.L.
2
Produc b’s Name
24.00/100mls
Amoxicillin
Pison
K.D.H.
G.P.L.
I
3 Tetracycline/Oxyteixacycline
Pioneer
Pharmadesh
Hoechst
Albert David
Squibb
I.C.I
G.P.L.
4
Teracin
Oxalin
Hostacycline
Aldacycline
Sumycin
Imperacin
G-Tetraeyeline
0.90/cap
0.97
0.90
1.00
0.98
1.05
0.50
Sulphametnoxazole & Trimethoprim
Burrough Wellcome
Square
Therapeutics
Opsonin
Pioneer
G.P.L.
Septrin
Cotrim
Thera trim
Chemotrim
Sephtazol
G-Cotrimexazole
2.30/tab
1.98 .
1.80
Paracetamol
Cetamol
Pyralgin
Fitamol
Paratan
G-Paracetamol
0.25/tab
0.25
0.27
0.25
0.25
0.15
1.73
1.90
1.25
26.00/60mls
22.00
22.00
16.00
2.100/100mls
5 Paracetamol
SPI (May & Baker)
Square
Hoechst
Pisons
Nicholas
G.P.L.
6 Metronidazol
BPI (May & Baker)
Square
Pioneer
Opsonin
G.P.L.
Glagyl
Amcdis
Metazol
Metril
G-Metronidazole
Tk. 0.78/tab
0.70
0.60
0.50
0.40
.../21
- 21 -
Company Name
Product’s Name
Capsule/Tablet
Price
Syrup/Liquid
Price
7 Asprinf jOOmg)
K.D.H.
Fisons
G.P.L.
8
i
Avlocid
Antacil
Nutracil
G-Antacid
0.45
0.25
Lasix
G~Frusemide
. 1.30/tab
0.60
Tk. 23,oo/225mls
15.20/226mls
16.00/228mJ3
14.00/200m^s
0.20
0.20
Oral dehydration Salt Sachet (27.5 gm)
Pioneer
G.P.L.
12
0.50/tab
0.25
0.20
0.50
0.125
Frusemide (40 m^j
Hoechst
G.P.L.
11
Sedil
Saslum
Sudex
Sedalin
G-BiazeDam
Antacid
I.C.I.
Squibb
K.D.H.
G.P.L.
10
0.12
0.10
0.75
Diazepam (5^)
Square
Opsonin
Peopled
K.B.H.
G.P.L.
9
Asprin
Genasprin
G-Asprin
Oralite-B
Labon Jaler Sarbat
fiO.R.S.) •
10.00
2.50
Derrous Fumerate with Folic Acid
Fisons
G.P.L.
Folte Tab
G-Iron with Focid Acid
* 2 Bangladesh Taka
0.06
0.05
Approximately One Indian Rupee.
important or whose use we wish to discourage. For example we make a 6.57%
profit
proiiT; on ampicillin and.
and 3.27b
3.2^> on 1paracetamol (which are below our overall
margin of I0.I570) and make it up with ai 56.670 profit on diazepam and 85*6^0 on
frusemide.
GPL hopes to market about 6O-7Q/O of its production to government , government
agencies and charitable health services in bulk supply, This is deemed the
safest ? quickest way to channel the benefits of cheap drugs to people most
in need. The remaining 30-40% will be sold on the open market but this involves
a system of education (most, including doctors , believe the higher the cost, the
better the drug) and distribution. It is difficult for even doctors to come
by unbiased drug information since there is no Bangladesh National Formulary
and oiten the product information leaflets are very different in content in
.../22
22
third world countries than they are in first. The only way
then for doctors to keep abreast of pharmaceutical developments
is through foreign medical journals, etc. and most don’t have
access to the foreign currency necessary for purchase of these.
In this respect, we have used our Bengali language health bulletin
'Monthly Gonoshasthaya’ to disseminate various information in
relation to the baby food issue, abuse and exploitation in the
drug market and other ,vital health-related topics.
Bid for Government Tender
Each year, the government calls for a large tender for medicines
for rural health centres. In 1978-79, the government after
proper calculation, put pressure on the government-owned Albert
David company to sell them their ampicillin at a price of 95
paisa/capsule. In 1979-80, Albert David management contended
that due to rising costs they couldn't supply lower than 99 paisa
In 1981, GPL bid for the. tender of 10 million ampicillin capsule
at 93 paisa, basing our calculation on the raw materials price
cited by one of the leading trading houses and considering our
high overheads. The 'day after submitting the bid, we were
informed by the Trading Company that they could now quote^a^
better raw material price. The previous one had been 95-120
US dollars per kg, the new one was 89-100 US dollars. This
cheaper price would have resulted in a lowering of 5-17 paisa
per capsule., LWe later learned that the -Trading House in Question
is owned by the wives of the Managing Directors of three large
pharmaceutical companies, one multinational and two national,
national.
Still later, we learned that some multinational and top-selling
national companies had a meeting before the tender. We did no'G
win the tender. It went to a national company which had bid
at 80 paisa per capsule. The retail price of the same company’s
ampicillin is 159 paisa. For the governmenJ, this was the
cheapest ampicillin they had rmr purchased and giving. cred._ u
us bo
where credit is due, some officials thanked us, requesting
:
keep up the good work.
Role of UNICEF and WHO
UNICEF is the main supplier of drugs for primary health care in
the rural health centres of Bangladesh, largely through their,
drugs
are purchased
’Drug and Diet Supplement1 (B & BS) kits., The
r’
"
through a general
cjLie-xdl tender,
ucxidcr, mainly
rnainlv from East and West European
countries, packaged in Copenhagen and then shipped to the,recipient
We are pleased to say that UNICEF is now considering
countries
GPL as a supplier for the Bangladesh rural health scene.
Since one of our aims is to encourage the sale of generic drugs,
we thought the translation, publication and distribution of the
Technical Report series No 641 (Essential Drugs) would be an
important stepl We approached the WHO office in Caeca for
permission in respect of this request and, if .possible some
financial assistance for the project. We were
--- informed that
1 > Then
WHO in Bangladesh has no funds to support such a request.,
at the
followed eight months of lengthy correspondence, al
'-L- ffinish
,.0/23
25
of which we were informed that since Gonoshasthaya Kendra is not
a government organisation, permission could not be granted for
us to translate, publish and distribute on our own. (\tfe later
learned that there is no need for any permission as WHO public
ations are not subject to any copyrights). 1'his is a vital
document which should have wide distribution in all third world
countries, yet little has been done by WHO in Bangladesh to see
doctors, pharmacists, etc, informed about the guidelines, they
themselves have established to help us reach the goal of
'HEALTH FOR ALL by 2000’, in fact, when the Expert Committee
was sitting earlier this year and requested eight copies of the
booklet, it could not be found in the country and had to be sent
for (by which time the Committee had already submitted its
report).
Relevant here is an article which appeared in the Monthly
±veview (December 1981) by Trushen and thebaud who aruged,
medical aid, like food aid, is a weapon of foreign policy wielded
by donor nations, and it provides an easy entry to vast third
world markets for multinational corporations - in this case the
pharmaceutical industry. In the past decade, drug companies have
increased their influence on WHO through participation in
three new programmes: human reproduction, tropical disease
research, and essential drugs for primary health care. The drug
industry’s penetration is indicative of WHO’s continuing
reliance on technological and industrial approaches to problems
that are economic, social and political. Rather than promoting
'Health for All’, isn’t WHO furthering the medicalization of
underdevelopment?”.
Furthermore, the politically neutral attitude of WHO prevents it
from directly denouncing various forms of domination such as
colonialism and neocolonialism which are at the root of many
health problems. Trushen and Thebaud have r.-ghtly pointed cat,
’’WHO’s technocratic approach is a refuge: lu permits the
organisation’s doctors to identify a disease and describe it
scientifically without calling into question the economic,
political and social mechanisms that ensure its development and
transmission.”
And that very approach prevents essential drugs for the poor’
from becoming a reality. Establishment of rights of the
oppressed is always an up-hill struggle.
********************
. . </24
24
VI
D-9/334.(J;l)
21.10.1982
THE BANGLADESH BAK ON HAZARDOUS AND IRRATIONAL
DRUGS
Its Review and tiie present Status
28th April 1982:
An 8-member expert committee commissioned
to evaluate all the pharmaceutical
products in Bangladesh and draft a
rational Drug Policy - met for the first
time .
Important outcome:
4140 products in the market were evaluated«
16- criteria were laid down for evaluation.
(12 criteria selected on scientific
grounds).
Based on these, 1707 products were re
commended to be banned. These were divi
ded into 3 categories or Schedules as
follows:
Schedule I - This included 265 locally
manufactured and 40 imported drugs re
garded as positively hazardous to be
banned immediate1y.
~
Schedule II - included 154 drugs which
required reformulation and were to be
banned after a period of 6 months.
Schedule III - included 742 locally
manufactured and 526 imported drugs
These
drugs either had little or no proven
therapeutic value or could easily be
manufactured by local drug companies instead of the multinationals producing
them at higher costs, thereby depleting
the country of much needed foreign exchange
I.
I2th May 1982:
The Expert Committee submitted its report
to the Government.
29th May, 1982:
The Chief Martial Law Administrator and
his Council of Minister approved it. The
date of the ban of Schedule I was changed
from 1 to 3 months and the banning dates
of Schedule III drugs from 6 to 9 months.
7th June 1982:
Formal declaration of the new policy was
made .
12th June 1982:
The Drug Control Ordinance was promulgated e
June 1982
Reported pressure exerted on the Government
by the Bangladesh American Ambassador on
behalf of the US multinationals to have
.../ 25
D-9/334-(J:l)
21.10.82: a
- 2 5the policy amended. The negative stand of
the USA regarding WHO’s International Codeagainst unethical marketing practices of
milk food is well-known.
The British, Dutch and the German Embassies
.joined to exert pressure on the government.
The anti-government campaign having failed,
the focus then turned to the Expert Commit
tee which had recommended and pushed the
drug policy
July 1982
The 4-member Expert Scientific Committee
of various pharmaceutical manufacturing
companies was brought by the US Embassy to
further pressurize the government to
reconsider the ban. .
19th August 1982:
In Washington Post it was reported that the
US State Department spokesman had acknow
ledged; ’’that the Pharmaceutical Manufac
turers Association, a trade organisation
the drug industry, asked it to bring
pressure on the Bangladesh government to
delay implementing the law pending discussio
ions with the manufacturers”. He added:
’’The State Department has a statutory
responsibility for assisting American
interests abroad. In this particular case,
the US Government is also concerned that
these regulations may inhibit further
foreign investment in Bangladesh’s US S. 30
billion market in the developing countries
would be at stake if other countries follow
ed suit.
12th August 1982:
Report submitted by the Review Committee
constituting of 6 military doctors set up
to re-examine the matter in view of the
pressure mounted by the multinationals and
their respective governments.
6th September 1982:
The Drug (Control) Ordinance Amendment
announced by the Government after studying
the Review Committee’s Report.
AMENDMENTS
SCHEDULE I:
Ban lifted from only 1 item of imprtance Imodium (an anti-diarrhoeal).
Six other misused/abused dental remedies
reinstated.
TOTAL BAN OF SCHEDULE I DRUGS will remain EFFECTIVE 3 month
period as decided earlier all harmful
drugs to be destroyed by 12th September 198---.
.-./2 C
D-9/534-(J:l)
SCHEDULE II
^-264 eye preparations containing anti-biotic
and steroid combinations allowed (contra
dictory to the Expert Committee’s
recommendation) <>
Heptuna plus a capsule containing iron folic
acid, Multivitamins and minerals produced
by pfizer (very strangely) allowed to remain.
Ban withdrawn of total 7 drugs in Schedule II.
Time limit extended according to the
amended ordinance from 6 months to 12 months
for the drugs listed in Schedule II,
Lobbying for this so called necessary ante-natal drug for the
under-nourished anaemic pregnant woman was done by the country’s
gynaecologists headed by the President of Bangladesh Medical
Association, shareholder and member of the Board of Directors of’
Pfizer, Begum Feroza.
Facts about the Bangladesh Drugs Scene in Brief:
Bangladesh is the third poorest country in the world with
a per capital income of US & 70 a year.
That 70% of annual drug sales are of drug described as
useless or therapeutically insignificant by the British
National Formulary, the National Research Council, USA and
the Federal Drug Administration, USA.
Out of 51 products of Glaxo available in Bangladesh market
in 1980, only 17 are available in the UK and only i are
present in WHO’s list of essential drugs.
Of 31 products of Pisons available in Bangladesh , 17 were
combination of vitamins and minerals. And only 5 of these
drugs were available in the UK. 60% o Bangladesh’s health
budget is spent on drugs«
In 1981 about 1250 million taka was -spent on a lopathic
drugs in Bangladesh, but due to poverty and the high cost of drugs less than 15% of the population was in a position
to buy modern medicines.
SCHEDULE III
28 drugs (manufactured under the third party
licence) were allowed to remain. Time limit
extended from 9 months to 18 months effective
from 12th June 1982 - date of promulgation of
drugs.
SCHEDULE
Under this new schedule, 88 balms and vapours
IV
of small national companies were to be allowed
to be manufactured for 18 months with effect
from 12th June 1982.
WHAT’S NEW?
All hazardous drugs of Schedule I were to be completely
destroyed by 12th September 1982.
There is a move on by the drug companies to apply for
.../2 7
B-9/334-(J:l)
27
licence to export them to Saudi Arabia, Western Africa, etc,
via Europe. These applications were made on 10th September
with the support of Secretary of Health. The Drug
Controller has refused and the matter has now been taken
up vith the Industrial linistry. The Drug Controller has
recommended that if this move should go through, all these
products should be previously labelled saying the drugs was
recommended to be destroyed in Bangladesh: by 12th September
1982.
The failure of Sri..Lanka and Pakistan to have a progressive
drug policy has been quoted by the multinationals to sub
vert the attempts of Bangladesh Government to ban hazardous
drugs.
What is probably the most humiliating comment on the social
consciousness of Indian health personnel is that our drug
policy is being quoted by the multinationals to criticize
condemn the Bangladesh ban. Here it would not be out of
place to quote from a medical journal from Bangladesh,
6th September 1982.
In India, 43606 drugs are registered and sold. Even these
have not upset their possibilities of further industriali
zation in spite of their technological advance and
pverty .. . . ” (sic).
The above information is based on newspaper reports from Bangla
desh and elsewhere and the personal communications from socially
concerned health personnel in Bangladeshnlike Dr Zafrullah
Chowdhury.
Availability of supply of essential life-saving drugs for the
majority at reasonable cost9 should come before profits of the
drug companies. If these profits derive from the sale of hazar
dous and irrational drugs or drugs with little therapeutic value,
they need to be curtailed, and policies which allow drug compan
ies to continue producing them need to be seriously questioned.
We want a rational, people-oriented drug policy, and any effort
in this direction anywhere has our support.
As mentioned in our handout ”In Support of Bangladesh Ban” we
repeat ’’Sabotage of this ban at this stage by the application of
pressure or by money power will be a blow to all those who since
rely believe in socially relevant and socially just health care.
Consequently, this is not a question of Bangladesh’s fighting
a ’Bangladesh problem’. It is in fact a question of a higher
premium being placed on profits than on the welfare of human
beings - if the ban is withdrawn under duress. This is therefore
a move against which the public opinion of all nations, particularly
the developing countries should be raised. It is a cause worthy cf
global support specially from those involved in health work.
What would we do if we knew that the sale of hazardous and irrat
ional drugs would continue because of the pressures and marketing
strategics of the Drug companies? Would we continue stocking them,
in our pharmacies and prescribing them? We request our readers to
boycott such hazardous products, because a Government ban on them
may come too late, or never come because of vested interests.
SOURCE:-
Low Cost Drugs & Rational Therapeutics.
* * % * * * * * *-x-* % *-x-* *
« 28 -
CURBING DRUG MULTINATIONALS
Wil
Inc1!^
o 1 low Bang la oxample ?
~ by Sumanta Banerjee
Little Notice has been taken here of a momentous
decision taken by the Bangladesh Government recently«
In a sleeping new drug policy, the Government has clamped
an immediate ban on 237 largely harmful medicines, and has
recommenoed the removal of another 1500 unnecessary drugs
by the end of 19d2<>
Quite predictably, multinational drug manufacturers have
taken umbrage at the decision, and have succeeded in
pressurising the US Government to ask Bangladesh to “reconsider 11
the new national drug policy» Apart from inhibiting their
future foreign investment in Bangladesh in particular, they
fear that other developing countries might follow Bangladesh’s
exampleo world wide drug sales to developing countries
by these companies exceed $30 billion a year. It is no
wonder that they are unhappy at the Bangladesh decision«
The new drug policy of Bangladesh bears important
lessons for other developing countries and India in particular
which shares in common with Bangladesh a number of problems
pertaining to the pharmaceutical industry and people ’s
healtho According to Bangladesh’s Health Minister,
Maj Gen Shamsul Huq, the Government had to adopt the new
policy because ‘‘incomplete transfer of technology, restrictive
business practices, and purchase, of raw materials by the
multinationals at inflated prices from tied sources"
were "detrimental to our r atior.al economy'h <» • • <» » 0 0 »
The stakes which the multinationals have in the
Bangladesh drug market can be measured by some figureso
The Experts 1 Committee which drew up the new drug policy
revealed that 75 percent of the Bangladesh market was
controlled by just eight multinational companies—Fisons
Glaxo 9 ICT 9 May and .Baker 5 Pfizer, Hoechst, Squibb and
Organono Pfizer dominated the market with more than
$10 million in sales in 1961, while Squibb sold around $5
million in the same yuar. Nineteen Pfizer drugs appeared
on the list of drugs to be banned immediately including
its Stericol capsules which contain Clioquinol* Among
the 22 Squibb products listed are Quizaline tablets and
suspensions, both of which also contain clioquinol.
- 29 -
The Chairman of the Experts Committee3 Prof. Nurul
Islam9 noted that banning of these products would help
to improve health care and added s ’Nobody will die because
of the want of medicines in the country if we stick to
only 2^0 essential drugs9 including 100 life-saving
medicines ’. in fact this conforms to the WHO report of
1979 which identified about 237 basic drugs- and about
303 single ingredient formulations of these drugs which
were considered as most needed for health care of the
majority of the population.
(However9 at the request of the US administration95
Bangladesh has since revised the liw by removing 41 drugs
from the list of 237 harmful ones and extending for 16
months the production sale and distribution of 71 others)
The reaction of the foreign multinationals is significant<>
The Pharmaceutical Manufacturers Association (PM/O 5 a trade
organisation for the drug industry of the US has described
the new drug policy of Bangladesh as “precipitous" and
prejudicial to public health. It has warned that blocking
the flow of drugs from its member companies could open the
market in Bangladesh to uncertified and potentially impure
drugs from other sources□
How far is the fear justified? The Bangladesh Government
has announced9 while banning these drugs5 its policy to
encourage local industries to achieve self-sufficiency in
the manufacture of essential drugs. The multinationals
are expected to move out of the production of the simpler
preparations and use their technology and resources to
provide the more complex and innovative drugs which may
be necessaryo
A local organisation o Gonoshasty a Kendra (People’s Health
Centre) has already established a limited company3 Gonoshasthya
Pharmaceuticals Limited 9 which in 19dl began production with
two of the 33 most essential drugs for primary health care-ampicillin and paracetamol <> By 19629 they were producing
six more drugs. It is essential that more and more such
local industries are encouraged to manufacture drugs to
replace the ones sold by the multinationals.
Groundless fear
Besides9 contrary to the fear propagated by the multi
nationals that a drug scarcity is round the corner in
Bangladesh9 it must be emphasised that the Government has
not banned all foreign manufactured drugs9 but only those
considered harmful and unnecessary. Alternatives are
available for each of the drugs that have been, banned 9
including cough or pain relievers.
- 30 -
It has to be admitted at the same time that the new
drug policy in Bangladesh goes only some way towards
strengthening the local incustry5 and still leaves many
questions unanswered . in a-developing country like
Bangladesh (which is the third poorest country in the
world3 with the lowest per capita income? the lowest life
expectancy and the highest infant mortality of all the
developing countries)? more curative measures however
indigenous and inexpensive that might be are not enough.
Zi. preventive approach that will aim at removing the basic
causes of diseases (po/erty and malnutrition) forms the'
basis for primary health care in such a situation.
One still ought to recognise that the Bangladesh
Government has taken an important first step curbing the hold
of the multinationals and seeing to it that resources are
not wasted on inessential drugs. One wishes that our
government takes courage in both hands and at least implements
the recommendation made by the Drugs Consultative Committee
to weed out 22 fixed dose combinations as an immediate step?
and narrow down the number of drugs to 116 (as recommended
by the Hathi Committee).
extr ac ts*TFr6m
-4
- 31 -
BANGLADESH POLICY JJNTJE:R U.S. PRESSUE
.
US asks Bangla to relax ban on cl.rugs
- by T.v. PARASURAM
Express News service
Washington Aug 20:
The United States has urged Bangladesh to reconsider
a new national policy designed to ban hundreds of drugs9
though 70 percent of the banned drugs are considered by
the Uo Federal Drug Administration and its counterparts
in Europe to be dangerous or worthless»
The state Department acknowledged Wednesday that its
intercession with Bangladesh was in response to an appeal
from several multi-national drug companies which fear
that other developing countries will follow the lead of
Bangladesh and this could undermine their 30 billion
doll ar wo r Id m ar ke t.
Bangladesh is playing it in a low key. The economics
attache of the Bangladesh embassy in Washington said
the Bangladesh law was a good step forward? but the
review requested by the state Department "is normal and
not important". The US consumer groups do not share this
benign view of the US government ’s intervention and have
blasted the administration.
The Washington Post noted in a front page despatch
that among the drugs Bangladesh wants banned are several
that are not permitted in the US3 including clioquinol, a
c hemic a? that is known to cause serious damage to the
nervous system.
A Stat~ Department spokesman acknowledged that the
Pharmaceutical Manufacturers Association of the United
States (EMA) 3 a trade organisation of the industry 9 asked
the department to br±ng pressure on Bangladesh to delay
implementing the law9 pending discussions with the manufact
urers. The spokesman defended the US intercession by saying •
’the State Department has a statutory responsibility for
assisting American interests abroad, In this particular
US government is also concerned that these
case5 the
i
regulations may inhibit future foreign investments in
Banglad esh.
The Carter Administration had drugs or pesticides
banned in the USA would not be allowed to be exported
abroad. One of the first acts of the Reagan administration
was to overturn that rule with the result that drug
companies can now export from the US any item banned
here. There was never any ban on the manufacture of such
drugs abroad □
The us action has been condemned by several international
and us charity and consumer groups. About the latest state
Department action requesting Bangladesh to review the
ban on certain drugs 9 a spokesman for War on Want said in
London9 ’encouraging this review is certainly not helping
the people of Bangladesh’.
The Public Citizen Health Research Group9 a Washington
based organisation in a letter to Secretary of stage
George Shultz called the j department ’s action ’unconscio"
nable’. It said i ’Perhaps you are unaware that many of the
US based multinational drug companies are foisting on
innocent people in the developing countries drug which our
own medical authorities consider worthless and unnecessary
Thu group expressed <dismay ’ that the state Department had
allowed itself to be used by the giant multinational drug
companies to promote and protect their exploitation of the
impoverished citizens of unde rd. eve loped countriesThe Bangladesh government announced the new law9 prohibi
ting 'the sale of over 1700 drugs and immediately banning
237 products which are considered dangerous, in June. Among
the US drugs affected arc some made by Merck, Pfizer, Squibb,
Searle and Upjohn.
According to the members of the committee that drew up
the new Bangladesh policy 9 eight multinational companies
including Pfizer and Squibb share 75 percent of Bangladesh’s
100 million dollar a year drug market.
market, Pfizer dominates the
1OO
market with over 10 million dollars in sales in 1961 . Squibb
sold five million dollars worth the same year □
Nineteen Pfizer drugs are on the list of drugs banned
in B ang1ad esh immed iately <» They include sterlcol capsules 3
which contain-- clioquinol.
--------- ---------- Among the 2 2 Squibb products
#
affected are <_
quixaline tablets and suspension (Q and S caps)5
both of which. als_lo_> contain clioquinol. Neither Pfizer nor
Squibb would comment on the new Bangladesh law or the drugs
named in it« They obviously prefer to deal with the matter
through the state department.
However 9 a spokesman for the industry fs Pharmaceutical
Association 5 which recently led a delegation to Bangladesh
in an unsuccessful effort to secure reconsideration of the
law 3 described the new law as precipitous and prejudicial
to public health
- 55 -
PMA argued that blockinj the flow of drugs from its
member companies could open the market in Bangladesh to
uncertified and potentially impure drugs from their sources
Approximately 60 percent of Bangladesh's health budget
is devoted to the purchase of drugs compared to less than
IO percent in the USZi* Because of that Bangladesh is eager
to bring its drug outlays under control and to begin to
produce some of the less complex drugs immediately.
The Bangladesh committee acknowledged ’’with appreciation lb
the role of the transnationals but urged them to devote
their “machinery and technical know-how“ to producing
important and innovative drugs and leave the production of
simple ano cheap drugs to the domestic companies»
sources
7jT^2TT3732
- 34 -
Bangladesh situe^tion
Source/Available at
1
L INK vo 1 o 15 No o 13 May -'June
19ol (Asian Community Health
Action Network Newsletter)
>W—>•
K'
>■ >11
X7-T>..>—>■>»>>«>■<■ Xu.«^u-.,
Go nu shasthay a Ke nd r a
- a programs- report
2o Goneshasthaya Kendra
- a progress report
(Aug5 19o0)
Handout available from
VHAI5 Neu Delhi
3
Health for the Millions
(VHAI Bimonthly) VoloVIII9
NOo69 Dec ember 19<j2 SPECIZiL
ISSUE o
Bangladesh finds the
right prescription
4* Drugs in Bangladesh
L INK Vo 1 o 2 9 No o 3 9 Aug - Sept
19d2 (Asian Community Health
Action Network Newsletter)
£• In Support of Bangladesh
Drug Policy
Handout of VHAI Cell on
Lov; Cost Drugs and Rational
Therapeutic s o
6
The war against Bangladesh
- Claude Alvaros
A Rustic/vHAI publication
7o
Bitter Pills—Medicine
and. the Third World Poor
- Dianna Melrose
OXF/JM publication 19p2o
j££iian situation
1. Report of Committee on
Drugs & Pharmaceuticals
Industry (Hathi Report)
Ministry of Petroleum and
Chemicals ? Government of
India9 April 1975»
2» Medicine-as if people
mattered
Special Issue of Health
for the Millions5 VHAI?
New Delhi9 April-June 19SI
3. Aspects of Drug Industry
in India - Mukaram Bhagat
Center for Education and
Development9 Bombay
4.
Insult or injury
~ Charles Medawar
Social Audit 9 .England 9
1979
.
- 55 -
5. Health for all
an
alternative strategy
ICMR/iCSSR group
VHAI3 New Delhi
6
medico friend circle,
VHAI, New Delhi
Health Care which way
To Go
7o Bulletin of Sciences—
Special Issue on Drug
Policy
Science Circle, Indian
Institute of science,
December 1983, New Delhi.
’for ’further in form atrorT contact
lo Gonoshasthaya Kendra
P.O. Nay arhat
Via Dhamrai
Dace a 9 Bangladesh
2
Low Cost Drugs & Rational
Therapeutics Cell
Voluntary Health Association
of India
C-14? Community Centre9 SDA
New Delhi 110016
3
medico friend circle
50 Lie Quarters
Un iver s i ty Rd ad
Pune 411016
4
Asian Community Health
Action Network (ACHAN)
Flat 2a3 144 Prince Edward
Road 5 Kowloon, Hongkong
- 36 DRUG ACTION NETWORK NEWS
1)
Drug Action Network is a growing informal network of people,
professional groups, projects, consumer education groups and
activists who are keenly interested in drug use and misuse and
dng policy issues in India.
Members of the network have been and are involved in various
drug issues including campaign against EP forte preparations;
misuse of anti-diarrhoeals, anabolic steroids, .clioquinol,
paediatric tetracyclines; banning of dangerous drugs; need for
a code of eithical marketing for companies; popularising event
in Bangaladesh including new drug policy, anti-TB drug shortages
and so on.
For m-re information please write tos
Low Cost Drugs and Rational Therapeutics Cell,
Volunt ry Health Association of India
C-14, Community Centre, Sardarjung Development Area,
NEW DELHI 110 016
2)
November 1983 is Drug Campaign Month
Various individuals and ggroups, part of the Drug Action Network
and others in India will be launching; a concerted campaign this
month on Drug and Drug policy issues, For further information
contact:
a)
Medico friend circle,
50 LIC Quarters
University Road
PUNE 411 016
c)
Arogya Dakshata Mandal
2127 Sadashiv Peth
PUNE 411 030
e)
Centre for Education .and
Documentation
3 Suleman Chambers
4 Battery Street
BOMBAY 400 039
g)
Kerala Sastra Sahitya Parishad
Parishad Bhavan
Trivandrum 695 001
*******
b)
Centre for Science and
Environment
807 Vishal Bhavan
95 Nehru Place
NEW DELHI 110 019
d)
Consumer Education and
Research Centre
Near Law College
Ellis Bridge
AHMEDABAD 380 016
•f)
Lok Vidnyan Sanghatana
People's Science Movene nt
18 A J^jivan Nivas
Behind Arora Talkies
Matunga
BOMBAY 400 019
h)
Federation of Medical
Representatives Association
of India
General Secretary
IE Rajendra Nagar
PATNA 800 016
- 37 -
ssues
Bitter Pills: Medicines and the Third World Poor
Dianna Melrose
OXFZi4 Public Affairs Unit
October 1962
£4.95
Medicines can cost the poor many times their
daily wage. Many people do not have access to
drugs which could save their lives, yet in
Third World countries sale of tonics and
multi-vitamin preparations are high.
This report examines the relationship between
health problems and the sale of medicines» It
produces evidence from Oxfams field experience
and calls for greater international control of
pharmaceutical sales and promotion»
O o o
o
The G-reat Health Robbery
Baby Milk and medicines in Yemen
Dianna Melrose
OXFAM (PAU), 1981
£1.30
A study of the tragic, frequently Ratal, effects of
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Arab Republic. The Yemen case illustrates a problem
which exists throughout the Third World where Western
manufacturers exploit new markets without consideration
of the context in which their products will be used.
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BIODATA OF
Dr. Zafrullah Choudharyz
Director, Gonosasthya Kendraz
People's
Health Centre
Savarz Dhaka, Bangladesh
BORN 27th January 1941
1964
Passed MBBS with Distinction in
Surgery.
1965-71
Trained as general and vascular
surgeon in England. Returned to
Bangladesh to join the liberation
struggle and helped establish the
Bangladesh hospital for the War
victims on the war front.
1972
Bangladesh hospital transformed to
Gonosasthya Kendra, also known as
the People’s Health Centre, or the
Savar Project, in Community health
circles of which he was the
Coordinator/Director.
1974
Awarded the Swedish Youth Peace Prize.
1978
Awarded the highest Bangladesh National Award —
The Independence Aijard.
1982 Jan.
Along with his team in GK organized an international
Conference on "Transfer of Technology" and inagurated
the famous "GK Pharmaceuticals" producing reasonably
priced, essential quality drugs - run by a cooperative.
1982 June
As member of the "Bangladesh Drug Expert Committee"
was instrumental in formulation and passing of the
internationally acclaimed National Drug Policy - based
in its entity
on WHO's recommendations and concept
of Essential Drug List.
1983 April
Along with GK team organized an international
workshop on ‘Alternative Medical Education' to focus
on the need for appropriate need based medical edu
cation for a third world country like Bangladesh.
The aim being initiation of an innovative alter
native medical school in Bangladesh. Both these
conferences were also aimed at bringing together
like minded groups and individuals from the third
world together, for building mutual support systems
for demands for Rational Drug Policies and relevant
medical education.
Member British Medical Association and Bangladesh
Medical Association.
Has contributed actively to international scientific
and social journals - a few of the outstanding
papers beingJResearch-a method of Colonization",
"Tubectemy by Para-professionals",'tinder the law in
Bangladesh" "Essential drugs for the poor a myth and reality in Bangladesh."
*************
4
Health As^''31'10” of In***
Voluntary Community Centre,
C-U»
Development *rca'
Safdarjans
flew Delhi’111016,
Gonoshasthaya Kendra
P.O. Nayarhat via
Ohamrai
Dacca, Bangladesh
'KT
'A
iN®. 7
AUGUST TOO
'STH
/
*
NIZAM YAS MURDERED
WE RECOVERED HIS BODY
WITHOUT THE HEAD
\ we Wlsn^Pt^- ■>-.r
WHY CAN’T THE EXISTING LAW\?
PROVIDE JUSTICE ??
K. V
DEDICATED TO:
THOSE WHO -HAVE DIED FOR
and
THOSE WHO CONTINUE TO FIGHT ALONG WITH THE PEOPLE
INTRODUCTIi N:
Gonoshasthaya Kendra (hereaft er referred to as GX) came into being
with the birth of Bangladesh and its development cannot be separat
ed from the life struggle of the country itself-
Since independence,Bangladesh has been the recipient of an increas
ing amount of foreign aid,while at the same time,the number of land
less peasants has considerably i tiereased. ( 1) The price of food has
risen sharply- In a country where 70-80% live below subsistence,this
does not mean denying oneself some delicacy,it means that there are
millions of families who go one or two days a week without anything
to eat. In an agricultural country,a farmer without land is a dis
contented man,but a man whose wages no longer buy enough to feed
himself and his family,is a dangerous man.
The restlessness is on every side. No programme seems to succeed.
The growing deterioration shows itself in increasing banditry(repoeted mainly in the Bengali language daily),in frequent strikes,
rioting and in a general lack of willa Consequently ,30*5% of the
total revenue budget Is now spent to ’’maintain’’ law and order and
’’defend” the people !!(2)
GK ’ s ideas and ventures have often been a response to different
problems in the country as they came to be perceived in the course
of it’s work.
2/
-2The structures of the country still oppress the children of the poor.
In answer a school was started at GK for the children of the land
less. Those who take part in the vocational training programme are
given a taka(about US 7e) a day. This money is kept in an 'account1
for them Gafur came creating a ’hue and crydemanding that he be
given the money from his daughter's account ...
. y. .
The structures of the country still oppress the landless. In answer,
a credit cooperative attempting to free the landless from the money
lenders began. The members of the cooperative themselves stand sure
ty for each man or woman who gets a loan. Gafur(the same man mention
ed above) owns no land but lives on sharecropping, He paid back the
first loan received from the co-op and was granted a second. Knowing
the cooperative money is available,the landowners have raised the
price of supplying water to sharecroppers from the "government"
government
deep
tubewells. Gafur needs his daughter's money if he is to get the water. to save his crop. It is not pleasant to be hungry ...
The structures of the country still oppress women and GK’s programmes
are weighted towards them, Minu,a paramedic,was able to get work for
her husband in the Project, One day another woman and her child appeared at the Centre,saying that Minui’s husband had married her first,
but had left her without provision for maintenance for herself and
child. Minu was challenged. Had she known ? Yes,but her mother had
said she could no longer eat at home and threatened to commit suicide
if Minu did not marry this man. Minu’s mother herself,is one of three
wives,now left to manage on her own with her children - all girls.
A1er own insecurity did not allow her to consider the insecurity she
was causing another •••
Yes,the structures of the country still oppress,and it seems that
each solution GK attempts has a built-in flaw,but the attempts have
not met with failure - only difficulty after difficulty,sometimes
causing frustration to mount very high. That is why there are moments
when we wonder about the validity of the work - about the risk.
HgALTH P^OGRATIS:
More villages were included in the intensive health programme during
the last 2^ years. Mirerchangaon sub-Centre began functioning (see
Progress Aeport No.6) and the village-based health worker was intro
duced. Previously workers served the villages using either the main
Centre or a sub-Centre as their base. During this period the village
based approach was added whereby the worker stays in his/her village
home,providihg health services from there,reporting in at intervals
to the main or sub-Centre.
The Village-Based Worker: 14 paramedics began to work out of their
village homes,and this has resulted in a icloser
'
’ ’ *
' \ ‘between
relationship
the resident worker and the villagers. Three of these paramedicsj resigned when they realized village-based work was not an extended
holiday. They came from middle-class background and as such,felt ■chat
by staying in the village,their prestige was somehow reduced.
Even with the 11 remaining village-based paramedics ,the interest an 3
enthusiasm displayed when they were working from the main Centre was
lacking,but with increased supervision this was remedied. The envi
ronment , life- style and experience of group living are elements of
the main Centre which exercise a strong attraction. However,those
who have been based in the village for over a year have found satis
faction being involved not only in health care,but also agricultural
and educational work,thus bringing new inspiration to themselves and
the villagers.
3/
-3Sub-Centres: There are still only four sub-Centres in operation,but
the population/area they cover has been increased. Each sub-Centre
has two beds for emergency patients and facilities for minor sur
gery including tubal ligation,menstrua 1 regulation,etc.
Based on the concept of a community centre,activities are aimed at
drawing the villagers into active participation in various programmes health,agriculture,vocational,educational,etc. A combined staff of
22 health workers operate out of the four sub-Centres - 12 boys,10
girls,providing services to people in their homes in the surrounding
area.
Sub-Centre staff are encouraged to use their initiative in imple
menting their preventive programme. The paramedic-in-charge of Jorun
now has her team giving health/nutrition instructions in three near
by Government primary schools every week.
We are in the process of looking for land for two more Centres,. With
community centre’
c-r basic theme being the establishment of a ’'community
’ fa
our
previous criteria has always been that the people of the area donate
the land for the Centre themselves.. Experience has shown that unfortunately,the rich man :is usually the one who donates the land to his
advantage and the subsequent disadvantage of the poor whom we really
aim to reach with our services.
This is well illustrated with the example of Mirerchangaon. The do
nor of the land for this sub-Centre has 16 acres of arable land(he
actually belongs to the country's 10% of very rich farmers who us
ually have more than 50 acres,but they have trasnferred the title
deeds to their wives,sons and other relatives to comply with the
law),plus a jack-fruit orchard from which he earns over one-hundred
taka annually selling fruit. He has 3 wives,who along with his bro
thers and other relatives,own almost the whole village and as such,
virtually control the whole commuhity since the landless are depen
dent on him for their livelihood.
When construction was being done on the mud-houses for staff quar
ters and clinic area,he attempted to force us to purchase earth from
his highland,though earth was being offered free of cost by another
party, ^e next requested a tubewell free for the exclusive use of
his family from our village cooperative tubewell programme which is
meant to be exclusively for the poor with 20-25 families sharing one
tubewell•
The power strugglw was well and truly onwith this man making it ex
tremely difficult for the staff to deliver services to the poor. He
wanted his children's tutor appointed as paramedic. When this fail
ed, he embarked on a course of harassment trying to obstruct the
paramedics work,being especially rude and aggressive towards the
girls. To this purpose he used the poor village men,telling them that
unless they did as he told them,they would have no land to work. With
the memory of Nizam’s fate still very strong in their minds,many of
our senior paramedics gre reluctant to remain under this strained sit
uation and we have had to change staff several times. We are however,
encouraged by the fact that as a result of our presence,some of the
village people do speak out occasionally at village meetings.
Seven years ago,tired of the tyranny,a group of local school students
beat this man and burned his and his relatives houses in protest against his oppressive measures, However,he continues to thrive on his
•steam-roller* rule in much the same way as the Union Chairman des
cribed in ’Under the Law in Bangladesh'(previous GK publication).
Though Panishyle and Jorun sub-Centres have also had difficulties,
they are not of the magnitude of what has been faced in Mirerchangaon.
There is hope that,if these poor families can see that we offer some
alternative to this ’one-man rule',they will themsdlves organize to
protect the Centre and its staff in their own interests.
4/
^4-
On 27 July 1979tthere was a dacoity in the Panishyle Centre. 10-12 dacoits came in the middle of the night apparently to take the cycles
and Narikendra sewing machine,these being the only valuable items in
the Centre. Because of the spontaneous,large-numbered response of the
villagers on hearing the first cry from the Centre,nobody was hurt and
the bandits got nothing. For two weeks following the incident,the vil
lagers guarded the Centre to boost the morale of the workers. Villagers
later caught 2 of the bandits and handed them over to the police. They
were subsequently bailed out,free to roam at large,enjoying life in
much the same manner as those responsible for Nizam’s murder.
Insurance Scheme: Our new health insurance programme is gradually ex
panding. In our last Progress Report,we mentioned having modified the
old scheme. The new method divides the service population into three
groups of people,according to economic condition. The first priority
group is those families who cannot afford,from any source,two meals a
day throughout the year for family members. The second group is those
who have up to 5 acres of landfnot necessarily arable) and the third
group includes those who have more than 5 acres of land.
The members of the first group receive registration card free and pay
50 paisa(about US 5e) per patient/visit. Other charges such as pathology,operations^x-ray
_ .
*’
.
.
* and’ admission
1 are included in the 50 paisa.
For members of the second group, the registration card is 12 taka and
10 taka/year for renewal. They pay 2 taka
per patient/visit and also
bear the subsidized cost of other
servic
- ----- --- -- i es •
Members of the third group registration charge and renewal is the same
as for the second,but they pay 5 taka per patient/visit as well as
bearing the cost of other services at a higher rate than does the second group. This system assures that the poor will get health care at a
minimum cost,which is our main concern. In 1386 (April ,79-,8o) 4?%
of the recurrent expenditures of our health programme were met by in
surance fees.
Preventive Service: Preventive medicine (vaccines,etc,) is given free
to all. Most villages in the Project area have less than 60% coverage
of BCG,DPT and Tetanus immunization,but a small number of paramedics
have reached ?0% in their work area.
All sub-Centres do not have facility for storing vaccines. At Shimulia
and Panishyle we have our own kerosene refrigerators while in the ot
her two Centres we take advantage of occasional refrigeration facili
ties of the nearby Government agriculture centre. However,these are
not always in good functioning condition, This means that the paramed
ic must then cycle to the main Centrefin one case 18 miles one way)to
collect the vaccines and then return them at the end of the day. An
other problem affecting the vaccination programme recently has been
the frequent change of workers. Our paramedic training programme is
highly regarded in the country and at least 20% of our workers leave
GK annually to work in either Government or private organizations, The
programme was also hampered for quite a while due to shortage of vaccines available in the country.
Our Tetanus immunization of women in child-bearing age has met with
difficulties(see Bhatsala section of this report). In one survey area
where we had 1115 pregnant mothers,there were 14 deaths from neonatal
tetanus. Of these,2 expectant mothers had had 2 doses and 1 had had 1
dose of tetanus vaccine. The vaccines were not expired and according
to reliable studies,even one dose should protect mother and child.
This is confusing to health staff as well as villagers.
However.we continue to keep close records on <all pregnant women with
a special programme of visiting those at risk.> They are checked in
5/
-5the village for blood-pressure,urine,signs of anaemia,toxemia,oedema
and advised accordingly. 146 cases of eclampsia and delayed/difficult
labour were referred by the village midwives for hospital management
last year. Of these,there were 11 deaths.
Over population is a manifestation of poverty and therefore family plan
ning cannot be isolated from other social and economic problems. In our
insurance area,25*4% of married couples are active users of modern me
thods of family planning such as Depo-Provera injection,pill,menstrual
regulation and sterilization. Equally important are the traditional
methods of withdrawal,abstinence and breast-feeding which account for
another
- 10-12%.
Consequently our growth rate is one of the lowest in
the country.
Sterilization and menstrual regu7.ation are done almost exclusively by
our paramedics with a failure rate of 0,26% and 1.7% respectively,1 Menorrhagia
has pfoveh a major delayed complication of tubectomies.
It has been our observation that villagers are using abortion as a method of family planning far more than we (or planners) realize, iLast
76 cases oi
of incomplete abortion were admitted to our sick room.
year 7b
Over 80% of these used herbal sticks while the remaining used quinine
and hormonal preparationsetc« During the past year we had no prosta
glandin so most cases in their second trimester were refused. In a few
selected cases,we used the catheter method.
Since beginning the use of Depo-Provera at GK in 1974,we have had 7,358
acceptors. This was to test the suitability of the drug for Bangladeshi
women. During the period of use,our findings were consistent with tie
observations reported in the British Medical Journal of ’’menstrual
chaos”(3) and in just the past eight months,we had 11 cases of severe
P/V bleeding which actually required hospitalization. One of these need
ed blood transfusion and subsequent hysterectomy. However,histologically,the tumour was found to be chorian carcinoma.
We became worried by some of the questions raised by Steve Minkin re
garding immuno-suppression and effects on child growth in Depo-Provera
users (4). Also to date,there have been no scientific studies done mea
suring the prolactin to decide the issue of increased/decreased lacta
tion in these women.
With no clear answers on these questions and in view of Bangladesh Gov
ernment’s decision to start a national programme (as a result of inter
national aid pressure) in which there are bound to be abuses,a meeting
of our health workers in mid-November 1979 decided to stop Depo-Provera
in the Project area.
By withdrawing this method}we don’t know if we have helped our women
or not. Despite the various side-effects,they still prefer Depo-Provera
to the pill or IUD whose complications they must now face. Because of
past mis-use and no follow-up care with the IUD,there is tremendous re
sistance to this method. However.we are trying to re-institute its use.
Despite insertion in the main Centre under sterile conditions of 27
coils,there were 4 complications with 1 having to be removed.
Curative Service: In 1336(Bengali year) a total of 66,948 patients were
seen in our out-patients clinic (this is excluding treatment given by
paramedics in their village work). 1^090 were admitted to our sick room
giving a bed occupancy rate of 97*4%.
In spite of our concentration on aroup 1 insurance card holders,they
haven’t taken proportionate advantage of our clinic services. Travel
ling to clinic and waiting to be seen,etctakes up several hours of
their working day which they simply cannot afford. However,they account
for 30% of our sick room admissions,indicating they come for treatment
only when they can’t work any longer<>
6/
■ft
-6The socio-economic oppression of women is leading to increased inci
dence of attempted suicide with insecticides in our village society.
Last year we admitted 24 cases# Since the oppressed have no ’right*
to revolt or take their lives,but only to suffer in silence,every sui
cide casd must be reported to the legal arm of the oppressor,the po
lice. Therefore our statistics represent only a small number of the
actual incidence*
The following is a breakdown of some amissions to our sick room(1386).
The large number of admissions from ’o atside*$avar ’ is due to the fact
that the thana boundary XS only
mile fi'om our Centre#
.... . ......
.......
EssetMas
—.
__
Admf sSio'ns/Ceath
Savar
MInsurance
Tetanus
..
... >9 •' C- ■•■
';■
JO
Adir issions/Luath Admissions/Death
10
•<
50
5
9
4
Sdvar
Non-Ins urance
2
1
6
1
2
1
Outside
Savar
12
3
25
2
9
2
Total
24
5
81
B
20
7
= -,- = - = = == = = == =; = --== = ==■ = =:==== =7.-= = = = == a:x== = = = ==:== = =:= = =- = === = = == = = = I: = =.
Abrotion
Admis gions/Death
Preg Problems
Eclampsia
Admissions/Death
Admissions/Death
Savar
Ins urance
24
12
Savar
Non-Insurance
15
7
4
5
Outside
Savar
57
18
6
10
1
MA M,**..
Total
--- = = — = = = = = —= = = -. = _= = =76
=
. C'j -u
11
1
,
1
<7
10
26
1
= == = = = = = = ======= = = = == = = = ==:= == = = = = = = = = = = = == = =
'IC
Water and Sanitation: ;Mer;ccnsidered a
unavailable to many in rural Bangladesh#
wells,tanks and rivers which 'are usually
estimated 633 000 acres of land lying in
country.
’natural* element by most, is
Drinking water is mainly from
contaminated. There are an
derelict ponds throughout the
Our lobon-gocr sorbhut(common salt and noiasses) programme has reduced
the death rate from diarrhoea among children,but not the incidence of
diarrhoea due to the absence of clean water and sanitation facilities.
In our effort to supply both clean water for consumption and increase
production of fruits and vegetables around the house by irrigation,
the hand-pump tubewell programme came into being as part of the agri
culture extension^
In liason with UNICEF,Government has given hand-pump tubewells to many
villages. However, the major:-have been situated on the rich man’s
property,resulting in limitation of its use, Also,no reliable provi
sion was made for maintenance resulting in a common item in the Ben
gali daily payers being the fact that a. largo
number are out of
order.
7/
-7In our programme one tubewell is to serve 15-25 families(none of these
having either private or Government tubewells on their homestead). The
tubewell is donated by UNICEF but the digging and platform expenses
(not more than 500 taka) are borne by the family members the well will
serve. A committee,made up of the various family members is responsi
ble to see that 100 taka is deposited (and this sum maintained at all
times) in either the bank or post-office for the maintenance of this
tubewell. All who use the tubewell must contribute equally to this
fund,otherwise we are likely to run into the same system we are trying
to overcome of one (rich) person bearing the expenses and thus holding
the power over who can use the water supply.
We
?Ze provide a wrench and training for small repairs to one of the mem
bers and money for necessary spare parts is taken from their 100 taka
fund. None of these tubewells are allowed to remain out of order for
more than 43 hours except in the case of resinking necessitated by a
shallow water depth. So far we have helped install 12 tubewells on
the above conditionsc
There is also a dilemma regarding the type of latrine suitable for vil
lage environment. Both the pit and the water-seal latrine have diffi
culties and limitations. The pit must be dug to the proper depth,other
wise it is merely a breeding ground for fly-borne disease. The water
seal type needs adequate (2 gal,) water for flushing and in most places
this needs to be carried a considerable distance.
As far back as 1958,WHO reported the unsuitability of this type of la
trine (” .
r
. . «►*
they are often used as chicken coops or grain
silos") (5),yet UNICEF continues to promote its use in Bangladesh, pre
viously they used the concrete slab method.but more recently have im
ported 4,000 highly flammable plastic-type latrines. If they are goii.
to continue using it,a better alternative would be jute-plastic whic.i
would be cheaper and more durable.
For the last 2 years we have been experimenting within our Project; co:?.pound with a type of latrine which is commonly used in Vietnam (6) The
purpose of this type of latrine is to make use of human excreta as a
manure fertilizer. The object is to keep the waste matter dry,adding
ash and leaves to the box contents at ' .e cad of the day to create anorobic conditions. When properly done,this waste becomes black in 5 6
months and can be used as fertilizer, However,if dry conditions are
not maintained during use,the box fills with maggots and flies. We
have used the manure from two of our latrines in our agriculture fields
this year for growing vegetables with good results*
We have 8 such latrines in our Froject,situated in such a way as to
be utilized by a variety of workers and we have observed the mainte
nance of the latrines is according to the health consciousness of the
various workers. The main problem lies in the cultural tradition of
using a good deal of water to wash the buttovks. With this latrine,
the cleansing cannot be done over the same hole where defecation has
taken place. Our experience is,a good bit of health education is nec
essary for people to understand the principles involved in the use of
this latrine.
The Chinese have adopted a modified version of this latrine(7) which
may become the ideal for use in rural villages. We plan on introducing a modified version of the Vietnamese latrine into the villages
where our extension co-ops are operating. Sanitation has to be done
in conjunction with water supply. We feel the ideal programme will
to provide a hand-pump tubewell within a few yards of whatever form
of latrine is used,otherwise a truly hygenic situation will not exist
when carrying water great distances is involved.
8/
- -
-8TRAINING PROGRADE
Some years back GK began to consider the possibility of utilizing its
staff,buildings and health programme as a field practice training cen
tre the intent being to bring greater relevance to medical training in
the country. It was not until 6 May 1978 that the Syndicate of the Uni
versity of Dacca finally approved the programme and due to further de
lays originating in the Institute of Post-Graduate Medicine,alternative
nrogrammes involving groups ranging from illiterate grass-roots workers
through graduate physicians holding Government posts were inaugurated.
I.R.D.P,Co-Operative health Worker:
303 thanasfan administrative unit
comprising 150,000-300,000 population) are under Government’s Integrat
ed Rural Development Programme (IRDP). 28 of these have women’s co-op«
eratives. One course was designed (8) to train 120 women of these co
operatives from 12 thanas. At completion of the course they were to act
as health workers in their respective villages.
The first programme began in August 1978 with 10 women coming to Savar
GK and 10 to Dhatsala GK(our Project in Jamalpur) for an initial one
months training period. Instruction during this time included general
health with emphasis on maternal/child health and the treatment of our
diseases commonly found in Dangladesh villages - worms,seabies,diarrhoe.
and simple fever. On completion of this months training,the women re
turned to their villages for 5 months to put into practice what they
had learned. During this 5 months they were evaluated by a team of GK
staff,usually 2 paramedics,or 1 doctor and 1 panamedic when this was
possible. The object of this was to see how much the women retained,to
identify the particular problems they had to contend with and arrange
the subsequent training accordingly. It was encouraging to note that
though 54% of these women were completely illiterate, they retained
/o
of the material they had been given.
Returning to the Centres for a further months instruction period there
was review of what they had been taught previously as well as intro
duction of 2 more common diseases. This was again followed by 5 mont s
in their villages. The third and final months training was then given
in the various sub-Centres. Familiarization with the vaccine programme
as well as another 2 common diseases were incorporated into this peno .
Most trainees were married women between the ages of 17-50 witht a mean
""They had 0-8 living children (average 3).These
average being 31 years
women were enthusiastic about the training and about learning to ride
bicycles, This indicates that given time,certain orthodox social barriers may be broken.
In the process of
Needless
Needless to
to say
say there were problems to contend with,
selecting which women would receive training,it' was again the families
of position and power• who dictated. They realized the relatively sub
"
j it a certain imporimpor
stantial training period attached to the work gave
tance and prestige and there was also the small remuneration to
o bee
borne in mind. Consequently they promoted candidates who^though more
obscure and oppressed in the villages,were nonetheless often their
relatives .
There was also a reluctance on the part of IPDP's supervisors to go
-supervisory-activities.
into the field to do their■ supervisory
-activities. They
1 ney (
I supervisors
super vx^x o ),
had only one weektraining
week'« training for the entire women'’s programme and us •
than the health programme. A
ually gave priority to :interests
--------- other
--lack of interest in and understanding of,the problems facing these
trainees can result in serious problems, Such was the case of one young
trainee from Gopalganj tnana.
moral standing in the community
Rumours
Rumours were
were started to discredit her e Women’s Programme from Dacca
which finally led to the Advisor to th
the actual facts.
undertaking an investigation to find
i--- out
-
9/
-9The IRDP worker,Nurjahon was a lively,outgoing young woman from a poor
family. Her father was an old man and there were no brothers to earn
wages to keep the family. NurJahon had been married to a day labburer
from the local mill who was eventually approached by his foreman with
the proposition to marry his (foreman’s) daughter in exchange for an
assurance of a permanent job. Naturally this meant leaving Nurjahon
and her two children on their own and she,as the woman,whs immediately
presumed ghilty. r,If her husband left her,she must be a loose woman”.
To supplement her IRDP volunteer work,she found it necessary to obtain
paying employment* Seoauee of her training,she was able to get parttime work in family planning. Unfortunatelyttho IRDP Project Officer
regarded this as something a ’respectable* woman would not be doing.
Neither had NUrjahoM taken her ’permission* for work other than I3DP.
When questioning the ^i-llage elders Me to NurJahon1 s behaviour,they in
formed us that not only did she net wear her aari oter her head,she
didn1! even step off the road for them when they were passing her ! Ap
parently her experience at GK had led her to believe that they also
might give way sometimes.
The facts of the ease then were: Nurjahon was poor,her husband had left
her with two children and she was doing family planning work, However,
because she was poor,she should have been cow-toeing to others and in
defending herself,became a ’loose' woman.
Eventually her innocence was proven (9),but undoubtedly she will re
tain her ’title’. Thus a programme designed to liberate women seems to
have brought further oppression,setting them against one another*
will surely not be an isolated case in the annals of IRDP and who is
going to travel the country investigating and rectifying even the rela
tively few instances reported ?
The question was raised at one GK staff meeting ’who does the IRDP
really benefit ?• Sadly enough, ”... it(iaDP) does little for the land
less and near landless who comprise nearly 50% of the rural population”
(10),seems to be a quite accurate response.
Medical Students ’ Field Programme: A further training was offered to
the undergraduates of three Medical Colleges in groups of 12-1^ (cur
riculum available at GK). Initially the Health Ministry,which -as close
control over medical education,did not include female students for fear
that they ’’wouldn’t be able to manage life in the villages’^. However,
at our insistence they were included in the 10 day periodlwhich we felt
to be frustratingly brief).
In the morning®Tstudents made visits to the villages and interviewed
people regarding their health problems. Afternoons were spent discus
sing the visits and possible methods of treatment for common diseasesAt the conclusion of the course,each group was of the opinion that the
education they were receiving in Medical College is not designed to
equip them to deal with the diseases of rural Bangladesh. The 15 grouos
who did the course,have since established study circles at their re
spective colleges. One particular group challenged the idea of the an
nual 3-week tour of establishments in the country which is part of the
college curriculum (usually found to be an extended picnic). They sug
gested that instead,students be divided into small groups and spend tl
entire period in an area of the country which had a specific health
problem,such as the tea gardens,mills,etc,,coming together later for
an exchange of experiences. However,their idea was not accepted.
Though the curriculum had been submitted before the course started to
the health Ministry,once the programme was completed,complaints began
arising -from the teachers of the Medical Colleges. Studentstthey said,
were asking too many questions. Initially,some of the students also
complained of being ’brainwashed ’ by the GK training staff,though this
’brainwashing’ consisted of nothing more than a realistic exposure to
10/
-10the health situations of their own country - who receives treatment ?
who cannot receive it ? why ? Does the background of medical students
make their effective involvement in change impossible ?
The training formally started on 28 October 19?8 with the following
number of fourth year medical students involved:
Dacca Medical College
Rajshai Medical College
Salimulla Medical College
51 male
31 ma1e
29 male
28 female
19 f ema1e
10 female
111 male
57 female
total of 168 students
Post-Graduate Doctors Field• Programne
:r From February through May of
1979,the field practice and dissertation section of a course leading
to a Diploma in Community Medicine was conducted (curriculum available
from GK). The course itself is run by NIPSOM(National Institute of Pre
ventive and Social Medicine). 10 graduate physicians,some health admin
istrators ,others clinical medical officers in hospitals,attended. They
came with the impression that by studying material available in our li
brary , previous case studies on rural health in Bangladesh and inter
viewing our health workers,they could fulfill their research work/ob
ligations. Uning this method,they could commute daily from Dacca. How
ever,after discussion of methodology,etcthey realized the value of
remaining in the Centre and working out of it to obtain their informa
tion. The first week,they found the life-style of the Project difficult
to adjust to and 2 actually left. The rest persevered. In the intro
ductory week they were taken to the villages to become acquainted with
the situations there. After this,they discussed their possible choice
of thesis topic with Dr.Colin McCord,Dr.Qasem Chowdhury,and others re
sponsible for the GK section of their course. Mornings they spent col
lecting data from the survey areas anc evenings discussing health needs
of Bangladesh.
As a whole,these post-graduate student! found the course useful,out ix
it is to result in more than an award-giving ceremonial,adding another
paper to their »qualifications',the health Ministry and those direct
ing the course at NIPSOM must be convinced of its value so they can be
supportive in following up and translating what has been learned into
practice.
It was agreed before-hand that the NIPSOM Professors would spend at
least 1-2 days with the students both here at the Centre and accompany
ing them to the village, However,only sne or two Professors actually
ever came and this only for a few hours one day. This is probably due
in part to a lack
---- -of interest and partly, to low teaching salaries foreing them to take on private practice in the afternoon/evening• It seems
imperative that if a programme of this type is to be successful,the
teaching doctor must receive a salary enabling him to devote his full
attention to that one job.
Having seen the fate of the first group., only 2 students of the same
course for 1979-80 are training here st present and will be with us
for four months. Students pursuing other courses at NIPSOM are com ng
for variable periods to get experience in specific areas.
UNICEF Health Workers Programme: In a recent seminar,one senior Bangladesh Government official rather sarcastically remarked that thanas^
are rented out to International Agencies for ’development*. So,UNICES
is working throughout the country in 20 district-level offices. In con
nection with their nutrition programme.40 workers,selected from 20 vil
lages were trained to provide
health care in addition to nu
trition education. These trainees,mostly young men of middle-class
background,came in groups of 20 and were give^i a 3 month training
course from May to November 1979. UNICEF is carrying out the supervislop of their work and GK is not involved.
11/
-11-
To link up with the health/nutrition programme,16 traditional midwives
from the same villages as the UNICEF trainees have just completed a
training course at the Centre. 50% had never attended a delivery in
their life(see Table below) which fits with the UNICEF tradition of
so-called TBA(Traditional Birth Attendent) training in the country.
Number of T3A.
&
8
b
Tota?^ Number of Deliveries
nil
less than 20
more than 20
For the last year the health and Family Planning section of UNICEF has
been conducting training with the allurements of special ’’dai” (T3A)
kits,expensive colour*brochures and an allowance. As we were aware of
the fate of UNiCEF*s past training programme^i960•s)twe gave our un
solicited opinion of what was likely to happen with this approach. Un
fortunately t they organized the program ie in such a way as to include
the rich man’s wife and daughter wno cire often more concerned with
dressing well than with the service they are to deliver. When this hap
pens , we ask ourselves, ’what are organizations like UNICEF, who have a
universally respected reputation,really working towards in our country?’
Adequate and appropriate reference material to fall back on is also an
important part of any training programme. In this respect we are indeed
indebted to Dr.Jack Lange of Lange Publications,DrvCharles Spencer of
Australia -and Inter Pares of Canada for their generous contributions
to our medical library.
NARIK3NDRA - C^NTag FO^ VOi-^iPS VOCATIONAL TA Al KING
.iThen GK’s vocational training programme began, we decided that one un
acceptable arguement would be that which depicts women as creatures
with greater limitations than men. Narikendra activities are based on
a simple philosophy that includes fundamental literacy classes and
other teaching in broader terms which can help them understand the
causes of their own underdevelopment and what to do to bring about
change. Unless this happens;they will still be tied to a male-dominated,
class society. Now,with the programme well underway,the young women in
volved in our Narikendra have proven themselves to be equally capable
with men in all worK,manual and mental» The many visitors who have come
as unbelievers filled with traditional arguements in regard to women’s
work,have gone away with a new perspective and hope.
With the growing Government policy of exporting skilled labourBangla
desh is gradually finding itself in need of craftsmen. Narikendra has
capitalized on this need and initiated a number of training programmes
with primary emphasis on young women. These include a metal-working
shop,carpentry,sewing(still much the field of men in Gangladesh),shoe
manufacture and a bakery.
Gono Shilpalaya (People * s Workshop) : The metal workshop has 22 trainees 17 female and 5 male. The trainees are classified as skilled and un
skilled. Skilled workers can cut,straighten and weld. They are also
able to understand the drawings enough to follow the measurements,ecc.
themselves. In short,they could earn money with the skill.
The workshop has been supplying the nearby army Cantonment and Atonia
Energy establishments with various construction items. Now our woric^rs
at the monthly meeting have questioned the validity of this,but the
workshop staff felt their own needs - the possibility of contracts
meant work,pay and further opportunities to perfect their skill. They
were not secure in the belief that more work would come if this was
turned down,so continued ~ probably using the same logic that allows
a landless sharecropper to work for the oppressive landlord.
12/
I
9
-12-
The staff can produce for competitive marketing: hospital beds,simple
operation tables,revolving chairs and pipe frame chairs,electrical junc
tion boxes,window frames and grills,steel racks and certain agricultural
implements.
?or the successful transfer of technology from our Centre to tae village
it will be necessary to have the workers exceptionally well trained and
this takes time. It is one thing to learn a skill well,but another to
run a competitive business. Therefore the expansion of our workshop pro
gramme has been deliberately delayed to assure that the workers,once ial
ly competent in their trade,will be able to face competition in the open
market•
There are a number of polytechnical schools located throughout the country. However,since their funds to purchase materials for practical work
are very limited,the curricula have become increasingly theoretical which
lakes it difficult to use these 'graduates' as trainees in our shop.
?or the exnansion of industry into rural areas,even on a small scale,
there will have to be a clear-cut Government decision in its support.
Jhile developing such,Government will have to give preferential treat
ment to the poor and find ways to involve them in inanagement and owner
ship of these industries,otherwise any rural industrial programme will
be simply another tool for widening the gap between rich and poor.
> eThis will be picked un by aid agencies to stabilize the hold
___
_
_
__
_____
Alexander
Kamilton(a
founding
father
of
the
US
lite who,in the words of
constitutional government),”must maintain control over the ’turbulent
masses'”. At present USAID lias initially committed 3 million dollars to
a rural industries programme in Bangladesh. The beginning of the green
revolution in a different shade ?
’
a.
_
sin
Other Narikendra Activities: Jood-work was added to the
programme
1979 and is already growing. Now in 19fi0 there are 2 trainers with 6
girls and 1 boy training. 2 village women also come daily to learn this
skill. The products include all types; of
c_ wood
---- -furniture with the neces7e
hope
to
expand
this programme as skilsary cane work and finishing,
led carpenters are badly needed and it could be a good source of earning
for women.
At present the market for juteworks within the country is very limited
and this unfortunately means we have to depend on foreign outlets, ihe
future of jutework is at the mercy of Government and unless tney promo
cottage industries within the country itself, there is little chance oi.
progress in this field.
In view
view of
of the
the above
above it
it is
is understandable that there is not always a de
mand for the jute products we could be producing and this in turn means
less income for those skilled in this field. However, financial gain is
not the aim of the programme being promoted and1 we have seen these women
of their exposure to
make great strides in other directions as a iresult
—
Narikendra.
Amena,the daughter of a poor man,the wife of a callous,even cruel husband and the mother of 3 children came to Narikendra to find wont, She
was trained in jute handicrafts and sewing and
--- - received classes in literacy,faJily planning,health/nutrition and childl care. She received a
small salary. In the meantime her husband, a rickshaw puller,gambled his
own pay,gave nothing to tie! household and beat his wife. Gather than
the potential
crumble under this,the
potential of
of Amena
Amena was
was realised. She decided to
••
•
Since he is a poor man,
leave her husband and return to her father's,
giving
half her salary(100
she left her children in her husband's house,
remainder
to
her father's housetaka) each month for their care and the l---hold.
number of women in
One day A^ena approached1 us to say that there were a
/Jhat
could be done
her village anxious
<------- to receive training as she had.
Centre
made
it impossible
for them ? The distance from the village to the
13/
-13for the women to come to us,but we gave Amena the assurance that if she
could organize and instruct them,we would guide and assist her. :4ith this
support , Amena proceeded. She now has 50 women in this group, training t . e.
not only in handicrafts,but also motivating them to self-awareness and
self-respect .
In 1979 Amena with 22 other women of Dapushai village branched out into
bamboo craft, Bamboo is locally available and,unlike jutework,also loca1ly marketable Vith GK backing,they started their own co-operative,run
ning it themselves and marketing their own goods. The idea was thought
crazy at first and some of the local men objected and tried to make
trouble. However, thos e who wsre benefiting by the women’s work banned
together to take care of the trouble-makers. The bamboo co-operative is
now a going concern with advance orders,
These women’s paths will continue to be filled with obstacles for in
this society they cannot move easily,but they are meeting opposition
with courage and purpose.
GONO PADUKA (people's Shoe)
GK’s shoe factory,a venture in rural industry,started in early 1978 as
a joint co-operative of skilled workers. It was a response to 5 young
men,skilled sandal-makers from Shairab in Mymensingh Distriet,approach
ing us for something different after having worked nearly 13 years in
the trade. The joint co-operative between workers and GK Trust offered
them the opportunity to become managers in their own business.
Oxfam(UK);through GK Trust,provided the initial capital and recurrent
expenses. Once profits were forthcoming,they would be used 1/4 for re
payment of the loan,1/4 divided to the workers and the remainder back
into capital.
Included in the programme was a plan to train 5 villagers,women among
them,in the skill. These could be considered ’skilled’ after a minimum
of 2 years training and thus be eligible* for inclusion in profit sharing.
A number of difficulties have arisen since the initiation of the pro
gramme. First we came up against the trade practice of retailers who,
though quite willing to pay the given price for shoes,would only buy if
the receipt recorded a smaller amount than actually paid. This was to
evade Government excise duties. Gono Paduka workers felt we should go
along with this accpeted marketing (mal-)practice and found it difficult
to accpet when we did not. In an attempt to tfell,we put a display shop
outside the GK compound next to the Canteen. Though we can’t claim any
great financial success,it has spread the reputation of Gono Paduka !
Though they had agreed to train villagers beforehand,the workers found
a problem in accepting girls as co-workers. Then too,these trainees
meant a potential wider distribution of profits ! There was also agri
culture work,a must for all GK staff. Though they were all from agricul
tural backgrounds.they felt that possession of a skill lifted them above such ’degrading’ work.,
Another difficulty was in the type of shoe manufactured. Our aim has
been to make an inexpensive sandal for a rural population. This also
meant a market of limited spending power,while the workers were accus
tomed to producing a more expensive shoe for a rich,urban population
with hopefully more profit.
Initial enthusiasm dwindled as these various problems presented them
selves and solutions were not seen eye to eye. Eventually these 5 work
ers began to doubt if this was wl at they had intended. 3 left to find
regular work elsewhere,a fourth,who was co-signatory of the bank account
slipped away one night taking far more than his share of the funds. In
spite of the odds,Gono Paduka is struggling on - destination uncertain
at the moment.
14/
-14GONO PATSHALA (People's School)
One of the reasons for the low rate of school attendance among children
in Bangladesh (Government statistics say 40% never enrolled) could well
be due to the fact that parents do not want to lose the valuable contri
bution that even little children can make to the home through manual la
bour , particularly by caring for younger family members and watching the
family's animals. Like children of Java and Nepal (10a), Bangladeshi chil
dren spend up to 8 hours of their day in domestic activities,girls spending more time and starting younger,than boys, Often the four-year old is
responsible for minding the two-year old as well as seeing that a fox
doesn't harm the chickens. At the same time he/she may have to keep an
eye on the rice that is cooking as the mother is busy elsewhere grinding
spices for wives of rich farmers.
Our school began 3 years ago,selecting its students from among the chil
dren of poor and marginal farmers and offering a curriculum relevant to
their needslsee Progress Report No.6). ?or each child who attends the
school,a real effort must be made,both by the child and parents. Tasks
that were being handled by the new student must somehow be picked up by
another family member,but often this is not possible. So the child must
manage to combine his family chores with his school work - carrying along to class a three-year old sister/brother,or collecting cow dung on
his way back home. Reaching there,more jobs will be waiting. As the chi?d
gets older,tasks at home increase and the chance of having to leave the
school is greater.
If we want these children educated (and their future and that of the
country depend on this) ,we have to acknowledge that the time they spend
at class is of value to their economic situation and must be compensated
for. Therefore their 14mch is provided as well as a nominal remuneration
to those engaged in vocational training.
At the school,classes are held 5 days a week instead of 6 as at the Gov
ernment schools. This is so teachers may spend 1 day conducting classes
in the villages. Older students are also obliged to hold classes in the
village for those who cannot come to the school site. Perhaps this is
an indicator of the form that the school will gradually assume - the
building may serve as the initial training ground with some students
staying longer than others,while the village becomes the accepted site
of a regular school programme.
The philosophy from which the school operates isi one of educating the
children for their own community. At the school,individuals are members
of a jgroup and proceed at the pace of the group,helped by it when they
drag behind,or helping if they are ahead.
The school is specifically for the children of the landless and margi
nal farmers who otherwise have no opportunity for education. Because of
this,admission was refused to the children of the wealthy families in
one village in the area. When refused,they put economic and social pres
sure on the families of the poor whose children were attending ,resulting
why do these rich families want their chil
chil-
in 7 having to stop coming.. Why
attend
when
they
know
well
the
only
participants
are
of
the
poor
dren to i
est class,they must all do agricultural work,eat together and the classes
are not run on a formal graded system,but functional basis ?
All Government schools are controlled centrally from Dacca rather than
locally. This results in very poor• teacher-attendance as no one bothers
Gono Pat shala, with all its seeming drawto check what is happening. So",
1
attraction of teachers on the job.
backs,does at least have ithe
-- ----10-12 year olds in the school are introduced into vocational training
for 2-3 hours per day. Presently 4 are in carpentry and 6 in metal works,
After 2-3 months training,they are capable of doing effective/productive
work and this is acknowledged by a small remittance which is kept in
their own savings fund*
15/
DECADE OF WOMEN
1’
Skilled worker of Gono Shilpalaya
Students help each other
Literate child shares
with mothers
tei
«
) 'I i:
-Ij "'it'
•
■
■•»
,
• -
: il4.
I =■
,‘™*“
^OfT-W
uMr-
w
y
-VwrA
•' *
Jt
b'
F. JL.V
<
1 |
Vocational training as
■
part of Gono Patshala
■V
’TV..
QflK
<4
■’
La. btClvvL*®
1
Narikendra girls at work
;
Passing on health education
IS
-S’ iWu.
■wOM
Si
Our Canteen is also staffed by girls
Paramedic giving spinal anaesthesia
Depashai bamboo
co-operative
members
■^1
-^%:/Z' ////7)
fV
■ <xj8
..... "W
Gono Paduka
‘‘struggles on”
F-
- has<^
tf*’’ Ij
fc’-G
O’
-
■ •'
w
Groundwork for fight against drug exploitation
Agriculture extention meeting
-15Another project they are engaged in is poultry breeding. Foreign bred
hens,while laying more eggs,need special food and are less disease-re
sistant than locally bred. The children are presently using an fXustrc
cock with a locally bred hen. Eventually these birds will be 25% foreign75% local breed mixture which,while having an increased egg production
of 3O“5O%,willjstill be able to live on local feed.
The children are taking the new chicks of about 12 weeks home to raise
on the condition that when their chicks hatch,they will return 2 to the
school for other students. This also encourages in them a spirit of co
operation which is so essential in village life.
To date the school has had 218 admissions with 46 drop-outs , derailed in
the following Table:
1
1384-1386(3.5.) Total Admission
»
\Continuation ]
April 1977 to
April 1980
Drop-Outs
years age
*
Boys
Girls
; Boys
103
115
• 89
Girls ] Boys/Girls __ Foys/Girls
83
172
218
Total
9-12 years
;
1
6
26
13
39
7
Land Holding of Continuers and Drop-Outs
Continuers (172)
No Homestead
Homestead only
Under 50 decimals
51-67 decimals
67-100 decimals
Over 1 acre
♦
100 decimals
Drop-Outs
(46)
14
81
47
5
29
6
4
15
10(2 from Porject)
2
5(all from Project)-
’X
1 acre
Fate of the Drop-Outs
1.
2.
3.
4.
5.
6.
7.
8.
Care of domestic animals,firewood
& cow dung collecting,looking af
ter home & small children
Became servant
Day labourer/assistant
Watering paddy in the rice husk
ing mill
Got married
Working in Narikendra
Miscellaneous activities
Death
Boys
2
Girl s
17
8
3
1
3
1 *
3
4
3
1
* working as a cowboy at GK
In spite of dropping out,17(5 boys and 12 girls) still continue occasi
onal’ classes in the village and are in touch with the school. Another
4 girls working in Narikendra attend functional literacy classes condu c t e d for GK staff •
The school links up with problem^/struggles of the daily life of these
children. Gurs is a pilot scheme going on with an as yet, untrritten cur
riculum. We are still using standard textbooks which in sections are
quite irrelevant. The writing of our curriculum and textbooks is now im
portant as there is an interest in the system in the country, However,
16/
-16-
one of our main difficulties has been in attracting and holding teachers
capable of working with this new approach, 16 have come and gone since
the school’s inception. Since the school itself seems determined to suc?;ceed,we have hope that this difficulty will, in time, be rectified.
GONO KRISHI KIIAMAR(People *8 Farm)
85% of the people of Bangladesh make their living on agricultural pur
suits. It is theref or e, no t an exaggeration to say that the fate of the
country depends on agriculture and for this reason,agriculture continues
to play an important role in our development activities.
The relation between the land owner and the producer is a main source
of conflict and any programme to bring about change cannot function with
out acknowledging this conflict. To understand this and participate in a
transformation of these relations,is the basic aim of Gono Krishi Khamar.
Many fail to understand that agriculture is a highly skilled technology.
The farmer(along with his wife and children’s contribution) is extremely
underpaid for providing this vital technology. We feel the only way for
those not actively engaged in this task to understand to some degree th^
exploitation involved,is by a programme of minimal participation. This
is the rationale behind the mandator)'- participation by all GK staff in
the Projects internal agriculture programme. An additional aim is to try
and develop new ideas for improving production and labour technique.
The Project cultivates HYV(high-yield variety)rice,vegetables,nursery
seedlings and has 3 ponds for fish cultivation. Our average paddy(rice)
yield over the past two years has been 51 maunds(27 maunds = 1 ton) per
acre,but last years crop was not up to expectation due to draught.
A once green Bangladesh is rapidly becoming barren and we are trying to
promote re-forestation.
Apart from our own use,our nursery sold over
1500 seedlings to local farmers last year.
On an experimental basis at the Centre,we have 1 large and 2 small ponds
for fish cultivation.-We initially tried to cultivate Rumi fish in these
ponds,but with frustrating results. After consultation with the Fisher
ies Department,we are again trying to raise Rumi and Migel species. Nei
ther has our production of Nylotica fish been up to expectations. We ar
now trying to cultivate Nylotica fish and paddy in the same field. More
than 1/3 of our land,due to the level it lias at,is suitable for only
one crop a year. However,if this land is dammed up,it can be used during
the rainy season for a second rice crop and it is in this field that we
are putting our ’third’ crop - fish. If this proves successful ,we will
try to introduce it into some of the villages in Savar Thana next year.
For cultivation of HYV rice,a good deal of fertilizer is required, This
involves us in the controversy of chemical versus organic methods, Ecology groups promoting natural fertilizers are going to the extreme qof
likening the use of chemical methods to cancer being introduced into the
soil. Chemicals also pollute the water making it hazardous for human use
and killing fish. Then too,developing countries are dependent on multi
nationals for the supply of chemical fertilizers and this further, extends
the chain of exploitation of the poor who cannot afford purchasing this
without borrowing from the money-1end ar.
On the other hand,organic methods not only improve the soil,but make use
of waste,thus improving the environment The problem with this method
lies in the amount of composting needed,the resources for which simply
are not in the hands of the poor. Thus it has been necessary for us to
experiment with the use of natural fertilizing in our Project cultiva
tion before we can promote it in the tillages.
Last year we did a trial on a 4 bigha(1.33 acre) plot of HYV rice using
only natural composting. The yield of this plot was 15.5 maunds/bigha as
17/
-17compared with 16.7 maunds with chemical fertilizer,so it definitely com
pares favourably yield-wise. We have not yet analysed this grain to see
how it compares in caloric/nutrient value. The kernels appear bulkier
than that fertilized with chemicals,but there is no difference in the
taste. The question is how to ma! e this a practicable method for the poor.
When using chemical fertilizer,60 kilo/bigha is required as well as in
secticide. Natural fertilizing requires 1000 kilo of composting and 1000
kilo green manure(cow dung),but no insecticide,for the same area. Com
post is bulkier than chemical fertilizer and due to its lower concentra
tion of plant nutrients(nitrogen,phosphorus and potassium content of
chemical fertilizer is several times that of natural) needs a much larg
er quantity. However,it is estimated that up to 1/3 of the chemical nu
trients are lost by leaching to the water,whereas the nutrients of the
natural fertilizer are gradually released into the soil. This means that
with repeated use,in 4-5 years time the amount of natural fertilizer re
quired should be much less.
In the final costing analysis of our trial,the chemical method(including
insecticide) amounted to 150.taka/bigha whereas the natural method was
425•taka/bigha(375•taka being labour cost). The natural method was cost
lier,but weighing in the balance is the improvement in soil quality and
employment possibility when one considers that for 5-7 months of the
year,many labourers in Bangladesh are un/underemployed. We feel there is
no question the natural method should be promoted. The question is ’how’
in the present land ownership situation ? Where does the marginal farmer
and sharecropper get the necessary materials,access to water sources a~d
space needed to do this composting ?
When our paramedic(late)Nizam was starting our loan programme (early
1976),opposition was not unexpected,it was merely a question of what
form it would take. The first group to accept our offer and terms num
bered 11 men. A few days before they were to sign the papers and receive
the cash,a young man(the son of a rich farmer) who had been a volunteer
in the early days of the Project came to call. He told us what a fine
thing we were doing,but didn't we realize the people we were giving the
loan to were so poor they would probably spend it immediately on food
and there would be no crop and no return of the money ? It was in this
regard he would like to offer his ’assistance*. 'We could give the money
directly to him. rle would stand collateral and be responsible for col
lecting what he could on the loan when a crop was in, but the amount he
didn’t realize would be his ’contribution’ to the programme. Just one
other small point - he would like to add another two names to the list
of loan recipients.
A number of the Staff on first hearing,thought his offer most generous.
On further discussion they realized it would be an excellent means of
perpetuating control over these poor men and the inclusion of his addi
tional 2 recipients (relatives with no need of this type of loan)would
give him the necessary ’in’ to the co-operative decisions.
The following day we went to the village to have the papers signed and
give the money,but no one turned up to accept ! The stories the villag
ers had been told, came together in pieces - ”GK runs a health programme,
not an agriculture d>ne and while they might give you money this time,
what is the guarantee there will be a second time ? The money-lender is
always here and it’s best not to offend him by turning down his assis
tance, even this once.” ”GK has already acquired land for their Project
which they say they want to expand further They want you to put your
thumb print to a piece of paper which you cannot read. How do you know
they aren’t out to acquire your land also ?” ”We villagers are one com
munity and should stick together without letting outsiders interfere in
our affairs.” And the final assault - ’’Who helped you bury your father
when he died ? It wasn’t GK,was it ? it
Needless to say,it was not until the next year,having learned some val
uable lessons,that our loan programme began ’ It is now well into its
third year and aims at helping the marginal farmer and sharecropper
13/
-18-
through inputs of cash,seed fertilizer,technological and organizational
advise,to understand- the anatomy of exploitation which keeps him subject
to the dictates of the landowner and money-lender,
;7e are working to consciencetize them to the reality that the present so
cial system has created and perpetuates their problem and only by uniting
and organizing themselves against the rich minority can they force a low
ering of rates for land rent and water ’rights’. Even though Government
has set the price for necessary commodities such as seeds and fertilizer,
these are available to the poor only at a price controlled by the minor
ity elite.
Not only is lack of land a major problem for these people,but also the
method of distribution among the sharecroppers, Often a landlord will
give a sharecropper a virtually unproductive piece of land to work. After
a years labour of moving earth,fertilizing,etc. to make the land useable/
productive ,the sharecropper will be given another similar piece of land
the following year (provided he has any money left to apply).However,as
the other land still needs to be cultivated,the landlord rents the pre
vious years improved plot to another sharecropper at a higher price,thus
causing friction among the sharecroppers,which is all to his advantage.
It is impossible to develop a programme that will help these cppressed
people without land reform and redistribution and these reforms will never come> unless the poor themselves organize and put pressure on Government planning.
Sometimes a landlord will forcibly take the crop a sharecropper has pro
duced. In the village of Kalma,a women’s group took a 200.taka loan to
cultivate egg plant. They harvested the first crop,but met with inter
ference by the landlord when time came to harvest the second crop. Al
though the women’s group went in full strength to the landlord,they ul
timately lost the crop as he filed a case against them at the police sta
tion and they had no clear contract and no funds to fight the case. In
spite of the fact that they lost monetarily,it was a valuable lesson for
them on how they can be used by the rich so they will take steps to guard
against this happening again.
To assist these marginal farmers and sharecroppers,fishermen and women’s
groups,our loans continue on the same terms as described in progress Report No»6. The utilization of loans to date is tabulated as follows:
Total Co-op Members
Total Co-op Groups
= 5 29
=
47 (34 male,13 female)
Groups by Membership
Table 1:
Members per Group
5-9
10-14
15-19
20-24
Number of Groups
21
13
10
3
Table 2:
Members by Land Holdings
Amount of Land
1.
2.
3.
4.
5.
6.
7.
Total
♦
Landlessfnot even homestead)
Homestead only
6-17 decimals of land *
18-33 decimals of land
34-66 decimals of land
67-100 decimals of land
101-166 decimals of land
Number of Persons
80
50
98
72
104
90
35
529“
100 decimals = 1 acre
19/
19Taole 3:Loan Utilization in Relation to Land Holding
Times Loan Taken:
Land_ Holdings:
up to 1 bigha
up to 2 bigha
3 bigha
4 bigha
5 bigha
1-3
4-5
6
7
200
62
17
22
8
11
2
9
4
5
2
2
3
58
48
3
4
2
Total/Percentage
232
81
77
16
6
(61%)
(18%)
(17%)
( 3%)
( 1%)
We are encouraged by the above figures to realize that the majority taking advantage of our loans scheme are really those with least resources
available.
The rich man is also the fertilizer dealer, so if the j.poor farmer is going
elsewhere for his cash,he can still be caught in the trap here,j We received a special dealership from the Ministry of Agriculture permitting
GK to supply directly to the farmers without a
< middle man.
To discredit our sale of fertilizer,a group of Union members and ferti1^Z®r feflers used the clever scheme of opening the bag,removing 1-2 kilo
of fertilizer,resealing the bag and selling it at 3.taka less than the
fixed Government rate which we were using. When some of the farmers
co rifronted us and complained about our price,we sent them back to th
the d. re. ers with instructions to weigh the bag they bought and also request; a
receipt of payment. In many cases the weight was less than it should 1
ave
seen and in no case could they obtain a receipt of sale.
Water is vitally important in an agricultural country and control of water resources is another means of controlling the people. The Government
introduced deep tubewells into rural areas for HYV1s and multiple cropping. These wells 1were provided,installed (on the premises of the rich
farmer) and maintained
---- at a cost of 0.25 million taka each by the Governwent.
Recently Government started a new policy whereby they charge a minimal
rent of 1200,taka/year and the maintenance of the well is turned over to
those using it. The rich farmers have formed co-ops with their family
members to control the sale of water to the small"farmers
------- ; and sharecroppers. The current rate is 300-500.taka/acre to irrigate (50% profit to the
rich farmer) and is likely to increase. After all,he tells the poor farmer - your loan is cheap because no bribes are necessary to obtain it
ejjy to^Jt
T/h6 d±sel’raaintenance’etc.,and these are not always
easy to get,without 'Hidden1 expenses.
There is nothing we can do about this but try in our village education
classes to encourage these landless people to become members of the co-
ment’s support of the rich ?
viuvexn
Zhen facing situations like these,we <are reminded
. - - of what Robert Tressel
wrote as far back as 1906 ... "Under the present system the
the people have really no right to be in the country at all. majority of
Under the
present system,the country belongs to a few. The
The majority
majority work
work hard
hard and
working at all. whether it can be altered or not,whether it is ri<<ht or
wrong landlordism is one of the causes of poverty. ... It(poverty) is
caused by private monopoly
- that is the present system. They have mo
nopolized everything that it is possible to monopolize . They have Jot
eaJth OTheeJJlJ’Jhe n’ln®5'als of the earth and the streams that water the
1. tbit it “
the daylight and th. air
20/
-20-
3 HA T S A L A -SONO SHA STRAY A KSN DXA
repeatedly faced the question
When Savar GK had met with some success,we
could this type of programme
from both local and international circles be duplicated ? Our basic,simple philosophy has alway been that ordieffectively
nary people,given responsibility and some training,can very
meet a challenge such as this and Shapmari has prove this theory.
Bhktsala.our Maughte'r. Jroj ect
village Shapmari,Jamalpur <
situate
«blv assisted by her senior staff
• ^.Ith care Proas a
development in trying
social^ economle&and educational .totu..
of the
fact that
they
111 SPitebefn
twithout
Ur'birth-p^nls^duririaJgZ
no doubt to the^seem-
been without its ’
ing affrontnto male dignity and supremecy that ^^amof^young women
could move in to organize and run something of this nature
male-dominated society.
_" Shapmari to set up a programme
We had been requested by the villagers of
with them to explain the aims and
in their area. When
Eva total
met agreement and set up a local com- Gita and in
1
advise
arneelfd.
5nf ortunately, i t has not always
methods to be used,they were
mittee to assist ^nd
-^assistance
’ which one would have hoped for .
been the type of ’-----Once the .o„ of on. cohcltto. member brought hi» d.ughter to t^C.htr.*
for an injection, ^’"/he paramedic on duty^reque.t^
therefore ha<1
was loud in his protest that it wa
noise appeared on the scene,
no reason to pay. rfhen Gita,attracted y
yoIIg women on his own
he left. Evidently he had been unable
unabl. to face two
t^ young
y^^
time
later
with
a
group
c-as he returned a short
’
come
out
and
talk
’
.
and challenged Gita to
son of the man »»
One day a young man (a .on
“ith the proposal for a new
"J ^Xhed Iva,her ...1.new
there
at
.
+n/-»n tn thp Project’s Cenvillage. As Gita was not there a
tant.,and requested that she relay this inio*ma^ refused. On Gita's retrhl Office in Savar without deiay•
proposal was not proper and if
turn,she also told the young man
woula hive to discuss it with the
he wanted to do something a ou
& decision together. This
existing committee and villagers a
proceeded to label her an
apparently ruffled the young a
‘ .nority), 'communist', 'anti'Indian agent'(Gita being o
ie .1
strangie her. A suggestion to the
government activist
activist'’ and threatened to stra g
behaviour met
U-ltte. member
member that he might try '“uM ^”r“li‘“
denial
that
his
son
’
with a strong ----ms son
that’.
about their work were
Numerous times,the paramedics(girls) as they went
a disrespectful manharassed by the young boys speaking ~
and ”acting
village
leaders and committee
5 GZta finally called a meeting of all
had to stop. The villagers tried
members and informed them that this I-the staff that nothing would
"“d ” cover up for their son, end ..sure
happen again.
assurances, history repeated itself with the arrival
their bicycles out for
Despite their many
especially when they took
f
ibly take their bicycles.
of the IRDP itrainees,
-—
Groups of young men tried to forcioiy
village work.
2 ’ i controlled by
staff knew that any
The staff therefore
soluti on
’ --- villager s,mostly members of
the
among
did some
/D1(i th.y
riculture
a
?
Did
they
think ^wasj^th^
need in the area ? Did theyjhi^
of the cco®ntry ? Did they
a
to carry this type of programme to
21/
-21realize how the rich men's sons were treating the girls/women ? Did they
intend to see that something was done to stop it ? - An emphatic "yes'
to all questions,
A meeting was called. Gita told the people that if the harassment didn’t
stop immediately,she had two options - to go to the police or close the
Centre,both courses equally damaging to the reputation of those respon
sible for the misconduct. The poor among the villagers were united and
loud in their demand for support of the Project. The rich trouble-makers
(or their fathers) had no choice but public apology and promise of amen ing their ways.
By coincidence, the I3DP local Director and SOO were present at the time
qf the meeting and were very favourably .•^pressed with all that trans
pired.
The problem is solved for the moment,but no doubt further instances will
arise. The Project offers preferential treatment for no one,regardless
of 'status' and this is hard medicine for some to swallow.
Bhatsala now has a staff of 12 girls and 4 boys with an intensive cover
age of 19»O3z* population and service available to an additional 10,000.
The main thrust of the programme is the same as Savar GK - preventive
health care,nutrition education and family planning. There is a theatre
for minor operations,a few beds for emergency patients and out-patient
clinic is conducted twice weekly at the Centre. There is a doctor,living
about 5 miles from the Centre,who assists part time at the clinic and is
available for difficult cases
cases.• A1e also participates in their training
programme.
The paramedics train mothers to treat diarrhoea,scabies,etc. in the home.
They also bring health and nutrition education to the villages with
special emphasis on pregnant mothers - looking for possible pre-eclampsia by closely checking the urine,blood pressure,etc. The maternal death
rate for Bangladesh is 8/1000,but Shapmari has their area down to
2.7/1000. 50% of all children in the Project area have had 3 defies of
DPT and 50% of women in child-bearing age are covered with tetanus tox
ide .
Our Projects (Bhatsala and Savar) are being faced with a serious nonacceptance of the tetanus toxide vaccine programme. The village women
we are trying to cover are convinced it is another 'contraceptive' in
jection and many refuse it.
If already pregnant t they are sure that if we have an injection to pre
vent pregnancy, we also have one to kill the already living foetus. We
have also had cases of unmarried girls receiving tetanus vaccine and af
ter having been married 2 years without cone eption,are convinced it was
’’that-” injection '(to*tanus ) , r-esponsibl e .
The paramedics have often tried showing both tetanus and Depo-Provera
vials together,but the women,usually illiterate,insist it is merely br
other company's bottle,thus the different shape,printing,etc., Unfort nately,as previously merit ioned, there are neo-natal deaths in spite of
tetanus toxide and this confirms the women in their conviction.
Bhatsala also began an agriculture extension programme (the same as
var GK*s) to assist those farmers who were totally dependent on the Land
owners and money-lenders. To date 16 co-operatives have been formed
122 members. 37 people have taken 1 loan; 75 people 2 loans; 10 people
3 loans and 5 people,though belonging to one of the co-operatives,have
taken none. 65% have repaid within the stipulated time period and the
other 35% are in the process of repaying.
In spite of the tensions and personal indignities these young girls have
had to put up with in getting this programme underway, their spirit re
mains one of dedication and optimism as evidenced by the following ex
cerpts from the report recently submitted by the Bhatsala Directress 22/
-22” - good health is necessary for good living and is the moral responsi
bility of each individual ... the question is ’how best to serve the
rural people ?’ and the only answer is,’amid them’, that is - bring the
health service and education to the village. Our people die of simple
diseases and these must be removed,but it doesn’t require a MBBStmedical graduate) to carry this out. Good health is rather the responsibi
lity of the village health worker and the villagers themselves.
- so far we have treated 21,369 in the out-patient clinic at Bhatsala
''
’beenL tended in their village homes by the
and an even larger number -have
_>
train
.
It
is
necessary
to
-- the mothers to recognize and treat
parame dies
simple diseases themselves -• diarrhoea with lobon-goor mixture,scabies
and other simple ailments.. COne result of the village programme is that
that scabies are eradicated.
our Project area can now 1boast
--
- in this male-dominated society,the woman needs her husbands permission
to practice family planning. We are convinced that the only successful
family planning programme is in connection with social and economic
change. In 1386(mid-April 1979-?80) 22% of our Project area were active
family planning users, desides these,a good numberl lO/o) are also using
conventional methods such as coitus interruptus,rhythm and of course,
we vigorously promote breast-feeding.
- the problem of education for the children of the poor faces us in our
P-oiect area ... the parents were keen on their children learning and
after discussion with them it was decided to conduct evening classes at
the Centre ... we had few materials ano when the class first started
they wrote with chalk using the cement floor of the clinic as a slyeOur efforts in this direction have met with some opposition from the
landowners(if the children are up late at night,how will they carry on
their work the next day ?). In their efforts to discredit tne school at
tempt, they have told the children that visitors havej come and given gifts
the staff at the
(biscuits,soap,etc. ) for the school children,but; that
i-Centre have kept these things for themselves. -In spite of the odds,we
hope to see this programme grow.
their health problems.
- the poor feel that lack of food is the root of
<
enough food is necessary for any
A change in the ability to produce <
initiated our agriculture
change in the health status .«oo this is why we
loan scheme.
, — area
--- 1 Por its good
- we feel that Bhatsala is well-known in the Jamalpur
also
grateful
for the sup■* . We are t
work and is appreciated by the people,
local authorities.
port it has with
— — the
-- —
the work at
4 the people of Kazirchar in Lasmanpur Union,having seen Land has been
Bhatsala,requested us to start a Centre in their village,
procurred and we are beginning to build,”
RONOSHASTHAYA PHARMACEOTICAl/S LTD.
Patient
'A' was brought to GK by his relatives complaining of a burning
feeling of
irritable and started nhoutinv
shouting at people.
people, After this
developed
his
complaints
e
’medicine’,then
t Family Planning section of
’ ; in the Government
The man,40 years old,works
that
about
5 years ago,he consulted a
a Rural Health Centre. He told us i--- -,
doctor because of fatigue,occasional liver pain(pai‘.n in the right hypoin family life.
chondrium) and a lack ox interest/enjoymwr.t
—---- — .
- The doctor prescribed 4 m-ideations,3 of which he couldn’t remember the
with 27.5% alchol
names. The other was Polytamin Syrup(a vitamin tonic
_o
reported
that he was
content)
15 days later he* savz
saw the doctor a
again and
’syrup'.
feeling better and more cheerful
,
especially
when
he
took
the
cheerful,especially
ieeiiHb
.
agreed it would be a good idea to continue
This being the case,hrs doctor <
2 3/
the syrup as vitamins are a vital element for good health(no advice was
given on nutrition in his daily diet).
During the subsequent 5 years he contii ued with Polytamin,3-4 teaspeonsful’after.meals,increasing the dose wh<n he needed to 'feel good’. The
previous night he had taken 1 cup(50cc) of the preparation. It was at
this point that we made his acqvaiixtanc a.
Patient ’B’ is a 30 year-old sharecropper. He consulted a doctor with
evening fever,decaaxonal abdominal pair and general body weakness. The
‘ ior
‘
of Penicillin and Streptomycin
doctor prescribed Combiotic(combipat
“
ciloicm
in.
ectionSr
When the fever did not
manufactured by Pfizer) and
T
er
r
a
my
in
(
f
iz
er
)
;
flecosul
es (Pfizer )and Verset tie . this v/as changed to
v
own
but
the
weakness
returned’
diviton tonic(Squibb). The lever went
on.
He
hadn
’
t
the
means
to
kepp purwhenever he stopped taking Verde- it
wor
’
without
it
and
sometimes
the
chasing Verdiviton;but he couldn't
£f
as
at
this
point
that
he
came
to
pain in his abdomen became severe,
our clinic. Ho needed a cheaper substitute for his ’tonic’.
The cases xn question illustrate odji of -the most startling and insidious
.jciated
forms of exploitation as.sooi
---- vrd
-- th health care services and particuthe
misrepre^entation,overpricing
and dumping
larly the drug in•’.nstry •
of worthless drug.-? its third world countries.
To take Bangladesh a.s an example, there are over 150 drug companies reg
istered in the country including 3 multinationals and about 22 national
companies Most of the v'Ua’inaxig' 120 e: 3.st only on paper.
The 3 multinationals and thoir subsidir.ries control 3o% of the drug amrket with the remaining 20% beJd by small and medium-sized nationals. Gov
ernment’s expenditure is abcut 10-15%(:deluding 16 7 million taka worth
of drugs provided by UNICEF foi- rural health services) of the drug mar
ket’s 1 billion taka business.
pharmaceutical Companies ar? considered essential industry and therefore
pa.y reduced d.“'■‘•■ies
on z.mpoi' ed raw cird packaging materials. i4or examp €
the raw material magnesium stcrcatn Sported by a pharmaceutical manu
facturing company will have a nominal tdx
whxle the same talc
tt.x of
imported by a cosmetic
-.11’. be
cosmetic company
compairr wj
yj-1
be taxed at 150-300%. Similarly pack
aging material suet,
?d,7 ff.ri
rt pap wr, imported by a printei or pu
such as paportoa .rd
lisher will havo a tax of up
Up to
tc 150%.
13C?^- In
ln actuality, many drug companies
instead of producing drugsz arc selling
xsclllj g cither
cztthe? the goods dr tne ?<por
cenoe f^'*'‘i-.o goods.
c'nc-rbc.: K
K lucrative business
I is? n ess with ho work involved ;
for +fhe
30-40% of the drugs marketed in developing countries are vitamins and
tonics, Another
are banned in developed countries (combxnaxxon
druo-s , out-dated cough mixtures and clixers and unnecessary preparations).
Only the remaining 40-50% arc useful drugs and these are sold at exoroxtent prices.
Although Government members are included in the drug-pricing committee,
it is virtually controlled by the multinationals. They decide what
will produce and a< vrhat price. Bangladesh Government had to ’beg tn^rn
to produce distilled water,which though necessary,nas not as much prolix
as Verdiviton ( Squibb ). Poly lamin (Ho echst): BG Phos(MSD) or Combxotxc vzou^d
fetch.
Exploitation of this type
type has led to 3uch publications as "^ho Needs
Drug Companies ?" by War n Want; "Insult or Injury" by Charles Medwar
and ultimately a Hot by WHO of 200 essential arugs for primary health
care in developing countries.
The question is hev to go about intr>c’ucing the use of ’essential gener
ic drugs only’ to a population exploited into the belief that only multi-treatment with the most expensive drugs on the market is.effective .
The trial in Pakistan r't with an e.v-ly 'oath blow. In India,a serious
attempt by a Socialist Minister resulted in only 11 generic drugs being
introduced just prior to his removal from Office. The fate of essential
drugs only’ is still unknown as the multinationals continue to control
24/
-24the entire drug market and in their own language, ’’You must understand
the reason multinational companies try to grab back as much profit as
possible out of the less developed countries is frankly because they are
suspicious of the future stability of their operations there. I would
just be talking rubbish if I were to say that the multinational compan
ies were operating in the less developed countries primarily for the wel
fare of those countries. They are not Bishops,they are Businessmen.”(12)
An extenuating problem is that the national drug companies have learnt
their lessons from the multinationals and they too are purely ’’Business
men” engaged in the same exploitation of their fellow countrymen as can
be seen in the following example: of 250mg. Ampicillin capsules produced
by various companies with their price variations:
r.86?
i 1.90 1.90
» ,
?! sd
t i
I
!» i»
t .
;; ii • -3h !:
H
t f -H |
>>
o
o
I
■>
t i
1.70
" i fi
u
":L V.
!
)
rj !
1.50
1.30
i Exn
& H •H <i : C i ii Ed ‘H
i: i •H ?
I ! -
t
»
co
o
« i
■
’
• ; 1.75
hr
sjii
•P
o
Xi , , -p W:
o 1 ’ W M
0) I • -H ©I
•
! rQ
il
■
O
’
d
r-I
co
&
(<
I O' i
h
• £ Oi
z
-
e.95
-
■ T,
{H „
H
I
!
i'S !
'■
I
:____
Multinational Co. National Companies
__ ___________________ _______________ -
o
c.,. <
Q
§
! -H
I P» /'3
J
»
I
t___________________________________________________________________ __
Beecham has no factory of their own in Bangladesh, Penbritin is producer
by Fisons under a third party licence. Bristol-Myers also have no factory
and Pentrexyl is manufactured at the Albert David factory and sold at
1.90 taka while Albert David’s Aldopen,containing the same properties,
sells at 1.30 taka.
Society cannot let this situation go unchallenged. A Dutch friend,Jan
tfillem van dor Eb and QK have been planning,since early on in our involve
ment in primary health care,how to provide drugs under generic names at
low cost. It took 3 years to complete the ’footwork’ of collecting the
necessary Government approval,documents,etc. By 1978 we had clearance in
order and in November 1978,construction began on our building. Today a
factory,one of the largest in the country,with 42,000 sq.ft, of floor
space is ready to go into production, in October with Quality Control and
Production Development Laboratory of the highest calibre.
The building design,central air conditioning installation and equipment
set-up has been done entirely by Bangladeshi. Specialized top management
have been recruited within the country and sent abroad for refresher
courses. Ve have also attracted highly qualified Bangladeshi who left
their jobs in developed countries to join the fight.
The factory will be ’different* not only in its production of quality
generic drugs at low cost, but in keeping with GK philosophy, a large- sec
tor of employees will be rural women. Some of these have already been
recruited for basic training in their work and Literacy as necessary.An
other distinctive characteristic is that all labelling and explanatory
literature will be in Bengali.
Gonoshasthaya Pharmaceuticals Limited is organized under the Company’s
Act like any other manufacturing industry in the country with one major
difference - there are no individual share-holders. It is 100% owned by
the GK Charitable Trust and by its’ chart er,50% of the profits will be
ploughed back for factory expansion and the other 50% to help volunteer’
programmes in the country with emphasis or. social sciences and indige-
25/
-25nous herbal medicine research.
This programme is funded by NOVIB of Holland,Bangladesh Silpa(Industrial )
Bank,OXFAM and Christian Aid.
GONOSHASTHAYA PUBLICATIONS
The cases of Patients * A 8c B’ previously described,illustrate how persuasive marketing shadows the minds of even highly qualified medical persons
and ultimately leads to unscientific and unethical medical practice.Their
lead is followed by the numerous unqualified village doctors,who in ac
tuality,are consulted for treatment by the vast majority of the rural populat ion.
IWo medical textbook would recommend prescribing an antibiotic without def
inite infection. Neither are B-complex vitamins recommended as routine in
conjunction with one course of broad-spectrum antibiotic. MIMS(Monthly In
dex of Medical Speciality) for developed countries clearly notes the con
tra-indication of such vitamin-tonics as Polytamin and Verdiviton,which
contain a high alchol content,in cases of hepatitis or other liver invol
vement. A large number of the Bangladesh population suffers from liver af
fliction due to both amoebic hepatitis and nutritional cirrhosis.
Medical education doesn't include instruction in the economics of drug
product ion/marketing and its social implications. Consequently,patients
are deprived of nutrition education which should be given instead of alchol-addicting vitamin tonics.A poor man will often pay as much as 1/?
his weekly wage to obtain a drug that could well be harmful to him and at
most,is probably useless or unnecessary.Our estimate of the ratio of Drug
Representatives/Doctor in Bangladesh would be 1:7. In Tanzania it is 1.4
while in Britain 1:20(13)•These marketing representatives are guilty of
’conning* doctors and consumers alike into identifying the healing proper
ties of drugs with brand names(and therefore higher prices). This is made
all the more easy by the fact that the only promotion material available
is provided by the drug company and is usually in a language which is for
eign to the person prescribing as well as to the person buying. To stop
such exploitation the health profession needs continued education and con
sumers need access to the ’restricted* information about the drugs they
are prescribed to ta-ke. To this end,our publications department came into
being about 2 years ago.
66,000 villages of Bangladesh were included in the departments research
programme,collecting information on how many qualified/unqualified persons
are practicing medicine in the country,what their practice habits are and
what information they would find of value in carrying out their work.
With this information at hand we have now published the second of our mon
thly health bulletin - Gonoshasthaya Monthly -(completely in Bengali) de
signed to give information on all aspects of basic health care. It will
also be used to promote the use of quality,generic drugs. To help instruct
primary health care workers,the excellent book by David Werner "Where
There is no Doctor" is being translated and printed.
There have been some fine exposees done for the first world on the way
the poor in developing countries are 'used' by multinational marketing,
but this information is not equally available to the people of developing
countries,again due to language barrier. vWe propose to translate and print
such information and are currently working on the War on Jant publication
"Baby Killer Scandal".
The publications department will also develop teaching aids and curriculum
for our village education programme as well as our primary school and med
ical training programmes. The work of this department is being financed
by EZE.
26/
*
-26POST SCRIPT
Organization: Gonoshasthaya Kendra is <a Charitable Trust,registered with
the Bangladesh Government. It is a non -Government Voluntary Organization,
dedicated to the promotion of rural health and community development,. It
has a Board of Trustees,of which the Projects Co-oridnator is a member,
’
that annually overviews the programmes run under the Project Director and
Managers.
The.Project programmes are partially financed by the Trust resources,
lo*
resources,local donations and the health insurance
scheme.
remainder
,apart
------ -----. For For
the the
remainder
, apart
from those Organizations already mentioned,we gratefully acknowledge the
contributions of Oxfam towards the
health
----- 1 programme; Inter Pares - the
health and vocational training; Terre des Hommes - the school; War on
Jant and a private French group "Comite de Soutien au Centre de Sante Pop
ulaire de Savar” - the agriculture extension; and Bread for the World the Bhatsala Project.
The Project(excluding Pharmaceuticals) has three categories of workers
(apart from the trainees). The first includes those who are totally illit
erate up to ones who may have as much as 10 years of education.Their mon
thly salary, scale is 300-1500 taka. The second category is professionals
with a salary scale of 1200-2500 taka and the third category includes the
Project Co-ordinator,Director,etc. in a 2OOO-3OOO salary range. In 1978
the workers made provision for an annual increment of 50.taka/person,irrespective of category,if the person’s work remained satisfactory.
Everyone contributes 10% of their salary to the Staff Welfare Fund. In
the case of the workers with a salary up to 600 taka/month ,their contri
bution is matched with 10% by the Project. For those in the 650-1200 taka
salary range,the Project contributes 5% and for those above 1200 taka,2%
is contributed. This Welfare is refundable to any worker who remains up
to three years in the Project service.
Breakdown according to Category:
1st.Category
2nd.
3rd.
Total number of persons
114
4
2
Usual starting age
16 yrs.
25 yrs.
32 yrs.
Annual increment
50./=
50./=
50./ =
Special increment at completion
of 4 & 6 years work in Project
50./
nil
nil
Mess contributions are scaled to salary,but everyone gets the same food.
Housing is according to need(single,married,married with family) irre
spective of salary. ilealth insurance/benefits are the same for all. Lit
eracy classes are available to illiterate workers. Training in various
skills is available according to the a billties/interests of the workers
at the pnoject’s expense. Presently one boy is studying under the elec
trician , anoth er man is learning mechanics and another driving. Similarly
cashiers and storekeepers have been trained for their present jobs.
All Project workers are divided into mixed(education/salary) groups for
weekly discussions dealing with problens,policy making of the Project
and various articles which they have read which will help improve their
social awareness. There are regular monthly meetings in which all Project
members participate and at which major decisions are taken. An executive
committee to organize and conduct these meetings is elected by the work
ers for a 1 year term.
Nizam’s Murder: In November 1976 our senior paramedic,Nizam,was murdered
by elites
seeking to protect a corrupt village structure(see Progress
Report No.6 and "Under the Law in Bangladesh" ). Villagers told us that
if the murderers were not brought to trial within a month,we would never
see justice done. At the time,we doubted the truth of their comment. Now,
27/
f
-27almost four years later,the self-confessed killers remain free,and though
the prestige of the Project have us access to the highest power in the
country,this local village elite proved to be outside every control.
Minu's Death: On Sth May this year we were saddened by the death ox an
other paramedic. Minu(the same one mentioned in the introduction of this
report) was cycling from her work in the village to a paramedic meeting
at the main Centre when she was struck from behind by a bus(which did not
stop)• She managed to stand up and push her bicycle to a nearby village
shop where she collapsed with injuries due to fractured spine* She was
paralysed from the neck down and died five days later.
Internal Disruption: .In late February of this year one of the young workshop girls(married before and left by her husband)) informed us of her intent to marry our security guard recruited about tivo weeks previously (and
known to have a wife and children), A GonoPaduka girl was engeged(through
a marriage arranged by her parents) to a man who already had one wife.
One young female paramedic had a fight with one of the male paramedics
over a trivial matter. This combination of situations led some of the
senior female staff to call a meeting for the purpose of discussing ap
propriate female conduct. On the evening of 1st March 1980 they gathered.
The older staff members argued for greater discretion both for their own
and the Projects reputation. During the confrontation the workshop girl
who wanted to marry the guard was struck by her sister,a senior paramed
ic. This led to a scuffle with further blows and hairpulling.
It was a clash of generations and changing cultural attitudes with the
younger ones resenting the interference and restrictive attitude of the
older workers, They decided co sit again the follovzing Tuesday evening
and decide on a code of conduct agreeable to all. All felt that it was a
problem to be sorted out among themselves without involving the male mem bers of the Project.
The next day started as usual with agriculture followed by many of the,
paramedics and extension staff leaving for their village work,the rest
preparing for Sunday clinic and a group of expected visitors.
In the publications departmentsthe male translator jokingly asked th©
young typist what had transpired at the previous night’s 'rioting’. The
research scientist,listening in,rushod to the Project Manager to demand
a revolt at such ’an intolerable situation'. They were now joined by the
dentist(who has since gone to V7est Germany) and started pushing the young
girls to call others to an emergency meeting. There was a sudden commo
tion and cry to stop work and by 10:30 the Construction Supervisor and
Research Scientist had closed the inair. gate to patients and visitors.
Cleverly utilizing the name of the Project Manager of the publications
department,they assembled workers in vhe main hall to demand action against the senior girls responsible f< r the previous nights scuffle. How
ever, the scope soon widened and the meeting became a free-for-all of
speeches and airing of pseudo-grievances. Speakers argued that the Pro
ject was oppressive and exploitative of its staff and a number were ex
tremely abusive and insulting about senior staff.
The meeting concluded with the formation of a committee which would
fight for greater security and shorter working hours. Work resumed that
evening,but the ’strike’ was followed by some bizarre events.
A group of the main agitators had tape recorded the proceedings of vhe
meeting with a vievr to taking the story to the press. Most of the com
mittee members refused to allow this. At this point the Project Co-crdi-nator,who had been in Dacca during the day,returned. H© individually
questioned the suppossedly ’aggrieved’ girls to see what had really hap
pened and was surprised to find that rone of the newly-formed committee
members had asked even one of these girls what had happened to them per
sonally ! It was only then,as they tried to put all the facts together,
that the girls realized how they had leen used. The Project Co-ordinator
then requested to listen to the tapes before discussing the committee’s
demands. Four of those agitating for ihe story to be taken to the press
! 28/
*
-28then left for Dacca with the tapes. This alarmed most of the participants
of Sunday’s meeting and some went out to search for them. The four later
’gave themselves up’ along with a copy of the tapes.
When the four ’absconders’ were questioned as to their motives,it became
clear that at least the translator and research scientist had joined the
Project with the intention to disrupt it. Employed in the publications
department,both were highly qualified individuals coming from the wealth
ier class,but willing to work for small pay and take part in all the Pro
jects ’common’ activities.
The translator was a member of a left-wing political party which felt the
GK ’counter-revolutionary’ work,because of its effectiveness in bringing
some relief to the poor,would subsequently forestall the inevitable and
necessary ’Revolution’. The research scientist claimed to have had exper
ience with herbal medicine and said he wanted to make his contribution in
this area. To gain employment with us he had played on the sentiments ex
pressed by the Project Co-ordinator in his article ’’Research: A Method of
Colonization" by stating his disillusionment with his own experience of
employment with Johns Hopkins and the then Cholera Research Laboratory.
We will never learn exactly who sent and paid them,but we found concrete
evidence of industrial espionage among the belongings of the research
scientist including photocopies of documents from the pharmaceutical
files and listening devices. Also among the possessions of the organizers,
who cast themselves in the roles of champions of women’s liberation and
worker’s rights,we discovered lewd rhymes about some of the female staff.
A further general assembly recommended 4 persons to be sacked for their
role in the disruption and another 2 asked to be released^ We have not
feel
increased security nor shortened working hours. We 5
’21 that our main
responsibility is towards the general population,and that we have a duty
Most
to make our limited funds go as far as possible. In
of the staff are
“ in
* i an organization
privileged by education and a reasonably paid job
which has a more truely democratic structure tlnan most other bodies in
the country. A certain dedication must be expected from them if the Project is to have any meaning.
However,the strike has crystallized some issues which have become impor
tant at this stage in the history of the Project. The first is the gen
eration1 problem - old staff members are bound to each other by the s ared experience of pioneering days of struggle,individual courage and msecurity. They feel that this gives them the right to set the tone or
conduct and work performance. The new members see the older ones as ar
rogant and fear for their own chances of promotion and recognition. T e
growth of the Project has naturally limited personal contact between the
and they feel powerless
Project leaders and the large number of new staff
g--- —
w
spite of the various departmental
seemingly
powerful
organization
in
in a j-_ _
by the articulate and confident few.
g — » ~— dominated
-----meetings which are often
- j famous within the
dreamers and pioneers,but peopl
comnetinrr for a decent job in a country with approximately 30% unemploy
men? Tht alienation showed itself in the ease with which so many work
ers joined the strike. This came as a shock to some of the leaders who
believed that the workers considered the Project their own and themselves
as part of a team.
Fach nerson.as a result of that day
has had
day has
had to
to look deeply into his/her
it and
» Some have left. Now for the
rest of us,that Sunday morning,like Nizam1
’!s grave,remains with us - a
not
challenge to what we are and what we are not..
29/
-29-
REFEx^ENCES:
1. Government of the Peoples Republic of Eangladesh/UNDP-FAO Report,
1977,3:i.
2.
’’Demands for Grants and Appropriations 1979-30”,Finance Ministry,
Government of the Peoples Republic of Bangladesh.
5.
’’Prospects in Reversible Contraception"(1eading article),British
Medical Journal,p.131, July 17,1976.
4. ”Depo-Provera - A Critical Analysis
Steve Minkin (article unpub
lished at the time referred to in this Report,since published).
5. ’’Excreta Disposal for Rural Areas and Small Communi tie s ”, E . G. Wagner
8c J.N.Lanocx, WHO Monograph Series No • 39, Geneva , 195 8.
6. ’’Health in the Third World: Studie s from Vietnam”, Joan K.McMichael
(editor), Bertrand Russell Peace Foundation(Spokesman Books),London,
1976.
7. ’’Compost, Fertilizer and Biogas Production from Human and Farm Wastes
in the Peoples Republic of China”, M.G.McGarry & J.Stainforth (eds.),
IDRC,Ottawa,1978.
8. ’’Development of Village Health Workers:Report on the Programme”,
Susanne Chowdhury,Advisor,IRDP/WP,1980.
9. ’’Husband Leaves Loose Woman”, Susanne Chowdhury, Advi sor , IRDP/WP , 1 97 9 •
10.
’’Rural Development in Bangladesh”, Steve Jones,
Dacca,1979.
10a.
’’Economic Value of Children Among Javanese and Nepalese Peasants:
An Anthropological Inquiry”, Moni Nag,presented at annual meeting
of American Association for the Advancement of Science,Boston,1976.
11. ’’The Ragged Trousered Philanthropists”,
view Press,1978.
12.
ENDA Conference,
Robert Tressel, Monthly Re
"In Sickness or in Wealth”, BBC(London)Broadcast,2 September 1979,
quoting George Teeling Smith,Director of the Drug Industry Finance
Research Group.
13. ’’Provisions of Medicines in a Developing Country”, John S.Yudkin,
The Lancet, April 15,1978, pg.810.
25 previously published/unpublished articles by Staff mem
bers are also available(some in English,some in Bengali).
Readers interested in helping defray the charges of cyclo
styling , pi cture printing and postage of this xleport are
welcome to make their contributions.
►
Voluntary Health Association of India
C*14, Community Centre
Safdarjung Development Area,
New Delhi-110016
D-9/334.(j»l)
21.10.1^82
A VHAJ
al
%
J
j-nj
Telegrams : VOLHEALTH
New Delhi-110016
Phone : 652007, 652008
THE BANGLADESH BAN ON HAZARDOUS AND IRRATIONAL DRUGS
Its Review and the present Status
28th April 1982:
An 8-member expert committee commissioned to evaluate
all the pharmaceutical products in Bangladesh and draft
a rational Drug Policy - met for the first time.
Important outcome:
4140 products in the market were evaluated. 16 criteria
were laid down for evaluation. (12 criteria selected on
scientific grounds and 4 on politico-economic grounds).
Based on these, 1707 products were recommended to be bann
ed. These were divided into 3 categories or Schedules
as follows:
Schedule I - This included 265 locally manufactured and
40 imported drugs regarded as positively hazardous to
be banned immediately.
Schedule II - included 134 drugs which required
reformulation and were to be banned after a period of
6 months.
Schedule III - included 742 locally manufactured and
526 imported drugs. These drugs either had little or
no proven therapeutic value or could easily be
manufactured by local drug companies - instead of the
multinationals producing them at higher costs,thereby
depleting the country of much needed foreign exchange*
12th May 1982>
The Expert Committee submitted its report to the
Government.
29th May91982,:
The Chief Martial Law Administrator and his Council of
Ministers approved it. The date of the ban of Schedule I
was changed from 1 to 3 months and the banning dates of
Schedule III drugs from 6 to 9 months.
7-th June>1982:
Formal declaration of the new policy was made.
12th June> 1982:
The Drug Control Ordinance was promulgated.
June? 1982:
Reported pressure exerted on the Government by the
Bangladesh American Ambassador on behalf, of the US
multinationals to have the policy amended. The negative
stand of the USA regarding WHO’s International Code
against unethical marketing practices of milk food is
well known»
The British, Dutch and the German Embassies joined to
exert pressure on the government. The anti-government
campaign having failed, the focus then turned to the
Expert Committee which had recommended and pushed the
drug policy.
July 1982:
<
The 4-member Expert Scientific Committee of various
pharmaceutical manufacturing companies was brought by
the US Bnbassy to further pressurize the government to
reconsider the ban*
47/t<F|^"'TV
CEU,
■I
D-9/534-(jsl)
21.10.82s a
2
S' >
19th August,1982:
In Washington Post it was reported that the US State
Department spokesman had acknowledged: ’’that the
Pharmaceutical Manufacturers Association, a trade
organization for the drug industry, asked it to bring
pressure on the Bangladesh government to delay implement
ing the law pending discussions with the manufacturers”.
He added: ’’The State Department has a statutory respon
sibility for assisting American interests abroad. In this
particular case, the US Government is also concerned that
these regulations may inhibit further foreign investment
in Bangladesh’s US $ 30 billion market in the developing
countries would be at stake if other countries followed
suit.
12th August 1982:
Report submitted by the Review Committee constituting of
6 military doctors set up to re-examine the matter in
view of the pressure mounted by the multinationals and
their respective governments.
6th September,1982: The Drug (Control) Ordinance Amendment announced by the
Government after studying the Review Committee’s Report.
AMENDMENTS
SCHEDULE I:
Ban lifted from only 1 item of importance - Imodium
(an anti-diarrhoeal).
Six other misused/abused dental remedies reinstated.
TOTAL BAN OF SCHEBULE I DRUGS will rejnain EFFECTIVE 3 month period "as decided
earlier all harmful drugs to be destroyed by 12th
September 1982.
SCHEDULE II:
4 eye preparations containing anti-biotic and steroid
combinations allowed (contradictory to the Expert
Committee’s recommendation).
Heptuna plus a capsule containing iron folic acid,
Multivitamins and minerals produced by Pfizer (very
strangely) allowed to remain.
Ban withdrawn of total 7 drugs in Schedule II. Time"
limit extended according to the amended ordinance from
6 months to 12 months for the drugs listed in Schedule II.
Lobbying for this so called necessary ante-natal drug for the under
nourished anaemic pregnant woman was done by the country's gynaecologists
headed by the President of Bangladesh Medical Association,shareholder and
member of the Board of Directors of Pfizer, Begum Feroza*
Facts about the Bangladesh Drugs Scene in Brief:
- Bangladesh is the third poorest country in the world with a per
capita income of US $ 70 a year.
- That 70$ of annual drug sales are of drugs described as useless or
therapeutically insignificant by the British National Formulary,
the National Research Council, USA and the Federal Drug Administ
ration, USA.
- Out of 51 products of Glaxo available in Bangladesh market in 1980,
only 17 are available in the U.K. and only Vs are present in WHO’s
list of essential drugs.
- Of 31 products of Fisons available in Bangladesh , 17 were
combination of vitamins and minerals. And only 5 of these drugs
D-9/334-(J:1)
3 -
were available in the UK.
is spent on drugs.
60% of Bangladesh’s health budget
In 1981 about 1250 million taka was spent on a lopathic drugs
in Bangladesh, but due to poverty and the high'cost of drugs
less than 15% of the propulation was in aa position to buy
modern medicines.
SCHEDULE III -
20 drugs (manufactured under the third party licence)
were allowed to remain. Time limit extended from 9
months to 18 months effective from 12th June 1982 - date
of promulgation of drugs.
SCHEDULE IV
(new)
Under this new schedule, 88 balms and vapours of small
national companies were to be allowed to be manufactured
for 18 months with effect from 12th June 1982.
WHAT'S
HEW?
All hazardous drugs of Schedule I were to be completely destroyed
by 12th September 1982.
18 a
tho dru£ companies to apply for licence to
expert them to Saudi Arabia, Western Africa, etc, via Europe. These
applications were made on 10th September with the support of
Secretary of Health. The Drug Controller has refused and the matter
has now been taken up with the Industrial Ministry. The Drug
Controller has recommended that if this move should go throu^i, all
these products should be previously labelled saying the drugs was
recommended to be destroyed in Bangladesh by 12 th September 1982.
The failure of Sri Lanka and Pakistan to have
have a
a progressive
progressive drufr
drug
policy has been quoted by the multinationals to
subvert
to subvert the
the attempts
attempts
ot Bangladesn Government to ban hazardous drugs.
What is probably the most humiliating comment on the social
consciousness of Indian health personnel is that our drug policy
is being quoted by the multinationals to criticize and condemn the
Bangladesh ban.
Hermit would not be out of place to quote from a
medical journal from Bangladesh, 6th September 1982.
"In India, 43606 drugs are registered and sold. Even these have
not upset their possibilities of further industrialization in
spite of their tec.hnologocial advance and poverty...." (sic).
The above information is based on newspaper reports from Bangladesh
and elsewhere and the personal communications from socially concerned
health personnel in Bangladesh like Dr* Zafrullah Chowdhury.
Availability of supply of essential life-saving drugs for the
majority at reasonable cost, should come before profits of the druff
companies. If these profits derive from the sale of hazardous andB
irrational drugs or drugs with little therapeutic value, they need to be
curtailed, and policies which allow drug companies to continue producing
them need to be seriously questioned. We want a rational, people-oriented
drug policy, and any effort in this direction anywhere has our support.
As mentioned in our handout "In Support of Bangladesh Ban" we
repeat "Sabotage of.this ban at this stage by the application of pressure
or by money power will be a blow to all those who sincerely believe in
socially relevant and socially just health care. Consequently, this is
not a question of Bangladesh's fighting a 'Bangladesh problem'. It is in
fact a question of a higher premium being placed on profits than on the
welfare of human beings - if the ban is withdrawn under duress. This is
4
D-9/334-(jgl)
4
therefore a move against which the public opinion of all nations? particularly
the developing countries should be raised. It is a cause worthy of global
support specially from those involved in healthwork1•
What would we do if we knew that the sale of hazardous and irrational
drugs would continue because x>f the pressures and marketing strategies of
the Drug companies? Would we continue stocking them in our pharmacies
and prescribing them? We request our readers to boycott such hazardous
products, because a Government ban on them may come too late, br never oome
because of vested interests.
If you are desirous of more information please write.
Mira Shiva
Co-ordinator,
Low Cost Drugs & Rational Therapeutics.
Ob4
*
NDP QUID LINES AND LIST OF BANNED DRUGS
This paper includes guidelines of National Drug Policy (NDP), name of the banned
drugs (Schedule-1), scientific explanations behind the bann with their list of references,
essential drugs list of World Health Organisation.
The technical details of National Drug Policy declared on the 12th of June, 1982 is
unknown to most of the physicians and pharmacists of Bangladesh till today. No cons
tructive step has yet been taken to enlighten and inform the physicians about the scientific
reasons and explanations behind banning 1707 harmful, useless, expensive and
imported drugs whose local substitute are available. This paper is an attempt to
inform the physicians of the country about the scientific reasons and explanations
behind the banned drugs as projected by the Expert Committee.
In accordance to the guidelines (vide infra) followed by Expert Committee the drugs
to be banned have been categorised into three Schedules.
* SCHEDULE—1 : It includes the most harmful drugs.
*
SCHEDULE—11: It includes drugs whose manufacture and sale shall be permitted
only if they are registered after change in their formulation in accordance with the
direction of the licencing authority.
* SCHEDULE III :
Drugs belonging to this schedule fall into one of the followings groups :
1. Combination drugs with no or trival therapeutic value and as such increased toxi
city. The combination may be of drug ingredients of the same category or ingredients
of entirely different categories. These drugs have no therapeutic value to outweight
the cost.
(2)
Drugs being marketed under a variety of names, but with only slight
difference in combination. (3) Imported drugs which are already locally manufactured,
thus impeding the growth of local industry. (4) Drugs which, in themselves are not
harmful, but are ; a) to become the responsibility of national manufacturing com
panies instead of multinational companies ( e. g. antacids, simple vitamin preps., etc. ),
(First Fl
-saooo,
or; b) some such drugs are produced under license from foreign companies which
do not themselves manufacture in Bangladesh. This is against national interest.
Some or its substitutes will be allowed to be produced under the name of the
manufacturing company only ( e. g. Penbritin, manufactured as ampicillin under the
generic or brand name—of whichever company is producing it) with their factory in
Bangladesh.
*
Drugs under schedule-1, 11 & 111 should be withdrawn from the market by 3, 6 & 9
months respectively.
GUIDELINES
i.
The combination of an antibiotic with another antibiotic or antibiotics with cor
ticosteroids or other active substances will be prohibited.
Antibiotics harmful to children ( e. g. Tetracycline ) will not be allowed to be
manufactured in liquid form.
ii. The combination of analgesics in any form is not allowed as there is no ther
apeutic advantage and it only increases toxicity, especially in the case of
kidney damage. The combination of analgesics with iron, vitamin or alcohol is
also not allowed.
iii. The use of Codeine in any combination form is not allowed as it causes addiction.
iv. In general, no combination drug will be used unless there is absolutely no alter
native single drug available for treatment or if no alternative single drug is cost
effective for the purpose.
Certain exceptions will be made in the cases of eye, skin, respiratory and haemmoroidal preparations, co-trimoxazole, oral rehydration salts, antimalarial, iron
folic, etc., as well as certain vitamin preparations, allowing combinations of more
than one active ingredient in a product.
v.
Two
Vitamins should be prepared as single ingredient products with the exception of
B complex. Members of vitamin of B complex with the exception of B12 may
be combined into one product. B12 always has to be produced as a single
ingredient injectable product. Other members of B complex may also be produced
as a single ingredient product ( e. g. Bl ; B2 ; B6, etc. ). Vitamins will not be
combined with any other ingredient such as minerals, glycerophosphate, etc.
It will be allowed to produce vitamins in tablets, capsules and injectable form only.
No liquid form will be permitted because of wastage of financial resources and
the tremendous misuse involved. However, paediatric liquid multivitamin ( with
no B12, E, K and/or minerals) will be allowed to be manufactured in bottles of
up to 15ml. size with droppers. Paediatric liquid preparations of single ingredient
vitamins will also be allowed to be manufactured in bottles of up to 15ml.
with droppers.
vi.
No cough mixtures, throat lozenges, gripe water, alkalis, etc. will be allowed
to be manufactured or imported as these are of little or no therapeutic value
and amount to great wastage of our meagre resources.
vii. The sale of tonics, enzyme mixtures/preparations and so-called restorative products
flourish on consumer ignorance. Most are habit-forming and with the exception
of pancreatin and lactase these are of no therapeutic value. Henceforth, local
manufacture or importation of such prodcuts will be discontinued. However,
pancreatin and lactase will be allowed to be manufactured and/or imported as
single ingredient products.
viii. Some drugs are being manufactured with only a slight difference in composition
from another product but having similar action. This only confuses both patients
and doctors. This will not be allowed.
ix. Products of doubtful, little or no therapeutic value are rather sometimes harm
ful, and are subject to misuse will be banned.
All prescription chemicals and galenical preparations not included in the latest
X.
edition of British Pharmacopeia or British Pharmaceutical Codex will be prohibited.
xi.
Certain drugs, in spite of known serious side-effects and possibility of misuse,
having favourable risk-benefit ratio may be allowed to be produced in limited
quantity for restricted use. These will be prescribed by specialists only.
xii. The same or close substitute of a drug which is being produced in the country
will not be allowed to be imported as a measure of protection for the local
industry. However, if local production is far short of needs, this condition may
be relaxed in some cases.
xiii. A basic pharmaceutical raw material which is locally manufactured will be given
protection by disallowing it or its substitute to be imported if sufficient quantity
is available in the country.
xiv. The role of Multinationals in providing medicines for the country is acknowledged
with appreciation. In view of the calibre of machinery and technical know-how
which lies in their hands for producing important and innovative drugs for the
country, the task of poducing antacids and vitamins will lie solely with the
National Companies, leaving the Multinationals free to concentrate their efforts
and resources on those items not so easily produced by smaller Nationol Com
panies. Multinationals will, however, be allowed to produce injectable vitamins
as single ingredient products.
xv. No foreign brands will be allowed to be manufactured under licence in any
factory in Bangladesh if the same or similar products are available/manufactured
in Bangladesh as this leads to unnecessary high prices and payment of loyalties.
In the light of this policy, all existing licensing agreements should be reviewed.
Three
xvi. No Multinational Company without their own factory in Bangladesh willbe allow ed
to market their products after manufacturing them in another factory in Bangladesh
on toll basis.
LIST OF HARMFUL DRUGS TO BE WITHDRAWN WITHIN THREE
MONTHS WITH THEIR SCIENTIFIC REASONS & EXPLANATIONS g—
Name of Products and the Manufacturing Company
1. Tetracycline Group of Antibiotic (Syrup preparation) :Clinmycin Syrup (Glaxo), Vibramycin (Pfizer), Terramycin
(Pfizer), Imperacin (I.C.I.), Restecline (Squibb), Sumycin
(Squibb), Aldacycline (Albert David), Oxaline (Pharmadesh), SQ-Cycline (Square), Kedoxyline (K.D.H.), Tetra
cycline (GACO), Ledermycin (Therapeutics), Tetracycline
(NIPA), Ledermycin (Lederle)
I
Remarks
Tetracycline syrups are
harmful to children ( &
pregnant mothers) as they
disturb bony growth of
children upto 12 years of
age & also discolour teeth.
Combination
of streptomycin & <clioquinol.
Clioquinol
|( iodochlor
Stericol (Pfizer), Fistrep (Fisons), Embequin, Nivembin and
hydroxy quin ), vioform
and Di-iodohydroxy quinoline bulk (BPI), Quixaline (Squibb),
( Diiodohydroxyquinoline )
Dysedin (Edruc), Siodoenterin and Enteroguanidine (Albert
is implicated
subacute
David), Ambosin, Adysin and Idoquine (Pharmadesh), Disedin myelooptic- neurop
(KDH)t Enteroxyl (GACO), Intosept (Zaman Pharmaceu
athy ( SMON ) which is
ticals) Dirroqulin (Syntho Laboratories Ltd.), Enterocide
manifested by abdominal
(United Chemicals and Pharmaceuticals Ltd), Auraquinol
pain & persistent diarrh
(Standard Lab. Ltd.), Asiquin (Asiatic Laboratories Ltd.)
oea and it proceedes to bil
Diquine (Orion Laboratories Ltd.), Dioquin (Doctors Che
ateral sensory disturban
mical works, ) Entenol ( Sarma Chemical works Ltd. )
ces, paresthesias & dysethPresotren comp tab (Beximco), Di-iodohydroxyquin Bulk
esias, preferentially in the
( Pharmatek chemical Ltd. ), lodo-chlorhydroxyquin Bulk
distal of the lower limbs,
and Di-iodohydroxyquinoline Bulk ( Halima Kowser),
but upper limbs & muscle
C.iediform (Siba Lab Ltd.), Enterocide ( United chemical
weakness are not exempted.
and pharmaceuticals Ltd ), Dependal, Entero vioform,
Blurred vision & blind
mexaform, Intestopan, Diiodoquin, Enteroseptol.
ness; disturbances of auton
omic
nervons
system,
psychological changes &
greenish discolouration of
Contd.
2. 8—Hydroxyquionline Derivatives
Di-iodohydrony quinoline etc. )
Four
(lodo-chlorbydroxyquin.
Name of products and the manufacturing Company
Remarks
the tongue less common but
present. Similar toxic ef
fects have also been obser
ved with other 8-hydroxyquinolines. These are se
vere genejalized furuncul
osis (iodine toxicoderma),
mild to severe
dermatitis, itching, diarr
chills,
hoea, headache.
fever, disturbance of thy
roid function, etc. Con
traindicated with patients
with hepatic damage or
iodine intolerence. Admi
nistration of iodoquinol
( diiodohydroxyquin, yodoxin ) to children for
chronic diarrhoea has been
associated with optic atr
ophy & permanent loss of
vision.
3. Alcohol containing tonics with vitamins and minerals:
Polytamin ( Hoechst ), Durol ( Pfizer), Rubraton elixir
(Squibb), Verdiviton Elixir ( Squibb ). Tonum ( Albert
David) Sev General Tonic ( Square ), Edicomalt (Edruc ),
Neuroplex Elixir, Neurolecithin and Neurona (KDH),
Vitatone C.1P (Zaman Pharmaceuticals), Vincaron (Syntho
Lab.) Ashoka cordial (Standard Lab. Ltd.) Bilogen paedia
tric with Vit, A & D, Haemoffen, Stanovine and vitamin
B Complex-(Standard Laboratories Ltd), Nuritone and Ext.
Kalmegh (National Lab. Ltd. ), Ext Kalmegh and Rouf’s
Compound ( Bengal Techno Chemical works, Dinajpur ).
Micaberi’s Compound ( Amico Laboratories Ltd. ), Neomalt
and Neovite ( New Light Chemical Industries) Ashoka
cordial (Dawn Co. pharmaceuticals and Doctors Chemical)
Combination vitamin ton
ic including vitamin B12
& alcohol. Alcohol is co
ntraindicated in liver ai
lments of which there is
a high incidence in Bangl
adesh. One of the grea
test abused drugs in the
market.
Five
/
Name of the Products and the Manufacturing Company
works Ltd. ), Liverex and Ext. Kalmegh Liq. ( Dawn Co.
Pharmaceuticals), Evcolecithin (East Bengal chemical phermaceutical works ), Vinolecithin and Vitrone Liq. ( ADDCO
Ltd.), Ext-Kzilmegh and Tr Nuxvomica. (Bectro Chemical
Ltd), Ferritone and plexovit ( Universal Phermaceutical
Ltd,) Feovit (PIP, Pabna), Ferrotone (Reman Drug Labora
tories Ltd), Phospotone and Ext Kalmegh (Bengal Chamical
Industries), Kalmegh Liq. Extr and Reoplex (Pephco Lab.)
Vinophos, Leakoplex and Vita-S ( Chemist Lab. Barisal)
Wineon Tonic ( Mukti Lab ), Genophos ( Green land
Pharmaceutical), Carnovyn Elixir and Carica Peptol Liq
(Carica Lab.), Zocoplex (Zaco. Lab), Bioplex (Bio pharm
Lab.) Neurotone ( Rangpur Drugs and chemical coop), Extr
Kalmegh (Health Lab Dacca).
Zymopax, Betalax and Haemapax (Standard Chemical works),
Vitfolin, Ext Kalmegh, phospholin, Khalpholin (Aman Lab)
Vidivin (United Chemist Ltd.), Vinoport (Sarma Chemical
Works Ltd.) Vinomalt ( Basted Drug and Chemical Works
Ltd.), Ext kalmagh (United Chemist Ltd.), Glypotone (Stan
dard Chemicals Industries), Oraliron (Colloid Lab. Ltd.),
B. C. Malt (Bangladesh Chemical Works), Ext Kalmegh,
(Bangladesh Immunity Co. Tangail), Kalmegh, Qumaresh
and Compiplex (ComiIla Lab.), Vitatone Forte, Ext Kalmegh
and Liq. Bismuth Co-Cum pepsin (Glove Chemical Industries
Ext. Kalmegh ) Great Bengal Chemical and Pharmaceutical
woiks), Ext, Kalmegh and Liq. Bismuth Compound
(Glove Ltd), Livergren and Asoke Cordial (Standard Pharm.)
Vinotone (Eastern Drug Co. Ltd. ), Tinct. Ipecacuqura (Najat pharmaceutical Co.), Ext-kalmegh (Eastern Drug crop),
Polytone ( City pharmaceutical Lab ], Ferrosis [ OASIS Lab],
Diapsin and Sipanal [ SIPA phermaceuticals ], Auriotone and
Elixir Vitamins B-complex [ Indo Bangla pharmaceuticals ],
Biorona tonic and Biovita [ BIOS pharmaceutical ], Opsolecithin [Opsonin chemical Industries], Kalmegh liq, Asoka
cordial and Livatone [ Sattar and Ahmed, Ctg ]. B-Bron-12
[ Purbadesh Chemists Ltd ], Vivalona [ Heilmerk Lab-
Six
|
Remarks
Name of the Products and the Manufacturing Company
I
Remarks
Dacca. ], Ext. Kalmegh [ B. Pharm Lab. ], Enget [ Eureka
Pharmaceutical ], Ext Kalmegh [ Jes chemical and pharma
ceutical works ], Kalmegh Liq [Khandaker Bros and Co. ],
Ext Kalmegh and Pestorine [ United chemical and pharma
ceuticals Ltd ]. Ext. Kalmegh (Green Lab) Natioplex (Natio
nal drug co ), B-G phos.
4.
Multivitamin combination with Enzymes a?d alcohol.
Diaptozyme (Edruc), Celuzyme (Albert David), Banaj liver
drops ( KDH ), Dizyme ( GACO ), Peptenzyme and Enzyme
zP ( Zaman pharmaceuticals ), Dienzyme (Huqsons Leboratories ), Dia^ita (Standard Laboratories ), Decazyme( Bengal
Lab. Ltd.), Prinzyme (Chemist Lab.), Zacozyme ( Zaco Lab.),
Zypolin (Aman Lab.), Enzyplex (Wee Pharma Ltd.), Deresol.
Syrup ( Seema Pharmaceutical Lab ), Peramin drops (NIPA
Pharmaceuticals), Fenozyme (Bios Pharmaceuticals), Citazyme
(CityPharm Ltd), Acipep (Batali chemo pharmaceuticals Ltd).
5. Appetite Stimulants :
Heptamin ( Albert David ), Perigan (National Lab. Ltd.),
Peridin ( Bengal Chemical Industries), Cypadin ( Sonear
Laboratories ), Cyptadin Liq (Therapeutics Ltd.), Penactin’
vita, Periactin, Peritol.
6.
Cough Syrup with Alcohol and Codeine :
Expilin ( GACO ), Partusis cough syrup, ( Anico Lab.),
Syp. Vasak (Universal Pharmaceuticals Ltd.), Keflex ( Mukti
Lab.), RDCCS compound ( Rangpur Drugs and Chemical
Coop), Broncholin (United Lab. Ctg.), Asmalex (NIPA Phar
maceuticals ), Promodyl { GACO }.
Multivitamin combination
with enzymes & alcohol.
Dangerous for hepatic ma
laises.
Cyproheptadine unecessay
appetite stimulant.
Contraindicated in steno
sing peptic ulcer, prostatic
hypertrophy, asthma, elderly
debilitated patients, nurs
ing mothers, new and pre
term infants. Known-side
effects are drowsiness,
somnolence, headache, agi
tation, confusion, visual
hallucinations, epigastric
distress, photosensitivity,
restlessness, paraesthesia,
blurred vision, thrombo
cytopenia and blood dyscrasias.
Cough syrup containing
alcohol &/ or Codeine
{causes addiction L
Seven
Name of products and the manuficturing Company
I
Remarks
7. Atromid-S { I. C. I }
Increases the incidence
of gallstones & cholecys
titis ; drug induced cardiac
arrythmias, cardio-megaly,
increased angina, claudica
tion & throm bo-embolic
phenomena. Clofibrate also
enhances the effects and
toxicity of other acidic dru
gs, such as phenytoin &
tolbutamide. Also implica
ted with an increased inci
dence of various tumours.
8. Menstrogen Tab {Organon j
Misused drug with carci
nogenic & teratogenic pro
perties.
9. Mixogen Tab { Organon }
Combination ethinyloes
tradiol ( oestrogen ) & me
thyltestosterone. The only
indication for use is meno
pausal symptoms, but has
more than 20 contra-indi
cations. A greatly misused
drug with carcinogenic pro
perties. Also a risk of high
blood pressure, hypercalcaemia, hypercalciuria, virilisation, enlarged clitoris,
acne, menstrual irregulari
ties, vomitting, nausea, he
adache, breast tenderness,
mood changes, uterine blee
ding etc,
10. Orabolin Drops {Organon}
Eight
Ethyloestronol. Danger
ous drug for children.
Name of Products and the Manufacturing Company
II. Baralgin Tab and Drops ( Hoechst),
and Inj. Buscolysin Comp Tab.
|
Remarks
Spasmocibalgin Tab
Combination
analgesics
with proven toxic effects ;
safer alternatives available.
12. Novalgin Tab and Drops, Novalgin Quinine Dragees ( Hoe
chst),
Aminopyrine
derivative
(dipyrone) causes
high
incidence of agranulocytosis
In some, it produces sharp
fall of total leucocyte count
associated with chill, fever,
headache, muscle & joint
pain. Aggravates bleeding
tendency.
13. Dytestoma capsule
14. Imodium
(Ediuc Ltd ),
(Square),
15. Influenza Tab (Square),
Apocodin (KDH),
Citapyrin Tab (City Pher Ltd), Refagan.
Combination of testoster
one, lohimbine, strychnine
& caffeine. Common toxic
effects are sustained & pain
ful erections ( of penis/
clitoris), priapism, serious
disturbance of growth,
sexual & osseous deve
lopment if given to chil
dren. According to WHO,
“strychnine should only be
used as a rodenticide.*’
Loperamide has dangerous
side effects such as causing
excessive sedation in chro
nic liver disease and in
children. Aggravation of
spastic bowel syndrome
& precipitation of diverti
cular, disease. Abdominal
cramp is common.
Combination of aspirin,
phenacetin & caffeine. Phe
nacetin is toxic and liable
to be abused.
Nino
Name of Products and the Manufactring Company
16. Rejuvin pill
17.
(GACO),
Gurantrop ZP [ Zaman Pharmaceuticals Ltd. ].
18. Different Preparation containing alcohol and other harmful
ingredients.
Vitaport [ Hugson’s Lab. ], Livetone [ Satter and Ahmed
Ctg ], Dentacure [GACO], Tooth Ache drop [ Anico Lab.
Ltd. ], Dentine [ Raman Drug Lab. Ltd. ], Dentisept [Bengal
Chemical Industries ], Dentine [ Big Benpuhermacenticals ]
Person liq ( GACO ], Phosphovit [ Orion Lab. ], Lyrex
[ Sheba Lab. ], Bioagrol [ Bio Lab. ], Quinigen Liq and
Santopia [ Standard Lab. ], Tonic Apyrex [Sarma Chemical
works Ltd. ], Eastion’s Syrup [ G. M. Lab, Glove chemi
cal industries. Popular chemical works. Green Lab. Dr.
Karim’s Lab. ], Bittergen [ Comillah Lab.], Acidak [Stan
dard Lab. ].
19. Gripe Water :
Companies formulating it :Fisons, Jayson, ZACO, Zaman pharmaceuticals. Standard
Laboratories, Amico Lab., New light Chemical Indus
tries, Dawn Co. Pharmaceuticals, Acme Lab., East Bengal
Chemical Works, ADDCO Ltd. Medicos Corporation,
Bengal Chemical Industries, Mukti Lab., Niramoy pharma
ceuticals, Rangpur Drugs and Chemical Coop, Health Lab.,
United Chemist Ltd., Tropical pharmaceutical Industries,
Globe Research Lab., Eastern Drug and chemical works
Ltd., Pure drug and chemical works, Bangladesh Chemical
works, G. M. Lab., Globe Chemical Industries, alpha Lab.,
Great Bengal Chemical and Pharmaceutical Works, Stand
ard Pharmaceuticals Ltd., Janapriyo Chemical Industries,
Wee Pharma Ltd., Seema Pharmaceuticals, Modern Research
Ten
Remarks
Ext. Damiana yohimbine,
Nux Vomica Etc. Poisonous
useless and Misused Drug.
Glucuronotacton Methion
ine 312 Etc. Harmful &
exploitation through Con
sumer ignorance.
Products containing al
cohol and other harmful
ingredients such as Stry
chnine, Nux Vomica, Bis
muth, Sentonin, Phenolpthalamin, Chincona, Ar
senic etc.
Gripe water has long
been promoted as a remedy
for a child with belly-ache,
especially
young
baby
with colic. One of the
most plausible suggestions
for the cause of colic is temporary immaturity o*
the nerve supply to the ;
large intestine which causes
hypermobility causing baby
to draw up its knees & cry.
The condition is self-limiting & harmless & no drug
is necessary, Most of the
Name of Products and the Manufacturing Company
Lab., Unique Pharmaceuticals, Sattar and Ahmed, City
Pharma Ltd., Unique Lab., Manners Pharmaceuticals, Bangla
desh Pharmaceuticals, Siba Lab., Eureka Pharmaceuticals.
4
1.
Pities,' 6th
2. BBri
Aritish
Nation^
r ; Macra
t‘sh ;,a
Assnn^.Ofla
I
formulary
Association &
3,
Pharmaceut/cal
4.
Eewis, J, j .
forii
E^iinbu^^
J notion tc
5.
1980.
6. Bovvr- Jn of Essential drugs; w
& Rand,
7. Bxtrafflan
Text Book of
iPh• _
1
arni
8. Physicians’ acopoeia> ;
Martindale,
9.
S,de Effects DofkDRefe^cnee-. 198 2
10. Unifed States. p. rug Annual-?,
- Eliarmacopei-a; Us
Note :
scientific
b0Ve sources. reas°™ for ban,
|
Remarks
time a child cries to draw
its attention for affection,
food or change of nappy.
Delays in providing atten
tion, make the child cry
louder & swallow more air
then draw the knees tow
ards the belly giving the
impression of bellyache. The
active ingredient of gripe
water is sodium bicarboan antacid whose
•'Offt.
n cause milk
ome and is
1 in renal isllowing inge.
um bicarbon& an uncomrarely dangelistention may
U1 but 5 gripe
in 5-10% alcothe toxicity
,s, gripe water
ving busiaess
jieal & consuce.
Some Notes ;
Note 1 ; Some of the drugs listed abovi
_
_ __
__-d with quite
different indication and contra-indications in countries where there is adequate drug
monitoring and control system ensuring sale of drugs through the prescription of
qualified physician only. In the absence of similar measures and poor economic
resoures such drugs have been ba med in our country to avoid the dangerous hazards
resulting from indiscriminate use by vast number of unqualified, unregisterd quacks and
self prescriptions by the consumers.
However, further addition and deletion of any drug from the list depends
the future development of Science.
upon
Eleven
Note II ‘Cough Syrup’ is one of the most misused drug in Bang’adesh on being
sold as ‘over th: counter drug’, like mony other drugs. Though this sort of prepara
tions are bring marketed in Britain through prescription of qualified Physicians, yet
British National formulary, 1981 Published jointly by British Medical Association
and Pharmaceutical Society states as follows ;
Expectorants: There is no evidence that any drug given by month, by inhalation or by injec
tion has a specific action in prormoting expectoration of bronchial secretion by stimulation
or augmentation of the cough reflex. The retching and vomiting which can be provoked
by gastric irritants, such as ammonium chloride, Ipecacuanha, and squill can certainly
expel mucus from the air passage at the same time, particularly in children, but the
assumption that ‘subemetic’ doses of these and other drugs promote expectoration is
aniyth. There is thus no scientific basis for prescribing these drugs although a harmless
expectorant mixture may have a useful role as a placebo. It is irrational to prescribe
an expectorant in conjunction with a cough, suppressant, antihistamine or bronchodilator
drugs. B. N. F. 1981, P-94
Comp. Preparation : There is no advantage in prescribing a preparation containing
several ingredients that have similar therapeutic properties, or in which each ingradient
has a different action.
Combinations such as expectorant and cough suppressant, sympathomimetic and
sedative, and any or all of the?e with other types of drug such as antihistamines are
to be deprecated If particular components are needed they should be prescribed sepa
rately and dosage adjusted separately, B.N.F Nov 1981, P-96
Note 111 For successful implementation of a people oriented drug policy in Bangladesh,
participation of Bangladesh Medical Association ( sole national organisation of doctors)
in all aspect is very much essential.
ALPHABETICAL LIST OF ESSENTIAL DRUGS
In accordance to the World Health Organization technical report
(series 641, Published in 1979)
A
acetazolamide
acetylsalicylic acid
adipiodone meglumine
albumin, human normal
allopurinol
aluminium acetate
aluminium hydroxide
amikacin °
amiloride
aminophylline
amitriptyline
amphotericin B
ampicillin
anti D immunoglobulin
(human)
antihaemophilic fraction 0
antihaemorrhoidal prepara-
tion-local anaesthetic, astri
ngent and antiinflammatory
drug
antimony sodium tartrate °
antirabies hyperimmune
serum
antivenom sera
ascorbic acid
atropine
azathioprine
Twelve
( Contd. )
4
»
B
bacitracin + neomycin
barium sulfate
BCG vaccine (dried)
beclomethasone 0
benzathine benzylpenicillin
benzoic acid + salicylic acid
benzyl benzoate
benzylpenicillin
bephenium hydroxynaph
thoate °
betamethasone
bleomycin
bupivacaine
busulfan
C
calcium carbonate0
calcium folinate
calcium glueonate0
carbamazepine °
carbidopa + levodopa 0
charcoal, activated
chlorambucil
chloramphenicol
chlorhexidie
chloroquine
chlorphenazine
chlorpromazine
chlortalidone0
clofazimine °
clomifene
cloxacillin
coal tar
codeine
colchicine o
compound insulin zinc
suspension
cromoglicic acid o
cyclophosphamide
cytarabine
D
dapsone
Thirteen
dieferoxamine
dexamethasone
dextran 70
deazepam
diethylcarbamazine
digitoxin °
digoxin
diloxanide 0
dimercaprol
diphtheria antitoxin
diphtheria-pertussis-tetanus
vaccine
diphtheria-tetanus vaccine
dopamine
doxorubicin
doxycycline 0
E
edrophonium
emetine 0
ephedrine 0
epineph rine
epinephrine 0
ergocalciferol
ergometrine
ergotamine
erythromycin
ethambutol
ether, anaesthetic
ethinylestradiol
ethinylestradiol + levonorg
estrel
ethinylestradiol + norethist
erone
ethosuximide
F
factor IX complex
(coagulation factors II, VII
IX. X« concentrate),
ferrous salt
fibrinogen
flucytosine
fludrocortisone
fluorescein
fluorouracil
fluphenazine
folic acid
furosemide
G
gamma benzene hexachloridc
gentamicin
glucose
glucose with sodium chloride
glyceryl trinitrate
griseofulvin
haloperidol
halothane
heparin
homatropine
1 x h zine
hydrochlorothiazide
hydrocortisone
hadroxo cobalarn i n
I
ibuprofen
immunoglobulin, human
normal
indomethacin
influenza vaccine
insulin injection
intraperitoneal dialysis
solution
iodine
iopanoic acid
ipecacuanha
iron dextran
isoniazid
isoprenaline
isosorbide dinitrate
L
levodopa
levodopa -f-carbidopa
levonorgestrelethinylest
radiol
levothyroxine
lidocaine
lithium carbonate
M
Magnesium hydroxide
mannitol
measles vaccine
mebendazole
meglumine amidotrizoate
melarsoprol
meningococcal vaccine
methotrexate
methyldopa*
methylthioninium chloride*
metrifonate
metronidazole
miconazole
morphine
N
naloxone
neomycin + bacitracin
neostigmine
niclosamide
nicotinamide
nifurtimox
niridazole
nitrofurantoin
nitrous oxide
norethisterone
norethisterone0
norethisterone + ethinyle
stradiol
nystatin
O
oral rehydration salts (for
glucose-salt solution)
oxamniquine
oxygen
oxytocin
P
paracetamol
paromomycin0
penicillamine0
pentamidine
pethidine0
phenobarbital
phenoxymethylpenicillin
phenytoin
phytomenadione
pilocarpine
0 Complementry Drug
piperazine
plasma protein0
poliomyelitis vaccine
( live attenuated )
potassium chloride
( oral solution )
potassium chloride, par
enteral
potassium iodide
prednisolone
primaquine
probenecid
procainamide
procaine benzylpeicillin0
procarbazine
promethazine
propranolol
propylthiouracil
protamine sulfate
pyridostigmine
pyridoxine
pyrimethamine
pyrimethamine + su fadox ine®
Q.
quinidine®
quinine
R
rabies vaccine
reserpine0
retinol
riboflavin
rifampicin0
S
salazosulfapyridine
salbutamol
salicylic acid
salicylic acid + benzoic acid
senna
silver nitrate
smallpox vaccine
sodium amidotrizoate
sodium bicarbonate
sodium clacium edetate
sodium chloride
sodium chaloride with
glucose
sodium fluoride
sodium lactate, compound
solution
sodium nitrite
sodium nitroprusside
sodium stibocaptate*
sodium stibogluconate
sodium thiosulfate
streptomycin
suKacet amide
sulfadimidine
sulfadoxine+ pyrimetha
mine
sulfamethoxazole + trime
thoprim
suramin sodium
suxamethonium
T
tJ
testosterone
tetanus antitoxin
tetanus vaccine
tetracaine
tetracycline
thiamine
thiopental
tiibendazole
trihexyphenidyl
trimethoprim + sulfametho
xazole
tuberculin, purified protein
derivative (PPD)
tubocurarine
typhoid vaccine
V
valproic acid
vincristine0
W
warfarin
water for injection
Y
yellow fever vaccine
Prepared by Sasthya Pratirakha Committee (Health Protection Committee) Bangladesh.
Address :
70/4, Jhigatola, Dacca-9
Printed by ;
Ideal Printing Press, 19, Shaikh Shaheb Bazar Road, Azimpur, Dacca.
A.T N.
*
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”It is a responsibility of the Government
to protect the consumers from being hood-winked
into spending their scanty resources
on useless, unnecessary and (at times) harmful drugs."
— DRUG POLICY OF BANGLADESH
JUNE 1982
;•
In June 1982f Bangladesh introduced a Drug Control
Ordinance which called for the removal of nearly
1700 drugs from the market because they were ■
useless, unnecessary or harmful. In a few short
months, Bangladeshis Drug Policy has attracted
world-wide interest. Jvz4J? OB WANT has prepared this
briefing paper to provide some of the background
to the events in Bangladesh and explain some of
controversy behind the Drug Policy.
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COMMUN'TY HEALTH CEU
/1'(RF17tHoo--»- ^rks Road
BAAluAtORE-SUOOOl
This briefing paper was compiled by Andy Chetley, and is based on
in the field interviews; press reports; War on Want, Oxfam and
Health Action International materials.
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Particular thanks are due to John Cunnington, Dianna. Melrose and
Charles Medawar for the direct and indirect assistance they provided
in helping to prepare this briefing paper.
Published by War on Want, 467 Caledonian Road, London N7 9BE.
November 1982
Further reading on the Bangladesh Drug Policy:
Medicines and the Poor in Bangladesh, by Dianna Melrose; Oxfam, July 82.
The Rational and Economic Use of Drugs, in the Third World; Health Action
International, August 82.
In Touch, newsletter of the Voluntary Health Services Society, Bangladesh,
July-August 82.
/^Further reading on pharmaceuticals:
The Health of Nations, by Mike Muller; Faber & Faber, May 82
Bitter Pills, by Diarna Melrose; Oxfam, November 82
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Drug Diplomacy, by Charles Medawar & Barbara Freese; Social Audit, Spring 82
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Who Needs the Drug Companies?, by the Haslemere Group; War on Want, 1976
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War or Want
467 Caledonian Road , Londe/? KZ
November 1982
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Looking ahead
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THE BANGLADESH DRUG POLICY is a significant initiative in efforts
to rationalise drug therapy. Health Action International, the
network of non-governmental organisations active on pharmaceutical
issues, notes that:
"Bangladesh has done what any health-conscious nation should do. If
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That includes, of course, industrialised countries. Although some
efforts have been made in Britain to rationalise drugs, the latest
edition of the British National Formulary lists some 500 products
of marginal or questionable therapeutic value. There are likely to
be other savings that could be made in Britain’s drugs bill —
perhaps as much as 20% of the more than £2 billion annual expenditure.
Bangladesh has demonstrated that a rational drug policy can be
introduced. It has also demonstrated that it is not an easy task.
One member of the Expert Committee commented recently:
"The battle is far from over. The policy still has to be
implemented in the face of continuing opposition and pressure.
A vigorous doctor/consumer education campaign needs to continue
in the country to counteract the deliberately planned confusion
which has been created in respect of the drug policy. II
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If the policy in Bangladesh succeeds, it marks a major step towards
ensuring that the people of' Bangladesh receive quality, low-cost
medicines which meet their specific needs. And if it succeeds, it
could stimulate other countries to introduce similar measures.
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The pharmaceutical industry is well aware of what is at stake’.
According to Business International, the success or failure of
intiatives like the drug policy in Bangladesh
"could well determine whether TNCs will be able to retain
their freedom to market a broad range of consumer and health
care products outside the industrialised world."
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As George Teeling-Smith, Director of the industry-financed Office of
Health Economics in the UK, said of the industry in 1979:
"They are businessmen, not bishops ... If there is a hostile
climate the companies must be expected to grab as much profit
out of a country as they can."
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And while the industry ponders its profits, and its freedom to market
products which do not necessarily cater to public health needs, it is
worth recalling a statement made by Dr Mahler of WHO, also in 1979:
"I have no illusions about lots of the cosmetic things going on,
and I can only say that perhaps we have got the ‘pharmaceutical
cardinals* slightly more on their toes . 1 . This is not because
all of a sudden they have been converted, but simply because
they realise that in the kind of world in which we are living,
there is a limit to indecency; and perhaps we have promoted a
beginning of a platform for decency."
Perhaps, too, that is what the Drug Policy in Bangladesh has begun
to do.
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LASOUR WEEKLY JULY 23 1WH
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? r’Ns ■ tx z’"
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■ Phu/Miur xu» ufien double as doctors and prescribe their own wares. Many are untrained and unlicensed. Any drug
< an be bought wuhuut a prescription. Picture Tom Learmonth.
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1‘lit glowing piwer of multrThey du however represent signifi
nuiiiui.il coinp.iiiics is a matter of BY JOHN CUNNINGTON
cant gains in terms of profits.
coiKcrn to gioc’itnncnts and indi
More sinister if not surprising is
viduals alike, f Iik is nut surprising„ for these reasons the British the move bv governments, partiuuparucusince ptcscui luuds suggest that b<>y Monthly Index of ethical drugs, larly the U§, to get the new policy
the vear
per cent of afl
>“ MIMS, lists, Orabolm as Not "reappraised”, when Lt Gen Erworhl tr.id«* will be conducted by Recommended for Children.
shad, chief martial law adminis
the ii<uliiii.ii«'U.ils
Yet the manufacturers in full trator of Bangladesh, was in New
the |’iiiu.«i>, d not Mile, motiva r
_______
.,._
7
_
__
_____
.--.-L/ to address the
possession of the medical facts 7_.L
York recently
tion ut iiuiltiiiahonuls is profit continued promotion of this drug United Nations lie was approached
tiMxnnbatiou la the held of drug for children in Bangladesh.
by the multinationals and urged to
produuiwii this is intolerable.
In accordance with the new pol- reconsider
--- — the drugv policy.y .•
I he govkiiuitviit of Bangladesh icy on drugs of sample technology,
Similarly in Bangladesh the US
has oJ.ipKii a luUmial drugs policy the multinationals arc also expec
expec- ambassador, Jane Coon, has also
to concentrate
technology
on the needs ut the majority ot the ted
' ----------—— (heir----*—’
approached Lt Gen Ershad and
population in Bangladesh. The and resources on the production of Major General Shamsul Hud’ gov
poky) is
■ polK
t> need
in. oiicnttd rather than complex and innovative drugs and ernm^nt
ernment health
health advisor,
advisor, on oenalf
profit motivated and therefore a to move out of the production of of the multinational interests.
| cuntlKt ot iniciests is evident from simpler preparations such as aspirits adopted slogan
„ i of
J Ihcuutwt
in, paracetamol, vitamin* and ant- -‘Health for Air’ one
one could
could be
» It upciis ttie door for similar acids. At present 40-60 per cent of forgiven for assuming
assuming that
that the
.tmtialivc* Iiuni other governments the manufacturing capacity of World
Organisationwould
would
------ Health
---- Organisation
iw ho Ims c ao xniiiitment to healthy
q
back a policy which
argues for
'people father than healthy profits.
putting into practice the recomIhc govcinniciH ut Bangladesh
mendetions of their "Essential
'has banned with iminediatc effect
Drugs List".
2D laijkly "iMinitul” medicines
The list itself has undoubtedly
and uidi'icJ the rclormulation or
made a great contribution to health
withdrawal <>| a further 151)5 "uncare since it was written in 1977. It
tu'cevsary*' diuga by March I98J. multinationals has been devoted to is thercfuic even more disturbing
Uh. mt wttc the rceuinmendatiuns producing drugs in this category,
•to
note at this time that according
The government has banned
of an cighi nmiibcr committee of
the WHO representative in
‘Third partv'’ licensing — the prac to
experts
Bangladesh
replying to a question
'ihc products arc- marketed by tice whtreuy a company without a regarding the adoption of the new
17b iiHiip.iiiics. although eight factory in-Bangladesh licenses an drugs policy "...it is not WHO’x
rnulii'iuiioiiul.s voutrol ttt) per crnl other company to make its brand rule to eithet applaud or condemn
of ihc drug iuurket m Bangladesh. name product, fhc ban comes as the poiky.”
Ihc basis lhi which drugs have no surprise given the appalling
Pie wakes are high and the
record of failure to invest by the
been hjiiiivJ lull into three main multinationals.
.
!la-d<w
calcgoi
calc
got ics. hairnful
haimtul or unnecess multinationals.
The
new
drugs
policy
is
expected
to
.
i<>. drugs
umrs produced
proutitcu by
uy uic
muiu- . ~
----- /-----1----ary'
the multi.1^ <?> had demunstrawd pren<
‘
‘
’
tatiimak
Which
require
only to produce foreign exch.rftge «IVsa,
in excess
ot million
£2 million
• kxluuilogy,
■ • ■
□ mgs ings
in excess
of £2
pc. per------v*°t
... ls»y j^st bow far it will go to
sitnnk
drugs...puxluccd
_
t-i.:This
_
i.i.. .i . the govern__
enables
.nr.bfm
P^versr invArsiou
xovereign iiuverair.ents
governments
urukr "ihird pur|y‘r licensing annum.
__ adapting
jdopting similar policies, in
men! and health workers to con- '*fom
agreements.
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when
ten
Pfizer
was asked
vas
Sri
Lanka,
wnl
on providing the most
Du li.irmtul or unnecessary centrate drugs
to a larger section 1°. prtwfo^ more 10 a<.coru«tnce
drug* ihc •irdiiiance bans those essential
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With
the
needs
of
the
country
and
with a lomlimatRiii ut different of the population.
Predictably the multinational also cut the manufacture of un
antibioiK-.. ;ni.tl2csics, prepara
necessary drugs from 40 to 25 per
tion* of duubiiul value such as drug companies arc far from happy cent the US government threaten
gn|x: water, <ough mixtuiev arid with the new policy By Use end of ed to slop all food aid under the
multivitamin* (except the B com June sources in Bangladesh indi PL48O agreement.
cated that some of the major com
plex).
Pfizer still refused u> modify
panies were threatening io with
Au example ot a drug tn the draw all production facilities in the production in accordance with the
hatmftil lategon is Orabolin. In country
intry ’including those for cses needs a>f Sri Lanka. Similarly in
Bjtiglad<*h inulnuirition affexts 97 sential
tial drugs unless the policy was 1974 a coniract to sell 4 million jute
pel cent of the ihildren. Oiabolm reversed.
bags to Cuba was seen to "be
is tccmiiniciidcd by the manufac
Most ‘•new" drugs arc highly prejudicial to the further committurersOrganon in their promotion Hucitiorublc in therapeutic terms, mr.nt cf USPL4S0 food aid."
al liter.ituic lor use- in children who bur example in
of the I.OS?
it reswains to be seen whether
arc malnouii-khc-l ,
drugs submitted io the US Fuud the gov*-< nment of Bangladesh can
( liulioltii is an unalxilic slcruid. and Drug Admitiutraiion. for pro- resist C-e picwurc froru multiI'M Hrihnti it is Used only in ot;«:o duct licences, just over 2 per cent national -cui'pc-rntipns tnd put into
jx^rr,. cIiiuok. kidney failure, ms!- were considcted to be of high pracL-.c a rational health pulky.
ignatH disease and lu build up therapeutic break through; a little
Or wbsd:»er, under pressure,
patients .iiur inaior surgery or over 8 per cent were considered to they wa forced to seek ways and
scoou. 4u ide iits.
be uf . moderate thcraiveutic a<l- means, -if Taodifying” the policy in
It anjMiiies ait ted to children vancc; whilst (he rcnutnmg hv per the imexzsu of their own survival,
the subs* i.n in avick'rxted gri/wih cent were claxsed as being of hide
may tic |>i|kn*cd by premature or no therapeutic udv«n*awe.
K A.’Aei Cunmngatn ii War on
stuiitmg h it.ay al.w) cause fluid
in other words 9 out of 10 drugs Wants
ojlictr for the
retention .mJ rumors of the liver. have little value in hcaith tcrnis. 'isultan u^^oniuifni.
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Dangerous medicines
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FOR MANY YEARS health workers in Bangladesh
have been concerned about the misuse and
abuse of drugs in Bangladesh. As early as
1957 articles began appearing in Bangladesh
publications about the need to control
the marketing of drugs in Bangladesh.
Help the- child to grow with
OraboHn
The problems that were noted were the
promotion of inappropriate drugs; the
expense of many drugs on the market, and
the fact that they often diverted scarce
resources away from less expensive and
as effective remedies for basic health
problems; and the presence on the market of
both useless and potentially harmful drugs.
A cki»d » -o-M -i
->, ; end louqMt’. Io»t
el po'»"ti. Ard I'.a’ i - •>!
ell ekiH't* r,,., to j-?heolt>.y exd alt • Jy
•vt d u r®t ol~ori re I'*bolorccd d ef. per- orn'1 ‘r
®r.<i lir»«i"l - '»*» eMr
in(ed<re W.th *: e ----el tl»ild e»
Two examples of the way in which the
pharmaceutical industry treated its
customers in Bangladesh are shown in the
advertisements reproduced on this page.
Orabolin is an anabolic steroid, manufactured
by the Dutch company, Organon. In Bangladesh
the product has been advertised as a good
treatment for malnutrition in children.
In Britain, doctors are advised by Organon
that the product is "not recommended for
children" because of the potential side
effects which include stunted bone develop
ment. A leading specialist in steroids,
Professor Jeffcoate comments:
"If anabolic steroids were used in Western
Europe to pi'omote growth in children, there
would be a massive public outcry,"
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Similarly, Bristol-Myers, a US-based
pharmaceutical company, showed little
regard for correct information in its
advertising during 1980 for CeeNu capsules —
which according to the company was a
life-saving anti-cancer drug. In the US,
it is only allowed to be administered by a
few hundred specialist for two specific forms
of cancer, because of its "limited
effectiveness" and "deadly adverse reactions."
The dishonesty of the claims made for many
pharmaceutical products like these was one.
of the factors that led to the establishment
of an Expert Committee to:
"evaluate all the registered/licensed
Pharmaceutical Products presently
available in the country and to
formulate a draft National Drug
Policy
consis
tent
with the
health
While Bri»tol-Myen may
tional trumpeted the introduc
needs
think it can convince the citizens
tion of CceSu capsules in the
of the
of Bangladesh ihai itXdiscovered country, and identified the drug
country."
a cure for cancer, consumers in a* a “life (wiving unti-cuncer”
Orabc-cn
Ensures
normal
grov/th
Stimulates
appetite
3'^4Wxi--u
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GROWTH IN EVERY DROP /^)
STRENGTH IN EVC1*-’
GRGANON (BANGLADESH) LKCT.’iD
Thp. Orabolin advertisement appeared in -7
ference magazine on "The Role of Ruril
in Child CarcK9 which took place in i'ac^n'r.
Children's Hospital in May 1981. The ^onferrnawas sponsored by the World Health
and the Bangladesh Ministry of Health.
Bristol Myers’ ‘Third World’ C&BHC8F CUTC
The Com
mittee was
set up in
April 1982.
Within 12
days, it
had final
ised its
report, and
the basis
for the
new Drug
Policy was
established.
the U.S. thinks to government
regulations tic protected from
such misleading claims In the
January JI issue of the Sandiadf\h Ttmt\ the U.S multina
agent, an inaccurate characteri
zation that uould not have hern
permuted in the U S.
When the Monilur received a
copy of the ad. uc immediately
B ANNOUhlCWENT LI
ere ptaeaed to »nr>our.:e &•.»! our Wt-M.ing AntlO’uj ~CmHu Ca'n«n*i i-sno» avalltbl* in Dacca
er ini^cfioni cM«v:o.u ur><J eruqji,l, "CmNu" win ;w
erresc tn if., pettont* o<M>- t'«i>',' aoclree pretcripMont
TM ConOoiiBr Qaneial ch'
t 4u3£>He». Cov»m'n«(-nt
e‘ W*> (“iri-fVsra R»oub1'>c c-l »SA9l»O»«h. Mt
B.e
weilmum rtltll erlce
*«■;►> eomtlnallon psck
(c*n1r!<Mn| I orpevtot)
Tk £->2 ?J
fckDRTSL-erm | ^SClACtSH | IMC.
ferecx* o’
Mimimiia twm lanmTmi
01VI5.'OK
fes-u Y&A. U J.A.
HcMmlJc o! Bretol-M>cr\’ rd
promotes
Optimal
V/'Jig hl
turned to th« 1‘hysicianC Iksk
Reference CP15R). an authorita
tive directory .ol vital tnfnrma
tinn on drejs- void tn the I S
CecNu‘% l’l>R entry paintx m
picture far different horn HrixtolMycrv’claitnx. I he d'up u of ex
tremely limited cffvctncncxx and
can pcnciati-deadly adverse rcai
lions In the 8 S . the I nod and
Drug Adm^eixtratinn rccorhmrnr.lv that %pcciii!Iy-trained
dcu.iorx nunt.J-K.ring only sev
eral hundred csthc entire country
- adntinivtcr tt ax a secondary
Ihciap) for t*o xpec'fic fornix of
cancer: brain tumorx and Hodg
kin v disease SSrishil-Mvers- ads
for the diuj in I1 S nicdicnl
jourmdv run 4o two lull pages.
■ nd include i» -detaifed accouni nF
hazardv axxecsii’cd uuh itx use
Millon I Ri*. t Brixfol-Mwrx
Gflicial. expro-vrd alarm #t the
ad I ■IH-Iling <1 "a litilc more
aggrcxvBc tham uh-n «c rm
XV-fii.x‘pirdg.<<I...dm>h|
thoxe rcxponxiKt, uninp •Ininterested in imex'icHinig uh.could he running nn ,«! Mr ibi. '
fllix cvpl iinx t'. ii xxhili
Hi ixfnl-M x< ix dpi i.|| » fnt
u holly -i»u m J
• ii»' i.l..,
round the m mid n i.
ni u tn ll’t tnit-in.i'ion ■'
btivinc-xx “ I in h
•
He reign ox i pi, ..I- i.i
d<K-x nni li.-i»c ii- .1
p- •
fampiiignx «iih i iiip •••
•quaik tx " \ l(.i .i* oio
arc incxpc ric m < d
lheve ptndiutx
fi.
Oh'iciatx at tin ft m|-i,id-x’h
r..
Fmhaxxy in tfi' I 'x an- not
moved h\ Rri.t.-I Mvctx
mrv
perience.” Amh.ixxn/im lohat.ik
lluvNitn 1»bx xml ilir nd vlong
with (ec’vu’v ri'i’ d •.rtihhi
to Ranghdrxl: xi.i 'li|'l-irnah<
pouch to: review hx ifu- • • •<< <i\ \
medical hoaid
l>n.
I’h* v'l he
taken ven vrui i'ik v> i’.inpi.i
dc'’h," emri't'.izi s
Alam. cnunsrihH
n thr
tfnhas*)
lr - tr- •< ■•/l
Bristol-Myers advertisement appeared in the 3] Jon 1980 is^e of the B.inaladceh
Report of the incident reprinted from Multinational Monitor,_ March 19^'
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Irrelevant med icmes
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ANOTHER PROBLEM facing Bangladesh was that many of the drugs on the
' market were irrelevant to the health needs of the Bengali people.
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In 1981, an estimated 1500 million Taka (approx. £39 million) was
spent on drugs in Bangladesh. According to the Expert Committee:
"Nearly one-third of this money was spent on unnecessary and
useless medicines such as vitamin mixtures, tonics, alkalisers,
cough mixtures, digestive enzymes, palliatives, gripe water,
and hundreds of other similar products."
One of those products, Polytamin Tonic, manufactured by the West
German firm, Hoechst, was described by the Expert Committee as a:
"combination vitamin tonic including vitamin B12 and alcohol;
one of the most abused drugs on the market."
Hoescht argues that:
"Bangladesh is in a chronic state of malnourishment, the vital
supply of polyvitamins is essential in countries where a
balanced diet is not available."
Dr Martin Schweiger who spent many years working in rural areas in
Bangladesh rejects Hoechst’s argument:
"Malnutrition is not treatable at all by drugs, and it is the
biggest single problem — malnutrition is treated with food.
People will die from lack of calories long before they die
from lack of a particular vitamin."
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Doctors at the Children’s Nutrition Unit in Dacca, a hospital which
only admits children suffering from third-degree malnuttition — the
most severe cases, agree with Schweiger. As part of their efforts to
deal with malnutrition, the doctors provide a training course for
mothers of the children and encourage the mothers to stay with their
children while they are in the hospital. In this way,
"the mothers see that it is food, not some medicine or drug
that we give their babies to help them recover. They then see
the importance of the right kind of food — and food that they
can afford."
Obviously, money spent on useless vitamins and tonics is money that
cannot be spent on purchasing the right kind of foo-d. In an industrialised
country like Britain, wasting money on unnecessary drugs is merely
foolish. In a country like Bangladesh, it can be a matter of life and
death.
This type of waste affects not only the individual family by leading
to a substitution of non-essential products for essential nutritious
foods, but also has a displacement effect on the production of
essential medicines. The Expert Committee noted:
"Though the mulatinationals have all the technologies and know
how to produce sophisticated essential drugs and basic pharma
ceutical raw materials, in Bangladesh these companies are engaged
mostly in formulation of simple drugs, including many useless
products such as vitamin mixtures, tonics, gripe water."
As a result, 90 of the 182 essential drugs needed for the public
health services are not produced in Bangladesh.
The International Federation of Pharmaceutical Manu■'acturers Associations
(IFPMA) — representing most of the world’s major p’ armaceutical companies —
states in its code of pi-actice that all the product:; made by the industry
should have "full regard to the needs of public health". In Bangladesh,
it is clear that regard has been missing.
nsive medicines
®
-sa ©
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BAD MEDICINE inflicts a high cost on health, It also costs in monetary
terms.
The pharmaceutical industry in Bangladesh constitutes a large
large drain
drain on
foreign exchange. Despite having 177 licensed pharmaceutical companies
in the country, it was still necessary to import nearly £8 million
worth of finished drugs every year. On top of this, an estimated
£16 million worth of raw materials are imported each year.
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Obviously, cutting back on the number of drugs — by getting rid
of those which are non-essential — is one way of decreasing that
foreign exchange drain. Another way is to tackle the structure of
the industry and control some of its trading patterns.
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The market for drugs in Bangladesh is dominated by Just eight transnational corporations (TNCs). They are:
Fisons (UK)'— approx 11% of total market
Glaxo (UK) — approx 9% of total market
ICI (UK)
— approx
approx 5% of total market
Pfizer (US) — approx 16% of total market
May & Baker (Er) — " 10% of total market
Hoescht (Ger) —
’•
9% of total market
Squibb (US) — approx 9% of total market
Organon (NL) — n
5% of total market
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Together, they control some 75% of the market, This domination of the
market by the TNCs leads to the opportunity for ’’transfer pricing" with
the raw materials. In this way, the local subsidiary in Bangladesh
is charged more by the parent company for raw materials than if the
materials were purchased on the open world market. Squibb, for example,
paid three times more than a local company to import tetracycline.
ICI paid five times more for levamisole than a local manufacturer.
May & Baker paid five times more to import metronidazole than local
manufacturers.
The usual justification for this.practice is to ensure quality. Squibbsays for example:
”We buy from our affiliates because we are guaranteed the materials
will conform in every particular to the exacting Squibb standards . .
We cannot risk wasting precious foreign exchange import licences
on critical materials from outside vendors that may prove to be
sub-standard and therefore unusable.”
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A Horld Bank study on pharmaceutical production in Bangladesh came to
a different conclusion. It estimated that considerable savings could
be made if the cheapest reliable sources of raw materials were used,
and if local production was undertaken.
The experience of Mozambique supports this view. Mozambioue tenders for
drugs on the open market, buying at the best possible orice. A recent
report notes:
Drug imports in Mozambique today cost the same as they did 10
years ago: about US gl per person. Mozambique is buying a lot modrugs for its money, simply by not wasting money on useless and
dangerous drugs, on fancy packets, and on well known trade names H
Making
•
<T>
policy
v/ THE EXPERT COMMITTEE had a difficult
task ahead of it.
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It consisted of eight members, all
with expertise in pharmaceuticaIs -indeed, three of the members had served
on a previous Expert Committee in
1971 .
Chairman of the Committee, Professor
Nurul Islam, noted the commitment
of the members of the Committee:
"The task u’er admittedly herculean.
The sincerity of the memberr- uvu?
much more than one could expect.
During the entire procedure the.
principle of unanimous dcricion with
up~to-date scientific logic was
strictly followed and eculd be
achieved. "
The Committee first of all established
a list of 150 essential drugs "con
sidered adequate for most therapeutic
purposes" and envisaged the need
for a list of about another 100
drugs to deal with specialist health
care needs.
After establishing the basic elements
and objectives of the Drug Policy,
(reproduced right), the Committee went
on to draw up a set of 16 criteria
for evaluating drugs on the market
in Bangladesh.
<:
The main clemenis ol rhe National Drug Policy
(a) to ensure that the common people get ti e.
necessary drugs easily and al a cheap rate
that such drugs are of good quality 2nd
eRcclivc and safe:
’He! nml
To ensure
useful.
th) io mkc steps io ensure that the pric? o{- f-cc imporTrd
as well as the locally mnmikicturcd drugs is. brought
vilhtn the reach of the people:
tc) fo slop in a gradual way import and f anufftefu’e of
such costly drugs as arc neither essential nor requi^l
for treatment and for which appropriate- substitute?
available. :
(d) to provide, on a priority basis, TtfqtnreJ +ac«f(fiesic
local drug manufacturing industries so that seKSix(Ji<.i<?rKy
is attained in the manufacture of «>$$(>n‘»-3l d-furs^
(e) to prohibit the import, manufacture am!
of *b»ugs
uhich have been or will be adjudged
or in
jurious by the experts. If any drug is spseiGce’ly
ficd as injurious to health, the import, mcinur<5<tu’-e.
distribution and sale of such drug will be- inv^ediat#ly
banned and steps will be taken to destroy its stock:
(f) to exercise government control over advert’iemenrso th.ai
common people are not hoodwinked bx
advertisement on health matters and on
necessary and injurious drugs:
Professor Islam said:
"AH ' the -criteria core scientific. No—one
anywhere could challenge it. Ve based th<
criteria on the most up-to-date scientific
infermatien — current information —
1982 information. 'This is rare for a
developing country. Usually the inferma'tion available is years out of date —
not fust one or two years — but several."
(g) to exercise control on the import of dru^C and raw
materials so that these arc made available nr icesonabfe
price. Government may establish control over thimport or manufacture of packaging and container
materials so that these do not lead to c-rre^lxc cost d
finished drugs.
The criteria are reproduced on the next
paae. Twelve of the points deal with
health aspects primarily, while the
remaining four deal with economic
considerations.
(h) to enirust the local companies, with the resvo’xobdity of
manufacturing tho^ drugs which they cef p.ruduce in
adequate quantity and to entrust the forevgn ec’-p^niry
to gradually manufacture high quality dn gj.
with their ability and skill:
Once the criteria were established,
it was a relatively simple task to
check the list of drugs on the market.
Out of 4140 products examined, the
Expert Committee decided that 1707
products should be removed. These
products wore divided into three
categories:
1 . Those that were positively
harmful and that should be
removed within one month —
305 drugs;
2. Those that needed to be re
formulated in order to stay
on the market, within 6 months 134 drugs;
3. Those that were useless or
unnecessary, either because
of a lack of efficacy or because
an alternative was already
available. The Committee
recommended 6 months for their
removal — 1268 drugs.
(i) to enirust all local/foreign companies with die rpspeniibility of ensuring that all the essential drug? are manu
factured in the country. With this end in mcw. the
government may make it obligatory on these <-«'mpnmes
to manufacture essential drugs according to tbnu pm
duction capacity.
The report of the Export Committee was
submitted to the Chief Martial Law
Administrator on 12 May 1982, and after
two minor ammedrnents -- extending the
time allowed for the first category to
3 months, ana the third category to
Q months, the Policy became law on 12 June.
I
(j) to ban the manufacture, sale and di'drihiit ;on of bo^uj.
adultcred and sub-standard drugs and to .n-A-a'd exemp
lary punishment to persons guilty of such .-’chons. S<
<>uc..
milaily, the production or sale‘distributwx nf <,
V'e. V'lll
prohibited as being unnecessary and
be penalised. This measure will also be rpphteblr in
the case of Ayurvedic. Homeopathic and Unem f'crlifines.
(k) to constitute necessary number of Diug Court’s to try
Such
guilty persons and to punish themi
Courts'shall have at least the powers of a
.. 1- • . 1 I
a « ‘ a
♦
I ZS
f I
t
/x • 1
re
(I) To strengthen the system of procurement, Storage and
distribution of drugs and medicines so that rb^r ;i?c
accessible to people in all areas of the country zind ai-.n
to ensure that there is no wastage of drugs .-m-l r^dicines. To achieve this, necessary admirisf^ifr.c *':•<lure of Drug Administration, Medical
-,n'l l--c
Drug distritution system may be improved.
'
(m) To lake gradual steps to manufacture, d-Vrib^te
sell drugs by their generic names
' 'd
—
I,
Criteria of the Drug Poliev
11
?
.
Il is unanimously decided that the following criteria will >crve
as the guidelines in evaluating all the registered/licensed Pharma
ceutical products manufactured and/or imported in Bangladesh:
'1
HI The combination of an antibiotic with another antibiotic
oi antibiotics with corticorsteroids or other active
subiiances will be prohibited. Antibiotics harmful to
children (e. g. Tetracycline) will not be allowed to be
manufactured in liquid form.
i
Oil Hie combination of analgesics in any form is not allowed
as there is no therapeutic advantage and it only increa
ses toxicity, especially in the case of kidney damage.
The conbination of analgesics with iron, vitamins or
.ikohol is also not allowed.
I
I
.1
!
J
(hi) I he use of codeine in any combination form is not
allowed as it causes addiction.
in} In general, no combination drugs will be used unless there
is absolutely no alternative single drug available for
ncatment or if no alternative single drug is cost-effective
for the purpose. Certain exceptions will be made in the
cases of eye, skin, respiratory and haemmoroidal pre
parations, cotrimoxazole, oral rehydration salts, antimalarials, iron folic acid etc. as well as certain vitamin
preparations allowing combinations of more than .one
active ingredient in a product.
.ta.nins should be prepared as single ingredient product
b» \with
the exception of B. Complex. Members of vitamin
1
I
. i
B. Complex with the exception of Bi; may be combined
into one product. B|; always has to oe produced as a
‘ii.gk- tngicdient injectable product. Other members ofB.
complex may also be produced as single ingredient product
(,*.K B,. B.; Bo, etc.). Vitamins will not be allowed to
bo uombin’ea with any other ingredient such as minerals,
gl)cerophosphatcctc. Vitamins will bo allowed to be pro
duced in tablets, capsules and iniectablo form only
Nu liquid forms will be permitted because of wastage of
financial resources and the tremendous misuse involved.
However, paediatric liquid multi-vitamin (with No. Bn,
EK and/or minerals) will be allowed to be manufactured
m bottles of up to 15 ml. size with droppers. Paediatric
liquid preparations of single ingredient vitamins will
abo be allowed to be manufactured in bottles of up to
15 ml with droppers.
(vi) No cough mixtures, throat lozenges, gripe waler, alkalis,
etc. will be allowed to be manufactured or imported as
theMS are little or no therapeutic value and amount to
gicat wastage of our meagre resource.
(VII} fhc sale of tonics, enzyme rnixlures/preparations and
Mj-uallcd resiotoralive products flourish on consummers
ignoiancc. Most are habit-forming and with the
exception of pancreatin and lactase these are of no
therapeutic value. Henceforth, local manufacture or
importation of such products will be discontinued.
However, pancreatin and lactase will be allowed to be
manufactured and/or imported as single ingredient
pinducts.
(viii) Some drugs ate being manufactured with only a slight
difference in composition from another product bui
having similar action. This onlv confuses both pauentx
and doctors. This will not be. allowed.
(ix) Products of doubtful, little or no therapeutic value and
those which are sometimes rather harmful and are
subject to misuse, will be banned.
(x) All prescription chemicals and galenical preparations not
included in lhe latest edition of British pharmacope ia or
British Pharmaceutical Codex will be prohibited.
(xi) Certain drugs, in spite of known serious side-effects and
possibility of misuse but having favourable risk-benefit
ratio, may be allowed to be produced in limited
quantity for restricted use. These will be prescribed by
\ specialists only.
(xii) The Sfinc or close substitute of a drug which is being
produced in lhe country will not be allowed to be
imported as a measure of protection for the
local
industry. However, if local production is far short of
needs. Ibis condition may be relaxed in some cases.
(xiii) A .basic pharmaceutical raw material which is locally
manufactured will be given protection by disallowing it
or its substitute to be imported, if sufficient quantity is
available in the country.
(xiv) The role of Multinationals in providing medicines for
this country is acknowledged with appreciation. In view
of the calibre of machinery and technical know-how
which they have for producing important and innovative
drugs for the country, the task of producing antacids
and vitamin will he solely with the national companies,
leaving the multinationals free to concentrate their
efforts and resources on those items not so easily
produced by smaller national companies. Multinationals
will, however, be allow'ed to produce injectable vitamins
as single ingredient products.
(xv) No foreign brands will be allowed to be manufactured
under licence in any factory in Bangladesh if the same or
similar products are’available/manufaciured in Bangladesh,
as this leads to unnecessary high prices and payment of
royalties. In the light of this policy all existing licensing
agreements should be reviewed.
(xvij No multinational company without their own factory in
Bangladesh will be allowed to matket their products
after manufacturing them in another factory in Bangla
desh on toll basis
I
J
OUUY 174 PRODUCTS manufactured by the eight leading TNCs were affected by the Drug Policy.
Iluwvver, in financial terms, the impact could well’be considerable. For example, seven
vitun.m and antacid products manufactured by Squibb which v;ere banned as a result of the
Policy, contributed 45% of Squibb’s total turnover in Bangladesh in 1980. Certainly, as
suc-n as the Policy was announced, the TNCs lost no time in protesting about it. The first
rcapnse was a full page advertisement in all the leading Bangladesh newspapers suggesting
iii.it inc policy would bring about the destruction of the pharmaceutical industry in
i'./.n.jladesh. Interestingly enough, most of the truly national companies in Bangladesh,
locked on the policy favourably, even though they had the most products that had to be
removed. In the long term, however, the Policy offered some safeguards for the prometion
oi local industry -- thus most national companies could hope to derive some benefit.
ca’i^e and
An appeal to the
Martial LawAuthortly
CT^
mdenma £'.3.
5-^)
V.IIILE TNCS PROTESTED about the
Drug Policy in advertisements
like the one shovzn on the right,
supper t from around the world
for the policy began to develop.
I
iI
wti
I ■ EE?:£:’;£■
Leading health workers, devfclopn.cnt agencies, consumers groups,
academics and politicians from
many different countries lent
their support to the policy, as
the news clippings below demon
strate.
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«
f)
UM
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BU.ix^.art-Me
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t^ru:2.
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l*t. * •/ ©a, , .c<MLnq 4«r»««e**
Gl IMM IICWWI* araa.^^a .M
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Bm.-S BiwaO VI 11 »Wa^ »• I*1 Wf »t
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t* MV-unot
a » •<*« *. ct aar-^ava
uh i.
“.*r
sr,’
•III
’ Si
*?
World reputed £
personalities bail? |"
•<**••
»*•■* **A(
drug ordinance
,
Bangladesh Observed
Member*
Bongfadesh Aushod S iiipc SorrJty
AMxn
O^Iadaa*! Uaiu**
Auc» L««•'•.'.*»/ Su*u«U
Aa«*c
•-»:«• L<tt> i»4
langue us r^as AasavDcal latorrr Im wl
*«a«u Tac*M Us-ktucc 7Tq«M irvlj Uau»4
Bajicvn
UommI
Oac-uft o^rntai ITatta 1.——4
F>«w {*M«<*a«r ) Uawad
o a. c-p-/
Cvuo
Uaai>«4
Mm jm ItaMT
Maaoaa r^nnacMUaa C«. Ud
IQ Ka? ■-I—« KiMhauin L**l
>ran
«m »cwi LuvM
I D M. DAdwari Unu‘ad
|U*«aal LaaxakMrwa Urnad
Qr«<Ma O*a«'^4W..
Ktsi L*>o>«>a<wa cfc»*gl*$a*'i Ua.nf
Koaiifaa* UJ>w»i«»k« U».iad
Cobtaaaaa
LKeuiad
Cfiiuay
*—rn» rue-UX
tsr^Ai^
4 u«r4W4
tAC^Alena U«hi«<1
id
' ii»«m
T*» 1 ^i2
r« Ua.-ad
r><ti.-ina (l«»]M<aN ma if
®»im
^leex.-.;
C*>»4 Ok««M.^a
-a
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C<
Utr^
Above: Full page ad in most Bangladesh papers,
Andrew Veitch on a Bangladesh coup5 JUL
.
The grepat i..,
drugs
T,
•
*
t’Jj.
u
■■.‘ .uu
I
**•■-.■
- -. c
•'
■ ;.
ar 1
*lorr<e,
J****-“•■^'-*^**r.-_
<^k
__________ < J
,» •
**
J'V*^n\\C
V
A cumber ef world rtoute/1
-»t>cr>o?jJiue*
in tb« field cA >,
SW^c*
SBKsca-jsaxaz:FiaTssasKsafcj
1' jncdia^e and
»qcU1 trmtx ‘ „ xv •- Q\ <.<4
'wad Dumber ot Interna:; xca! 0?•
\o*’
c;xnu>iJt:xxcs hart haDcd th*-. ,0. AB'<€^
.,a.ov O'.
T® .• &1 , receBlLv anacrxi*ced
ii'al'xx-.wJ
VIT/../’Jv'F
,
^W6' to^*' druf poii~-.' wad framlns
of
______ ___ ‘32 tl coO'
i* p
C-? t
..^6v
Drinrs iControl) Ordiruac*
lt*.\\c'
^.vaW * *■ to .I'artiLJcsh drs^nbuii
yoUcy kr >r\>5 ' C
V
•, ws courarwruj
v<_L'
^i.i that l t ' ■ , j5j c'Uevh c«a :.
t
tBet T’ep '»dn!nbk!
CUCIJileetU '
“leastv« ded.
.bUl
<,0^ . t txrittvv *ac m.'pfigr
cy -rizsxa
dr-e*'
\0
.
->U'
^Tpuhhuu
pft
c»' 8 wloo a-cd •. evurtzoe
- Zu
’n
0®. . “.f«0 ka.-litioo rrr-Kiru
'
Guardian, uondon, IS v’uZ
’/ ■1932
USS
A-4 a
differently. He told 4 «?mp>
THE MILITARY government
imlibP drugs of idKjuite
VinUter •*
V
tFcc-v *’.!so
«> ’’err.'-«! lhi<. gt'.ti
ster> >, m**
num :n Liverpool earher L*..s
’■>
fc'Jtrrlna
a.x\°
nf BanR)ades-> has st a etraka
quality, it rrisonible pruts,
i.ikia C-ofi 0°'
a*‘ w M,'cfo'-itranna in
m atber
atber >'
a-r-xw
; of
i »i w sh o»5
V5* «■-entries
th*
worfc
and
c
\
done
surretning
that
no
other
year: “The supply of medi*
ind
to
to
the
pcpulsuor.
"
ir
”
*
,n
’
lh«
work
developing
country — or
cine in Exng’adesh is ch*ra>
• estiblisn.nitionil dru lists
L
. k., 1
-ru eiiu-d Jfor iu
iu viswoua
viawou* imp
insp’’x
A-v.®’*^
iroj j^r.Uy »*
v.t«
0?*
developed
one
for
that
... including essential drugi
Censed
by
high
prices,
ExmuticQ.
—
.
r»*matter — La, dared to do :
selecied on the bisis of the
maianf drugs upavailtble to
fftie pcrionwlitirt who bailed
*0'^
st ha* enacted. al.T.)jt In its
:.-unlnes...“
brillh
needs
of
ccur/.r.:;
the
pocr
;
by
the
xale
of
“''■‘.'■■“J
the druc sl.L;, iicl-de rLMic.
r x*
enlirefy. the World Health
•gamThe World Health Orj
unnecessary
and
useless
R Lce;rua
Unirerwity of Cah-,
0 Assembly's
resolution
injlasiliva deirtibed the B*r
_
OQ
drugs, and by the continued
forci* t/u-rid Waracr of Ciilfcr
A''
essentia! drugs
Bo/.ltaJceb.
><xl
drW» move as '’very goi
xnarketing of drugs identified
nia Fxiberto Taiardo ci Moico
protress." »
Il has dra*7n up a list ci
as hartafui and binned else
Jxrx Aostzr
r-osser m Mcoituiacr \O
<0
^1
A Jar¥C
“A* • fwiiMcr
Yet the US which hai no
250
esM-ntial
drugs,
banned
where.
”
s
ci Washuunon
Sister fulncu
tU ^ri,'-n<*‘l'l*4~UvInl te:
little influence on W HO poli237 products deemed to be
VfoLf Chalrniaa of the vcwrd'
”
| "It is capitalism untemit contributes i
harmful, snd has • instructed
' cies
i\ winter FeJtb Contcr oo Coox
,
jpered by social conscience ©r
,rtt l.'“l »«
uduced O-D 1 . ,*' -»'ritc RciscMibuliv New York
quarter ©f the who budget
that l^CO others be discern,
e? ‘ .public
pressure,
engaged
it* jl v\m
— wi* Jeu c>Mhuj.aslic.
tinued when supplies run out.
- Father Clu-.de Lcruhaa Orccr
. ‘ .i’ solely 1b the D-.nimisjUon of
or,!, be l>»
. _>
Indeed, the US Ambasx.
1
®o! yrwr* Minor Sister RrrtQe
This draconian act has
;'■’dor ** profit*, ia soe? area* of tn«‘ ■
in
Daoca.
Mrs
Jane
Coxi.
been interpreted as > massive
Fen.stiener Siltcr Jordan Dshm
-\h...
economy this msy ba sciept-■w
assault o.t the multinational
fr.sirucled to call on the -< "nr
afcl«> bU ,B lhe
Of dru«^s Suter of St Fra.tce* Lr-ubu rue
Mirtul Law A.:miD it'i'or,
cornoanies that dominate the
"*
Father Michel Crosbv Piorinc:
production
and
disu.buLieutenant General Hussain
country'* dru? market
In
cf St Jvwoh Csruchin Order
Uon which pla; s vith the
fart, it should mean tiiat
Muhiwmad Lrsbsd and' the
*nd i:cv thnbl Dri«xx>!l pirtrt
y.evax^
tn*^
Loper and fears of lha
many mo?'- Eingliu'eshia ■*-iU
Levin
adviser,
*i-«pr- .
U? r.r-:i:t end >Tv-r Offie-t.
gel t'.ie drr.p they .really
_______
_Shstasu)
______
..Huq, io ' people, it a intolerable "
General
. A’ne ]otern»tload ora-Bi-e.
Wfit concerns the multina
need,
at
*
pn;«
the
country
jr-ske
|hv
US
position
J
..
-------------dear
DlnUv’-* ’•4'J'*
. .e;t L.*«
Her.* which h.ve J.*ilcd the r-j
tionals most of til h t ill tha
esn .».ffard
T/,e ■"•■
“»•- Dr
r'--.‘firienl
State
He';- a*e War On win! Lcndv'^
E-anglidein .-des will catch on
p.-ur<‘ «n
riari
...........................
I'.*,‘.down far
.........
~ i -AtMi'
’ K
id
wan
*.
>d
:
"
We
.vou-d
,
Chnstlao Aid Lur*6oo Prcre*
a- boli JL'.a.:_c.l_''j£j an-d
removal by
>)■ th? Mfist WM- I Lte »■> delay irap
.. ’eihe.-.U'.fon,
De* Hotr.s*. Interna.Iwia! pxn>
,H<*ltti
Ac'.;u.i Iniernalional
i’t 7
r-»p % ’
Jy11*'
milice tn-l
-- the
a ------fonuulated
<,t Xh.i law to il'.jw the
H.irwn’Li Foundation CsKh..-?
L- -**'t v;Ii. The ffijei world
k-'
policy Ihcl-j-^e
nation a
'e ccmbi
combinations
Gast'..j.ent arf Bi.-.sfitJcm
Li..-...’u^.u . >.o
nla National Women'* Health
- ----- -------------■ , Wij«
wide a. e mcrra-:u* : develo;*of different - nil'.- oUca, com
turt» • ' to,“,V/ .* ■x.'naaatrs*
aua the druj ehanufaciureri
Nctu-o. k US £ >*ton Worr.onj
binations of »n«)g**cs.’ nuP
conit we [IS
inuna *“* ‘3'.Ti’
,^-n cn-io wert out If.ttr diflerenci
S
Jr’ • eounu-.M
Health Bool. Cat^citive
ikrv
tivilamiBt. ■ rough mirtures. ’ Jt hai Txftn auRjtvstrd-V>
I millions’ c-rrth st
Chrtstija ki '-*i<jD Heap^'.a.biHiy
gripe wrter, producl* v.l!h a
d.nugs i year
y
Tr.e UK aiotw
■a review sand be jipoiDted
rTixi-uui-rti
lirrnix-enl
Vr-.-.^J
high akohol content, antbohe
acid £25>''j mu'licns* worth tl
to (lud/ th* rnartej- "
•
Fi'T'-s n'eri»n Church Fr«'du.an
steroid: (-Zurfi isaa iw«n
countrie*
c
The US drug firms. Pfirer.' • drugs so develc-pFng
rM
Fath.-.-' piantiuan Sau-nr
fiven to undtrnc'iirisJied chU■>o IteeiO. “
The
. . fart th*’. WHO
and Squibb, douur.a'.e the £35Ferp-rtiuC Adoration and Juxiv
oren). preduria cfintwcint
jutUiocs
cnntiining
~td lb* /.um-’itr ot
has narrest,
x year SaojuCrih
inoli FaJser*
and Brother*
J'"
L-.i
atrychnine and codeine,
n
i<5<in«. and '
down to 2W
essential drugs
dn
market. Together vrtth
xaeuiVcc* inurfLih Ccnitr 00
choquind (the active
h,..),*'
he ronrtironrtj- ••
suggestt that the vsst cup
..waned Fiscoi. Glaxo,
rv*pon*ibl!itv
Frot/ram
0.1
tuent of inc an;idia
’-K'**
"
■diarrbcea
,iy of that money ia spent
erliy
and JC1. V:e Franch-cwntd
PT-ii maocutleal* and the Phud
drug Entiro-VlufO'/n, - roundof q-jestioEsbX
•on drugs
.
Ltay
the vrriii-uu
Germen
■ ,y and B^ker. tuc
World.
to cause jogdus dxaiagt to
firm Herchst, and the Du'.ci • value.
Cuuf .1^X11
ZTh* comment* on tl>c tlrua
the nervous sisters:).
o. o prc^-ccatw*
■ JAi GSe Economics Mioir
coaconi^aay Orjinoa
In.iunou *nJ
i.
Col»cv
e.nd
crdlruijvx
eu-id diva
diue
. ... .
People si'’:, ng (hngerou*
me hang.'tdesa
hanj sdesa H:.:ti
Hi.rb Coo
Co
t.-oi 80 jmr cent ot ILc aupUi«
uwvc
have Lie;,
crtivevrd in
la &rp*
crcwryrd
J
hospiUl medicine* on the
•■
mission
jaissioo io
>o 1x4.
lz>f.-!ca.
-lea. Mr £»•
£
Tliet. ■•
.- • -v
.
o/ connrMa!.;
c4Mir.ru
nte. rr.er-jirtii
of
open lurtt-! stiiti.e fined *r
The jKr^n.UU^ ■
, . ST.d
flrdhti
fudhn
At.nicd
Ai.a^d
Du' |1 : “It
Th.s'.x'
rj
are
high.
tioE* 10
jo the
th*
Wnister
Mnister
<'•■
tryip: ifconcd.
Mv'.iir.atioaals
the
a-.Ks-.xt'onsli.
;
:e':f
■
la
t
T.
e
tlal
ahovJ
be
u\*n
Health .■■..'■.d ¥'.••.v.’at:>3 Contrc-l
Mill do longer be ii’.owed u
•by ai*i-y other cvcntriea,
arnoye-l at the ei’tibL*
at
.irr.rot
Major G<aersJ H
Shsoiiul
croduce lo* lerhtoion drugs
Ua
Te-ople'ii
jh<'■ ,<.’ o? Sr;:*./! where thers
Hao
like vi'i-rnins - Ixit firm* • of
nis tn t>
are a M of ..-.r, . jsery
’ Cer.tr*-. w > r no*w.ll do
:.• '.rid — snl they
turc* «!» i :■•,»■: dr-.-jj u .■' 5Jts'd.-un- ’
Lf r -. -.’■i
*:•
*!ll ill-. Li .-..;. i.,.i l> 1.VPJjn?
it.
:..(
'
r.
«r4
pif,.-f>p!h>\e ia har.pi^rtb, cut
prte with !->a jtjy ■ jnanufarjo
B'.u.' ir.i’y x.e f.t/Dt*.-. ?! j/t.'.nniflf nt*. !;>rr
lljrrd --r cduv-‘..
bihUK.< *•'. f> l ’-' .
ajsertisew•••>•>/
“nJ *--arn«
Ail
V ■ ’-t r-:r- tIJ be
t? c *. ge r: rr-jeb "
jng Cut s - MMuil.
av.r.jFF cq t'-.etr
entirely t:> >;• . wibS i.-> rcsoFerhazA
>■•- fl; i.'K.- •
prC-flll 'Tr.'f..': rtfeXlW i'.i Ul*
lu’. ; 1 p
.Lp «b? 'i.'orid
• Lir-glii «♦’.’• > la t « ijnn of
Joituliv-r v -i e
H'-il/n A
i.i Cchev*
•.;> -• '.-f
Y
ehu • rf'Ui
three J>!
:l .. *-..< ,‘t ;,»,-r <
r f f uf « .
j CStiWb
« •'» A
K
<J • • ' iijHiSbt 1
■
firri
2i.
.-.I
member s..;-i s.v
«&•*».•.
d
Druik policy
hailed
1
'4~wu -XU
bvcbmM «< LM U.aauc
COeX lUBM . i «•••Wa I .»Ui U M4
s it'S'S
'
!■
IM' »A —TM-
Bi
■pi I
JJI
w
Mnw . W4> W
it
ntvrw
i»y»«5
Y)v<
»»u«n4l
- - ■■ -r •>«
»••
•MisciM*.'iMat ag^aia* o*i;al warty
»•X^n.i I*-
I ?E:E:
o'
Urs-i.« ia a<
•—
>
!i «
1"] i
k o'
r*rt
7
>. -4 •>.
■ > m *r«
I ^r..:’-,'
The story began to hit the
headlines of some of the major
magazines and newspapers of the
world, with articles in Britain
appearing in the Guardian, (repieduced below, right)\ the Lancet,
and the New Statesman, as well
as many other publications.
:daj, Bdnglaaesh
e-^<
MtfxaiubM V’J» rUHn
r
7*
r 5Qi»- ’
r>. .n
M
». >f
v«rM Jw«m» •**
4-^ e«.«1 CM.ArA
txv
»r^. .
. Wi: /, »«-« .’•< r* ***»
IM tt« .'•«
• 4. /MH-T
UtM -•‘.•-'•1 «..VU P’-im
•» xu ••
r^- Cwr
I- •-w •**
7^!'.
p»
.
.•,-
TV.*
-.; r ■_
’ d.:'.rl*u!,cr.“
I-...-;
,
>
•
.'rd
.<r«.th
r.-D'rt. ■•-
'Grui*/; u-rr ! '
? ?.’. : i 1
-rd bur'.. •> /: KIL _ hij
L1J
.
X-.l it f'.ir
4,-^,• ■ *<«s.— -v. -
r '. u;'.
•’u tr
A'W
changes
AMIDST ALL THE PRESSURE, the Bangladesh government decided to establish
a Review Committee to take a second look at the Drug Policy. The Review
Committee consisted of six military doctors, and on 12 August it sub
mitted a report .to the government.
The report has remained unpublished. While waiting for a new decision
on the Drug Policy, the TNCs began a new line of attack. Because of
the support for the policy announced by War on Want and Oxfam, and
because both organisations have been involved in funding the major
health care project Gonoshasthaya Kendra (GK) in Bangladesh — a
project which includes a small pharmaceutical factory — the industry
decided to smear both organisations. In a one and one-third page
advertisement, the industry claimed that War on Want and Oxfam were
responsible for much of the content of the policy, and that our
intention was to destroy the pharmaceutical industry in Bangladesh,
so that War on Want and Oxfam could take over the import of drugs
into Bangladesh, and so that the pharmaceutical factory at GK could
have a monopoly on the production of drugs.
V.
Both War on Want and Oxfam were attacked for being '’foreign" organ
isations by the industry. Conveniently, the industry failed to
mention that its leading corporations were foreign.’ It was an
example of the industry failing to deal with and accept the basic
arguments behind the policy — choosing rather to attack anyone
who supported it. It was a way of trying to stir up antagonism to
the policy, by questioning the motivation of those groups and
individuals who supported it.
•
J
5
. . i
Happily, that strategy failed. On 6 September, the Government
announced an ammendment to the Drug Policy, arrived at after reading
the report of the Review Committee and reading it in conjunction
with the report of the Expert Committee. Four basic changes were
made:
1. 41 drugs that were originally banned, were permitted to remain
on the market. Most of these fell into the category of useless
or unnecessary.
2. The time limit for reformulation of drugs in the second
category was extended from 6 months to one year; the time
limit for removal of the drugs in the third category was
extended from 9 months to 18 months.
3. Existing third-party licensing agreements were allowed to
continue until their expiry date, rather than be terminated
early.
4. Some balms and ointments due for removal under the third
category may be reconsidered at a later date.
Thus, despite the pressure exerted by the TNCs and by Western govern
ments, most of the Drug Policy has remained intact. Several observers
in Bangladesh have commented that, undoubtedly, one of the reasons
for this has been the strong support the policy has received from
around the world.
f
Pressure
LOOKING FOR ALLIES, the TNCs turned to the US
and other Western governments for support. The
US responded quickly. US Ainbassador to Bangla
desh, Mrs Jane Coon called on the Bangladesh
government and urged the amending, if not the
rescinding of the policy. In late July, Mrs
Coon helped arrange for a group of rscientific
experts’* from the US to fly to Dacca and have
meetings with Bangladeshi officials. The "experts’*
were from:
the Pharmaceutical Manufacturing Association
of America;
Squibb;
Wyeth;
Smith Kline.
I
I
i
In August, the US State Department admitted
that the Pharmaceutical Manufacturers Association
had asked it "to bring pressure on the Bangla
desh government to delay implementing the law
pending discussions with the manufacturers."
According to a State Department spokesman:
"The State Department has a statutory responsibility
for assisting American interests abroad. In this
particular case, the US Government is also concerned
tha4 these regulations may inhibit further investment
in Bangladesh."
His words were virtually echoed by Douglas Hurd,
Minister of State at the Foreign and Commonwealth
Office in Britain:
"We are keen that the Bangladesh Government should use
its scarce resources wisely. We are also keen that they
should succeed in their policy of encouraging foreign
investment to help with the development of an industrial
economy. We, in cormon with other Western governments,
have explained this to the Bangladesh Government through
our High Corrmission in Dacca. It is important that in
trying to achieve the aims of the pharmaceutical policy
they do not discriminate against foreign owned manu
facturing companirs in Bangladesh and do not frighten
off prospective foreign investors,"
S MB
Squeeze
by drug
lobby
by Rc’t miry Righter
AMERICAN (Jrug cornpaniet
arc putiinc hfavy pceaturc on
Bangladesh, ^ne af the world'*
poorer
cc'iintri**. tp drop
plana whi-rh would make egaeerial
rheap-r and limit
the a*ta >af e«pen«iv» mrdi- 1
cine*.
Twa
a jo, >r;;<ir'4 orrecommcjssia’ioni by the!• W arid
Health f'«rf sniaaticn, i,
Atngltde*h
•pvin'jnced
ie,(ijl*tien
eatabtirh’-fj a liat of 250 e**entill medie«Afj. banning 237 at
dangerosrs. and dirceting that
lupplie* erf 1,300 orbert ahould
not be rerrwed.
Within dav*. the US tmbaa.
«ador tn
Bcn;lade«h, J*ne
Coon, urr-d th; government
to retonv-drr. She persuaded
It to act e.p a review commit
tee, competed of military doc
tor*, which it |n report in the
neat few day*.
The jorerr.ment. -which will
make its (decision within 10
I day* of receiving the comI mittee’s ea-irlutinnt. will be
__ | lobbied trp to the latt minute.
•
■
|
A
pre-up
ef
“ •rirnti'V
J trr<-ru ■■ H»w in<n f>,< , a
’ wi-rk (• help thr if>n'-«ii>r<
vr-j tn *ee
!• in
Clarfrd • rrnrr«entaf-i jhe
PlitrmeceadCFl
j- i ••rm<
Awxlition of Ammip
e-.r uil*T» from itnr'- rftrpota
t'crti w<lh *•»'.-< in
the
f !■>--.ar
F»nrlaHi<h
turkct, Squibb, hirh md
SmithMine.
A
VS SiatrrpoVi- mtn said nn
ih.M
Ibrir meetings, art. anurfl
Mr* Cnon, h«d br,
li»tfu; "
Hr
«o><1
I hr
I s
<c»ernmen( bectnir in<nhrr1
; eCii-sr i( h»ri a : espm.i.Si’.i i
“♦» 4»m»i eomparlrs thv h-.-r
p.obems w it h fnreijri r
n.t nlt ", Mr* Conn hr <.»ta.
had been •‘careful
«.s
the it »<t (hr ronrern< of Ihr
drug companiet: m r M*mp|<
want « tolntinn ■rrnplahlf to
bet h sides “
There had hern r
n'lr tn p'
to link (he issue to
« »>r! Io
"•angladfsh.
Hour
State D-partmen! is ronstrlet
Ing an invititinn bt 1 ninprm
goremments Io in-n ii<rm in
o f-rmal approach (n thr
Ranxladcsh. gnvernrnr’ii
tv
Companies dominate ’hr Rang
iflile-.h market*, bin nt her, a-e
•Ctire there. inrhiHmt |( !.
Fison* and Glaxo of Hurtin
T’>e companies are
tn
per«uade RanglaHech m list
more drugs as essential Thrt
also ebject tn the rol-ng that
local rnmnanies shn.i'.f p. n
duce simple products %■■< >>
».lamin*.
Th»r argue that th- en»e.n
rnent which wa* r-">i'-«t t>>
expert*, heanrd h» b<
„
Islam,
an
inie-n;.»f.,n .11,
rr’pecled paediatric*.™, sh oilil
have consulted th»nt
1 he "taxes for the rfrup rnni
pani*s are high. Rand <d<-sh <«
1b< fir*t eounlr* Io artrpt WHO
guideline*. These urge emr-n
menu io list dtug- that «i||
meet national health nerds. en.
rare
lhey
are
rrasnnahh
priced, and restrict the s.-»i- d
nnnecesiarj,
or
dangerous
drug*.
Other countries tnnld fn|ln<*
*uit, threatening the multi
national*1 huge and rapidk rt
Finding Third Moiltl mat let
*•5
9 Aug, 19't'.
U.S. Is Aiding
-tJ.S. Helps
Sell Drugs in Bangladesh
' 1' WASHINGTON POST, 19 A^f 1982
Di ng Companies
DRUGS, From Al
Nineteen Pfizer drugi appeared
important and innovative dran and
leave the production of ’imp'e nH
demned by several international and on the list of drags to be banned
cheap druRs to the domestic compa
immediately, including its Staricot
U.S. charity and consumer groups.
In Bangladesh "Encouraging
nies.
this review is certainly capsules, which contain clioquinol.
Worldwide drug sales to the de
nut helping the people of Bangla /Xnioi'.g the 22 Squibb products •
desh," said a spokesman for War on
li’tcd wpre QuixfiJine tenets and veloping countries exceed $30 bd'-on
Suspension, both of which also con a year, however, and the mui'ir’i- '
The United States, responding to Want in London yesterday.
The Washington-based Public
an appeal from several multinational
tain clioquinol. Neither Pfizer nor tional drug companies fear ’b.ti •
drusi companies, has asked Bangla Citizen Health Research Group, in a ■ Squibb would comment c>n the new other developing countries will Ivllow Bangladesh's example.
desh to reconsider a new national letter addressed to Secretary of law or the drugs named in it
The economics attache at the .
policy designed to ban hundreds of State George P. Shultz, called tha
K spokesman for the pharmaceu
drugs that it aays are -ineffective, action "unconscionable."
tical association, which led a delega Bangladesh Embassy in Waohinc’t'n
“Perhaps you are unaware that
dangerous or too expensive.
tion Representing the drts? compa said of the new law, “I think it is n
Among the drugs Bangladesh many of the U.S.-baaed multination- nies on a recent week-long trip to very good step forward." But h”
the review requested by the S'm’c
wants to ban are several that are not ft!’drug companies uz foisting on
Barnkdesh to make the ymlustry-’a
permitted in the United States, in inncccnf'people in the developing vie-.g known, described 11 - new law Department was normal and ’n-'’
v.uu...b clioquinol,
________ -a cherpicsl th
..........
cluding
'.t it countries drags which our own mc-d- aa “precipitous" and prejudicial to important."
k
- causa
-- ----h is not the first lime a de* "I ‘pknown
to
serious damage to. ,ca' authorities consider...wortiiless public health,
•
•
.the ncrvpus system. More, than 70 rind unnecessary^. thjJeitar said.
PMA argue, that bk-^Vr.g the ing country hns. tried to limit thr
The group-expnskd dismay that
percent of the. drijgs on the list have
flow of drugs from its rn rr^’er com cOnaumplit n of drugs produ-m-l by
the multinational drag compini’*
been described by the .toed and the State Department had allowed
panies could open the nuarket in
The government of Sri Lenka mst'e
Drug Administration or
or its
i British itself "U> be used by the giant rculBangladesh to uncertified and po
therapeutically
drug compsn.ies to proa direct approach to Pfizer in '!»
counterpart
nt,
tentially impure dtugs frvm other
mote and prota't their exploitation
early lOVl^ wking it to decree'’ ,!’.e
worthless.
eouxeej.
manufacture of unnecessary drac*
A spokesman for the State De cf the impoverished citizens of un-Bangladesh
is
the
thirJ-poorest
from 40 to 25 percent.
partment acknowledged yesterday developed countues.”country
in
the
world,
cc;
■■•Jin;
to
The law, which was announced by
“Pfizer refused to modify it.s pro
that the Pharmaceutical Manufac
statistics
from
the
World
Bank,
with
duel ion in accordance with the
turers Association (PMA), a trade the Bangladesh military government
the
lowest
per
capita
income,
the
health needs of Sri Lanka."
organization for the drug industry, in June, prohibited the future sale of
lowest life expectancy end the high
a-«kec it to bring pressure on the2 more than 1,700 drugs and imme- ■ est infant mortality of all f--e devel John Cunnington, the program of
B.inidndreh government to delay im:. distaly banned 237 products which oping countries. Approxirr.staly 60 ficer for the Indian subcon!inr,’>’ nt
plemcnling the law pending discus were considered dangerous. Among percent of the country's hc.^ h bud Ixmdon'a War on Want. “'Abi’
the American drugs mentioned were
more, the United States threa'fud
sions with the manufacturers.
get is devoted to the p’lrrr.&se of
“The Stale Department has-a products made by Merck, Pfizer, drugs, compared to less thr ; 10 per to ahip all f>tK! md if further a-tion
was taken."
statutory re»poniihihty for assisting Searle, Squibb and Upjohn.
cent in the United States
According to the members of the
No such threats are app-wr’-'N
America.'! interest abroad,", the
Because of ths*, Bm . k h is
committee that drew up tha new
being made in connection w-.’S »’tn
spokesman said. "In this p&rticulw
policy, eight rnJcina’. onsl compa eager to bring its drug out': -s under
new Ita'ic'fidi-h law, hut the In'rr
case, the US- government is alio
nies, including th? A;, ericaii
C'-nlrrl, andMo begin to
luce , f..;ih Oi tr on Corporate
nconcerned that these regulation’.)
conu- of the l<'?. ccmpiet,: gmumon ■ sib,i iy in Nc-- York I’.sld t-n' 'bi’
panies Pfizer end S-.-’sU h. shored 75
may inhibit future foreign invest
dru,:? d'ttncslica'ly.
percent of Bang'adoih's S100gcw-runieut Ihcre was 'psr-K,.'
ment in Bflj’gladesh,"
million-a-year dru? market. Pfizer
'i:
Banjl-.ntsh com-. .
e - sensilivi.' tn the Ur ie l S’. '■ - '
But the U.S. action has been con- dominated the marV.'t w;!h more
kfed "with fipprcc’ .’ v;' tin*
Cause the Uniird Stairs prea
Si^e DRUGS, A12,C©:.2 'v
[i'^ jiQ^m'liL o m ^lu'in j?3L
or i? niu'tinalionais, i’ urg’nl
substanli.d I,>i‘d ;od find t':-, ■ ■n'
•
i- whi's Squibb sold around $5 million
the?. to devote thc'i 'n .'rf ■
end
a’Sl^taiiiC tl. f ■ •■’I'r* ••-'j dcvclpr in the same jTar.
technical know-how" to
’cmg
program.’'
By Penny Chorlton
*>.»htnrwn Cimi suit wnwr
f
h
Avoiding the Policy
.-.J
f
I
Ai1
1
Ii
J
THREE WAYS OF AVOIDING THE POLICY have begun to emerge in Bangladesh.
First, drugs that were due to be destroyed on 12 September, have not
been destroyed. These are the products termed ’’harmful'’ by the Policy.
However, on 10 September, three companies — ICI, May & Baker and
Organon — applied for export licences for their-products. At first, the
request was refused, but finally on 6 October, export licences were
granted for their products, and for all the other products included
in the first category of drugs. The three companies all intended
exporting the banned drugs to other developing countries in either
Africa or the Middle East.
Secondly, companies who have products which must be removed within
18 months have begun asking for permission to import some raw materials,
in ordfcr to complete the ingredients required for particular drugs,
and thus be able to use up existing stocks of raw materials in the
country. So- far, those requests have been denied, as the Bangladesh
Drug Controller recognises that with careful juggling, a company
could continue producing a banned drug right up to the 18-month
deadline, and.then appeal for more time to use up the last of the
stock.
The third way of avoiding the policy is to appeal for the retention
of a particular drug on the grounds that it meets some essential need.
Pfizer has successfully done this with Heptuna-Plus„ an iron and
•vitamin preparation. One leading gynecologist, Professor F. Begum —
who is also a local director of the Pfizer subsidiary — claimed the
product was indispensable for the treatment of anaenai-a in pregnant women.
New Statesman, 29 Oct 1982
lories under their brand name-
ingredient for some preparation which they
must import in order to be able to use up
The drug companies responded by rally shocks of the other ingredients.. So far the
ing their supporters. British, US and Dutch government has held out against this.
diplomats visited government officials and
Concessions made to the drug companies
ministers to urge reconsideration. In ieidude allowing tliird party licences to run
August, while the World Health Organisa- tbeir terms (though they will not be renewa
~
.
lion’s local representative refused to ‘ap- ble); and extending the time limit on certain
XTOuUCtS banned in Bangladesh plaud or condemn* the new policy, rhe drug preparations from nine months to 18 months
companies themselves placed advertise to use up stocks. In addition, drugs cateare to be re-exported reports
ments in rhe major dailies denouncing it as gc^jised as harmful are now awaiting
Amrit Wilson
an international
plot engineered
by Oxfam,
slxipment
from Bangladesh.
According to
War on Want and Gonoshasthya Pharma Asady Chetley of War on Want who has just
ON 6 OCTOBER eight major drug com ceuticals (a Bangladeshi firm which had re rminied from Dacca:
panies whose products were banned as ceived some funding from the charities).
There is nothing to stop these drugs being
harmful or unnecessary under Bangladesh’s The Ordinance was, the companies claimed,
-exported to other develping countries. ICFs
new Drug Ordinance (NS 9 July) wrung a a Christian plot against the Mu slims.
rraeycline syrup mighi go back to England
major concession from the government for re-export -under a new label to Saudi
In the face of these pressures the Bangla
Arabia; EP! (May and Baker) may send their
they were granted export licences for the desh government has acceded to a number
drags back to West Germany to be re-routed
medical preparations which were due for of specific demands — the granting of the
«o West Africa; and Organon’s Orabolin drops
destruction in Bangladesh
oa
12 September.
. --------- --------- export licences for harmful drags is the
could
reach Saudi Arabia and Africa via
1 aesc preparations may now well end up in latest. Now, although the main principles of
Europe.
other Third World countries.
C_
* intact,
'
the drugs policy remain
there is a However Jeff Holman of ICTs pharmaceutiThe
Drug
Ordinance,
announced
in
June
danger
that
special
I
cases
are
being
created cal department said: ‘The drugs "are norbe__ !_ . .«
*
•
—
- - ...
’
------ - of ins
herc Whcre
gQ from
foliowring the recommendations of an Expen which will re-open the door for....
categories
.
ujpugg
Committee,
hadj ubannedj several• categories
of vzhich arc now banned.
Bangladesh is a commercial and legal quesdrugs, for example liquid formulations of
__ example, has_ successfully tiosL*
Pfizer,, for
antibiotics unsuitable for children (like Id’s cleared the drug_ Heptuna
Plus^This
is
" .
T___ .3 a
Will Bangladesh’s drug policy survive?
Imperacin Syrup); combinations of antibiot mixture of iron, folic acid and multi-vita Members of the Expert Committee, like
ics, of analgesics or of vitamins; and all mins. As such it had failed the criteria of
Pfe^Ssssor Nurul Islam, are optimistic. Inter
cough mixtures, throat lozenges and ~gripe
.
acceptability laid down by the Expert Comwaters”because they
‘ are of little therapeutic mittee. However, following rhe insistence of national support (from health workers and
nongovernment organisations) has been of
value end amount to a great wastage of our certain
gynaecologists
—‘ j
,
—
them crucial importance, tiiey say. The drug commeagre resources*. In addition die Ordi Professor
Feroza Begum,
of Pfizer■ panics now have a new factor to contend
. - —a director
—
nance put an end to Third Party Licensing,
that the drug is necessary treatment for vric^r ‘When people arc given prescriptions
under which multinationid drug companies .sniMnir
anaemic mothers, .kthe ban on j^
i Cpj
r una p|us they £re asking the doctors if any of the
with no factories in Bangladesh marketed has been lifted. Meanwhile, other drag com■ dr^s are banned . . . the policy has changed
products manufactured m Bangladeshi fec- panies are claiming to be short of just one the prescribing habits of doctors.’
'
sell on
f
\ i
about WHG?
THE WORLD HEALTH ORGANISATION (WHO) has been
slow to offer its support for the Drug Policy
in Bangladesh. At times, in fact, it has played
into the hands of the TNCs by either refusing
to comment on the policy, or by making ambiguous
statements.
WHO's representative in Bangladesh, Dr Z. Sestack,
was reported in early July as commenting:
"It is not WHO's role to either applaud or
condemn the policy."
i
1
1
*
i
I
i
It was a surprising statement, given that WHO
had developed an Essential Drugs List as long
ago as 1977, which formed the basis for.many of
the decisions incorporated into the Bangladesh
Drug Policy. More recently, WHO has initiated
an Action Programme on Essential Drugs which
is designed to encourage governments to pursue
rational drugs policies and concentrate their
efforts on providing essential drugs.
Professor Islam sees the Bangladesh Policy as
being a necessary step in providing essential
drugs:
"If you want to make good medicine reach
the people, you must take away the bad
medicine."
In order to clear up any misunderstandings about
WHO's position on the Bangladesh Drug Policy,
War on Want wrote to WHO Secretary General
Dr Halfdan Mahler in July asking WHO to publicly
support the Policy. War on Want received a
response that noted that Dr Mahler would make a
statement on the Policy in September' when he would
be in Bangladesh.
Finally, in September, at WHO's South East Asia
Regional Committee meeting held in Dacca, Dr
Mahler said:
"I take this opportunity of congratulating
our host country on its courage in star*ting
to put its drug house in order along the
lines recently endorsed by the World Health
Assembly."
I
I
V/HO
<
would vou like* the
_ World H.-.ilth
ini.-atb»n
H* n t«>
the
H
jj'Hv!
;•f »>f B.i’’.ghid->h to
niak- vii'iii'-nts <•!! your
Dr C"h« n, of WHt)
testily
•? whrn he ’a.i>
f*» eojnin* nt on
B.tr.ip.i'l- -h s ne^ N icior.il
Iy. uhkh will ban
more than ITi'1’ unne-. »-s<iry
druct'* by th*- t-n ! o‘ this y r.ir.
Since the new Bangladesh
policy was announced, WHO
has been swamped with requests
to make a statement on the
matter. For some time the
organisation has been
proposing that developing
countries adopt a list of essential
drugs. But WHO itself is under
pressure from the drugs giants.
WHO says that it is “not
entitled to comment on policies
of member states". But there is
the suspicion that the
organisation is unwilling to
tread on the toes of the
transnational drugs companies
I which have been lobbying hard
to get Bangladesh to reverse its
policy. Reportedly, they have
pressed diplomats from western
governments which ha ve made
representations on their behalf.
However, the United Nations
Conference on Trade and
Development (Unctad) has come
out in support of Bangladesh s
drugs policy. "We feel it is an
excellent policy for other
countries to follow", commented
Unctad’s Surendra Patel.
“Furthermore it is directly in
line with the recommendations
made by the non-aligned
countries in their meetings in
Colombo and Cuba."
Reproduced from
South, Sept. 82
Despite this statement, however, whenever Dr Mahler was questioned by
the press in Bangladesh, he studiously avoided comment on the Drug Policy.
This has led some observers to question whether WHO’s reluctance is
related to its dependence on the US for 25% of its budget.
i
i
\
Criteria used by the Expert Advisory Committee appointed
by the Bangladesh Govt, in April 1982 to evaluate drugs
Marketed in Bangladesh
It is unanimously decided that the following criteria
will serve as the guidelines in evaluating all the registered/
licensed Pharmaceutical products manufactured and/or imported
in Bangladesh :
i)
The combination of an antibiotic with another antibiotic
or antibiotics with corticorsteroids or other active
substances will be prohibited.
prohibited* Antibiotics harmful to
children (e.g. Tetracycline) will not be allowed to be
manufactured in liquid form.
il)
The combination of analgesics in any form is not allowed
as there is no therapeutic advantage and it only incr
eases toxicity, especially in the case of kidney damage.
The combination of analgesics with iron, vitamins or
alcohol is also not allowed.
iii)
The use of codeine in any combination form is not allowed
as it causes addiction*
iv)
In General, no combination drugs will be used unless
there is absolutely no alternative single drug available
for treatment or if no alternative single drug is costeffective for the purpose. Certain exceptions will be
made in the cases of eye, skin, respiratory and haemmoroidal preparations, cotrimoxazole, oral rehydration
salts, antimalarials, iron folic acid etc., as well as
certain vitamin preparations allowing combinations of
more than one active ingredient in a product.
V)
Vitamins* should be prepared as single ingredient pro
duct with the exception of B. Complex, Members of vitamay be combined
min B. Complex with the exception of B
into one product.
always has to Ibe produced as a
single ingredient Injectable product. Other members of
B. Complex may also be produced as single ingredient
product (e.g. B B? B_ etc.) Vitamins will not be all
owed to be combined with any other ingredient such as
minerals, glycerophosphate etc. Vitamins will be allowed
to be produced in tablets, capsules and imeciable form
only.
No liquid forms will be permitted because of wastage of
financial resources and the tremendous misuse involved.
However, paediatric liquid multi-vitamin (with No, B^
and/or minerals) will be allowed to be manufactured in
bottles of upto 15 ml. size with droppers. Paediatric
liquid preparations of single ingredient vitamins will
also be allowed to be manufactured in bottled of upto
15 ml. with droppers.
Vi)
No cough mixtures, throat lozenges, gripe water, alkalis , etc. will be allowed to be manufactured or imported
as these are little or no therapeutic value and amount
to great wastage of our meagre resource.
vii)
The sale of tonics, enzyme mlxtures/preparations and
so-called restotorative products flourish on consummers
ignorance. Most are habit-forming and with the excep
tion of pancreatin and lactase these are of no therapeutic
value. Henceforth, local manufacture or importation of
such products will be discontinued. However, pancreatin
and lactase will be allowed to be manufactured and/or
CONIWIUNHY iKAtTH CZU
47/1.(FirstFloor)St.
Road
BANGALORE-560 001
...2
:: 2 ::
imported as single ingredient products.
viii)
Some drugs are being manufactured with only a slight
difference in composition from another product but having
similar action. Thia only confuses both patients and
doctors. This will not be allowed.
ix)
Products of doubtful, little or no therapeutic value and
those which are sometimes rather harmful and are subject
to mususe will be banned.
X)
A1J prescription chemicals and galenical preparations not
included in thu latest edition of British pharmacopeia
or British Pharmaceutical Codex will he prohibited.
Xi)
Certain drugs, in spite of known serious aide-effects and
possibility of misuse but having favourable risk-benefit
ratio, may be allowed to be produced in limited quantity
for restricted use. These will be prescribed by specia
lists only.
xii)
The same or close substitute of a drug which is being
produced in the country will not be allowed to be imported
as a measure of protection for the local industry. How
ever, if local production is far short of needs, this
condition may be relaxed in some cases.
xiii)
A basic pharmacautical rau material which is locally
manufactured will be given protection by disallowing it
or its substitute to be imported, if sufficient quan
tity is available in ths country*
xiv)
The role of Multinationals in providing medicines for
this country is acknowledged with appreciation. In view
of the calibre of machinery and technical know-how which
they have for producing important and innovative drugs
for the country, the task of producing antacids and vita
min will lie solely with the national companies, leaving
the multinationals free to concentrate their efforts and
resources on those items not so easily produced by smaller
national companies. Multinationals will, however, be
allowed to produce injectable vitamins as single ingre
dient products.
xv)
No foreign brands will be allowed to be manufactured
under licence in any factory in Bangladesh if the same
or similar products are available/manufactured in
Bangladesh as this leads to unnecessary high prices and
payment of royalties. In the light of this policy all
existing licensing agreements should be reviewed.
xvi)
No multinational company without their own factory in
Bangladesh will be allowed to market their products
after manufacturing them in another factory in Bangla
desh on toll basis.
*
GONOSHASTKAYA KENDRA
(Formerly Bangladesh Hospital)
CITY ADDRESS
132 New Eskaton Rd.
Dacca 2, Bangladesh
PROGRESS
PROJECT ADDRESS
Bamnabari
P.O.Nay^arha t
Savar, Dist. Dacca
REPORT
TO
JUNE
NOVEMBER
1972
The months since our last progress report from June 20 we have not
seen any spectacular successes; we had to struggle under very adverse
conditions^ lack of funds prevented us from establishing oursel
ves, at our base, and apart from a small number who lived in tents
the rest of us had to shuttle back and forth from Dacca, in borrowed
vehicles to run our out-patient department, conduct classes for
paramedical volunteers and to supervise the health survey.
The correctness of our course has been confirmed when the government
published a scheme on November 3» 1972 for an integrated health and
family planning scheme, which is very much in tune with our plans
and we hajye been propagating these ideas since January, 1972.
We have been greatly encouraged by the help of nur ,*rous friends
and well-wishers at home and abroad, notably a group of students in
Holland and groups in Britain, France and Switzerland, and we wish
to express deep gratitude to them for their efforts on oUr behalf.
With the help of some friends and personal resources our Project
Director,
Dr. Zafrullah Chowdhury went abroad for a period of two
months in August and in September in an effort to raise funds from
felief agencies and other groups for our project*
Since relief
agencies can make large sums of money available only after committee
meeting decisions, we are still not absolutely certain when and
whether our future will be secure financially.
. ..
STAFF; A.ND VOLUNTARY HELPERS
•.
The permanent technical staff of the project consists now of four
fully1 qualified doctors, six trainee nurses, two trainee pathology
techhici^tis and one trainee pharmacist^
We have come to realize
tha^t' father than expensively trained specialists, a program ‘like
ours ne'eds general practitioners with some specialized knowledge.
Each of the doctors and hopefully the nurses will attend a fifteen
day course at the Cholera Laboratory in Dacca to study diarrhoeal
diseases.
Two doctors have also been booked for an advanced course
on the treatment of tuberculosis.
Unfortunately, none of the doctors in the team has a thorough
training in gynaecology - a gap which we must fill as soon as possi
ble.
But since trained gynaecologists are exceptionally rare in
this country, one of the present staff will probably have to take a
specialized course. We have already come across several gynaecologic . 1
problems which we find difficult to explain due to lack of facil
ities: women have told us that they have conceived after having
given birth without a menstrual period in the interval.
Another
case was that of a woman who claimed to have conceived after two
years without any period at all.
:
In Bangladesh, qualified nursing staff are much rarer even than
qualified doctors, the whole country boasts only 695 (only half of
this number is actually working), compared to 267,000 in the Unit.-'
Kingdom.
It is obvious, therefore, that we have to train suitable
men and women ourselves.
Our training is unlikely to be recogniz a
by the government (bureaucrats at the helm of affairs are too
strongly city and hospital-oriented), but we are convinced that a
certificate from us would give oilr ritirses employment in other
voluntary projects and they would also be able to work in various
capacities in their resepctive areas.
■ ■
■
■
-
•
: -ri
•
■ ;
If you have not. received the ”d^t;ails of o ir Project" and "last
progress!report” please write to us«
COMfv
'■
''■.th c/ij.
BAMGALORE-560 001
page two
As a general policy, we shall give high preference in any future
recruitment of staff to applicants from Savar, since the only
hope of success will come when we manage to involve the local
community*
One of the most encouraging aspects of our work has been the number
of people who have come forward to help on a purely voluntary
part-time basis*
Every Sunday we have more volunteer doctors, medi
cal students and family planning helpers than we need.
This shows
/tha; there an enormous potential force in this country of people who
want to work towards social development ao.d are' looking for an out
let for their energies and ideals.
Much Cobld be done if only those
people who are already motivated towards community development work
One
could be given tasks in a more organized and efficient fashion.
of the best examples among our volunteers is Mrs. Ayesha Rahman, a
mother of nine who has for the past four months come to our Sunday
Since her children
clinics to act as a family planning counsellor.
~
•
some
useful
activity and has
were grown up she has been looking for
There are many women like her in our
found it with our project.
country.
do
• :
i
ACTIVITIES
1Clinics
Since we established separate clinics for children under 12 a few
weeks ago, less patients come for treatment to our Sunday clinics.
But even so the attendance is between 600 - 1000.
In these clinics
we have been able to get an impression of the prevalence of various
forms of illness and disease in our villages.
In adults, these are
roughin order of frequency: 1) intestinal trouble, 2)general
body ;ache due to rheumatism, 3)peptic ulcers, 4)skin diseases, 5)ear
infections, 6)infections of the respiratory tract, 7)helminthic ihfec
tions, 8)mala(ria and kaliazar, 9) tuberculosis, 10)prolapse uterus and
menstrual irregularities.
In one clinic four frank cases of tuber
culosis were detected and we are certain thafj many early cases of TB
are being missed by our relatively inexperienced young doctor friends7
since there are no laboratory aids avail-ahle tn. Savar.. .... Njtght.:. blind
ness due to vitamin A deficiency has quitte. a high incidence.
We have
also come across some cases of veneiral diseases which we believe to be
a new
new arrival in our villages since due to' the social structure and
traditional taboos, promiscuity is extremely rare.
It is possible
that VD is occurring now as a result of ■ the/, h^c'ent upheavals of the
war.
If in the villages, it would be useful,if a sociologist could
do some research into this problem.
• i. ■
Ui 2
In children, diarrhoea, worm infection with anaemia, , malnqtritibri,
skin diseases, and ear infections are the commonest complaints.
If we ever had any doubts, these field clinics have/convinced us
that however much we want to concentrate our efforts, pn fhe preven
tive medicine'Jahd improve through this the general standard of health
and well-being among the population, we cannot completely dispense with
the curative aide*
Only a few days ago, a little boy of two yeats was
brought to us suffering fro an advanced stage of typhoid.
He died
only a few hours later, but while we were making what amounted to prac
tically a show of efforts to save him, we were able to convince his
father that his son would not have caught the illness if he had been
immunized.
Had we no facilities at all to treat the little boy,
we would have stood condemned in the eyes of the whole community,
A strict separation of preventive and curative care, as practised in
some East African countries is no answer to the sitjation in the
rural areas of Bangladesh,
.
We believe that a completely free medical service is not the answer
to health problems even with our poverty-stricken rural populati on.;
because it encourages abuse and corruption and instills the; same kind
of relief-taking mentality as ithe handing out of free food supplies
M> a new spirit of self-reliance and
We want to create in the people
the
prerequisite
for social and economic devindependance which is •
For
these
reasons
we
charge
50
paisa (2/^ pence)in sterling,
elopment•
c
nsultation
and
25 paisa for any subse?v.on;
urrency) for each first
ones<
page three
If medicines are prescribed as a result of the consultation, these
are dispensed free of charge.
For hospitalization we charge 5 taka
(25 pence) as an admission fee, but thereafter treatment, medicines
and food are provided free of charge for the length of the patient’s
stay in hospital.
In the rare cases (less than 20 percent) where
people are top. poor to pay these nominal charges, we waive payment
in the form of a family Insurance scheme: each family will pay two
taka per month if they want to make use of our services.
We have cal
culated that our whole project coxdc
be self-supporting as soon as
8:Q percent of ' the families in the thana agree to enter the scheme.
We found h sample surveys in various villages that most villagers
pay four to five taka per month on buying medicines and they spend
more on fares to travel to the nearest towns for treatment.
2.
Selection and Training of Local Volunteers
During the end of the summer we began with the selection and training
of our local volunteers who will perfomr the bulk of our preventive
We went to the wchoola of the thana and talked to student'
work.
leaders and also arranged public meetings in some of the villages,
explaining our work and aims.
We then asked for the names of two boys
to be submitted from each village who were considered suitable to un
dergo training as paramedical workers.
However, instead of two names
we initially got 8-10 from each village.
In the first instance we
accepted all these to spread the interest in our work.
After about
four
classes when it became cleafr that the boys could expect
neither money nor future jobs from us, about half of thS original
applicants' drprpped out, still leaving n^ore volunteers than we had
intended to train.
After ten classes, the two doctors conducting
the training set an examination for final selection of this first
batch of vdinteers .
One hundred boys fro = fifty villages were taken
on as future paramedical workers but the atteri^ancb of classes contin
ued to be about 150.
Apart from the school students we have been able
to attract four local ’quacks’ and some primary schoolteachers who
are also taking part in this course, and we are particularly proud cf
the fact that, we gained the cooperation of these ’quacks’ - who were
up till now the only people to whom the vil agers could turn in case
of illness, and to whose livelihood we could pose a potential threat,
Any medical care which reaches the rural population of Bangladesh is
given out by these unquali fied practioners, and whatever their medi ___unfair
_________
___
' ' t£
_ ___
_ _
_____________
If
cal mistakes
would be
and__fo
olish
push
the
m aside#
we antagonized them, wej would create a powerful enemy who has the
We want to train more of them and hope to
sympathy of the people.
incorporate them fully into our work.
This first batch of volunteers is being trained at our base in
classes on Fridays and Sundays.
For the next groups we want to go
to their schools ourselves, this being a far more economical method
than having all the trainees come a long way to our base.
We will
then hold our classes on ordinary workdays after lessons, in order
to leave Friday afternoon and Sundays free for the trainees' sork
in the villages.
The course proper started in September and the
original idea was that it should continue for 24 classes with two
classes each week.
But during thin
first course we are still
very much experimenting and wo are learning from our mistakes.
This
means that we will probably have to hold more classes than intended^
Next year, we will train boys from the rest of the villages in the
thana.
Our teaching methods and curriculum are still very much in
flux and we are only slowly groping towards a better conception of
how and what to teach, learning from our own experiences and seek
ing the advice of people who have tried similar schemes elsewhere.
In particular, Dr. Colin McCord, Associate Professor of John Hop
kins University, has helped us a great deal in this aspect of
our work.
For the provisional curriculum see App.
Since we are training school and college students almost exclusively,
and intend to keep them on a purely voluntary basis, we will,
of course, not be able- to use them as permanent staff ,for our program,
and we envisage training a new batch of volunteers each year.
In
this way, we will not cause any obstruction to the boys' education and
page four
we stress during the training that their involvement in paramedical
‘ *
After they
work must be done only in their spare time.
. finish schoolon
to
higher
education
in the cities or
some
of
these
boys
will
go
ing,
Although
training
new
village
workers
other
jobs
elsewhere.
take
each year will mean ai lot of work and organization, we feel that this
Their
is by no means 1lost
___ when the boys stop working for our project.
knowledge of hygiene and1 sanitation will stay with them and they will
and useful citizens through their experience
become more responsible
]
this
project.
involuntary work in
In the long run, we hone to u_se* our volunteers not only for purely
spectrum __of ____
t asks __
in ____
the ______
,field __
of __
vi 11 _
_______
. _ _ , but for a broad
i____ ,_________
pie
die al work;
age development.
In particular,, we hope
that we will be able to start
T ,
a sTheme of a duIt education, in which these boys could easily play
an instrumental role.
We believe that adults could be encouraged to
learn reading and writing much more easily if they were taught by
their own children.
.
. "
-^.T
n
'1
a_
- — —
— ——
1
1
V.
T
/-s
r'* •i-
>*•'
3• Family Planning
As we mentioned in our earlier report, we have been giving advice on
So far, our
family planning c ncurrently with our field clinics.
family planning activities have therefore been unsystematic and quite
haphazard -reaching only those women who happened to have heard of uj
or come to our clinics.
We have not yet begun to implement our poli
cy of one family planning counsellor for each village*
This will
have to Wait until we are permanently established at the site of our
project*
Nevertheless the results so far are encouraging.
130 women
have been given the pill and although there has been nobody to advise
them outside ithe clinics^ their personal motivatidnhs been
such that not one of then has forgotten to take the pill regularly
or has neglected to come to us, (often a walk of up to, 15 km), for
further supplies.
Ajs before we are convineed that the pi 11 is ihe_
only aethof. of birth~control worth promoting on a mass scale at
this stage of our activities.
Our reservations about the use of vus*^
ectomy and tubal ligation have been corroborated by the publication
on this subject (Ahmed, Ratcliffe and Duya).
The second follow up
1969
East Pakistan Vasectomy Clients
publication 1970), it was
found that 14.4 per cent of the vasectomy clients had wives who> were
13% of the
over 45 years old, i.e. above the reproductive age.
The
vasectomy clients were found .'£6 be over 70 years or aiore o,f age
IUD is subject to the same kind of :abuses as a study by M.D.Crooley
and.others (National IUD Retention Study in East Pakistan, Pub. 19o-)
shows<34% of the women interviewed in the sample survey admitted
that they did not have the IUD.
Material incentive is no answer
to this problem of overpopulation , but person to person contact will
certainly produce better results.
. The Survey
In the absenecZ of any statistical data about life in our villages
we dacided a long time ago fat it would be impossible to do any
meaningful health social work, without first carrying out a survey to
establish basic health data. Our
questionaire was .devised to find
out the following: number of family members, their age, sex, marital
status,
educational qualification, occupations, dates of last imm
unization
against cholera, typhoid, TB, tetanus, diptheria, polio
et c. • The survey has so far been carried out in eighty five viBaThe dod«?x« ' work of going into each house and eliciting the
ges .
answers as well as filling out the forms was done by our local vol
unteers.
Before we sent them to carry out the survey in each village
we gave them a short training impressing on them the utility of
vital statistics and the need for accuracy and conscientiousness.
Random sample checks were carried out by volunteer doctors who came
to help on Sunday at the clinic, and they confirmed that the survey
had been done properly.
We found that all the villagers iere willing
to cooperate with us in the survey in all its aspects except one:
They were very reluctant to talk about their dead.
In particular, wc
estimate that about fifty percent of the mothers refused to talk about
abortions and the death of infants.
The villagers justified their
reluctance by saying that the questions about deaths were unnecessary
and tha’t one should not disturb the dead.
page> five
1
DEV3L0PMSNT IN OUa THINKING
//hen we first started to work out tae plans for our project in Savar,
we being a group of medical men were deeply impressed by the misery
and ill health due to almost total lack of medical care in our rural
areas.
We therefore, concentrated on devising a scheme for a health
service which could be implemented in the context of limited resources
and scarcity of trained personnel.
We derived impetus from the convic
tion
tion that
that everything
everything tried
tried so
so far in the field erf health care had
miscarried because of a basic fault in a concept of medical care which
~ taken
__ over wholesale-' from the we st, in couple to disregard to
h Ad been
hugeTdifferences
in______
standards of living, social structure and
the 1_v
. ___ ____
,
We
are now
patterns of .....
health and
diseases
, more than ever convinced
“
correctness
of
tnis
assessment.
But through our practical exper
of the
ience we have come to a much broader understanding of the problens in
our villages: appropriate health care is of the essence, particularly
the preventive side which we have been stressing all along.
But bad
health - i s • intimately connect ed with ignorance, lack of education ,
inadequate nutrition and lack of agricultural development.
If we
concentrate narrowly op» health care without paying attention to educa
tion, and the production of better food, the results which We achieve
today will be short-lived and superficial.
For these reasons we
have begun to think sore in the terms of integrated co a unity develo
ment.;
This can obviously not be done by medical men alone.
In the
first instance we have thought of encouraging the production of more nttritions food .
We have foudJ that CSM and similar protein concen
trates are not acceptable to the villagers except in a time of acute
famiiie.
Fish is the most important Source of protein in the diet
of most Bangladeshis and the area of Savar, like the rest of the country
is full of ponds which could easily be used for more systematic
fish cultivations.
We have been advised by ^fisheries expert that the
genus telepis is easy to cultivate, needs little supervision and
breeds three tids a year.
We are intending to grow this fish in
the pond belonging to Gonoshasthaya Kendra and to encourage the people
to follwo oup .example.
We are als' . talting the advice of horticulturalists; and,agronomists about growing pore vegetables: spinach seems
a good proposti.on because of th,e ease witT/which it is grown and
' its high iron content.
Our hopesi’;of encouraging adult education through
the local volunteers have already, been mentioned.
All our ideas regard
ing lheSe hon-medical fields ofiactivity are still very tentative and
amateur, but we think that, in time,iwe will be able to spark the
interest of specialists who will be prepared to work with us in Savar
CONCLUSION
Bur greatest difficulty remains communication with the people whom
It
we want to convince of the’ necessity for change and self-reliance,
is a disappointment to us tha-, due to lack of funds and bureau
cratic holdups we have neft yet been able to move to Savar perman
ently.
At the moment a *accha hut is going up which we hope will
be completed in about three weeks time.
But so far we have no water
supply (water is carried to the site from a distance of one mile*),
nor electricity and telephone, all of waicii we need to function as
a health centre.
To gain the confidence of the people we must
live with them and be in daily contact with them.
Our Saturaday and
Sunday clinics, useful as they may be for the people of Savar and
also for ourselves, resemble too much a weekend outing of city
dwellers to the .countryside•
We must integrate with the rural people who make up 94% of Bangla
desh, "but this, in our opinion do es not mean having to go back
to a state of stone age primitivity.
PAGE SIX
As far as is practicable and useful we must make use of modern
'7e need transport to
equipment to increase our effectiveness:
A L -NDROVER, A
move goods and people within our project area
MICROBUS-C UM-AMBULANC E, A MOTORBOAT, BICYCLES AND
MOTORBIKES.
ZE NEED BOOKS AND JOURNALS TO KEEP US UP TO D ATE
7ITH MEDIC AL DEVELOPMENTS,
WE NEED ALL SORTS OF AUDIO-VISUAL AIDS TO C «Y OUT
THE TRAINING OF tOCAL VOLUNTEERS AND GENERAL HEALTH
EDUCATION.
WE ALSO NEED CONSTANT. '
RESTOCKING OF MEDIONES OF ALL KINDS,
AND VE CAN MAKE USS OF DISCARDED MEDICAL EQUIPMENT
FROM HOSPITALS IN EUROPE AND THE STATES.
APPENDIX
COURSE OF STUDY FOR PARAMEDICAL TR* NE :S (3-6 MONTHS)
I. HEALTH SURVEY
The first classes are taken up by instructing the trainees in the
importance of statistical data, methods of collecting data for
the health survey, etc. This is to prepare then as soon as
possible for work on this part of our program.
BASIC HUMAN BODY AND GROSS ANATOMY
II
III BASIC PHISIOLOGY pulse, temperature, respiration, water
balance systen of the body, shock
1) personal healt . and hygiene
IV HEALTH EDUCATION
2) community health
3) communicable diseases with emphasis on
local diseases: helminthic infestation, diarrhoea and dysentry,
cholera, smallpox, typhoid (enteric fever), tuberculosis, mal
aria, measles, diptheria, tetanus, venereal diseases
methods and types,
4) immunisation :*vaccination, inoculation ,
contra-indications and complications
5) nutrition: principles of food, basi«
requirements, balanced diet, food preservation, illnesses
caused by deficient nutrition - anaemia, night blindness, etc.
V.ENVIRONMENTAL HYGIENE AND SANITATION
1) water-sources, impurities, collection and treatment of wfcter
2) excreta disposal - significance, requirements and methods of
sewage disposal
3) refuse disposal
4) local sanitation in emergencies and disasters
5) bazar sanitation including camp and school sanitation
6) air and ventillation - composition, air pollution, ventillation
7) industrial and agricultural health problems.
VI PROBLEMS OP OVERPOPULATION AND THE NEED FOR FAMILY PLANNING
this will not include methods of family planning
)
(
The co-operative movement, visits
to dairy farm, co-operative
centers, Rural z\cademy
use of microscope and stool examination,
sterilization, immunization, first aid, visit
to medical and paramedical centres
VII RURAL COM.' UNITY DEVELOPMENT
VIII PRACTICALS
*
i
DUTIES FGR WHICH THE COURSE IS TO TRAIN THE PARAMEDICAL WORKER: •
vaccination, keeping records of vaccinations,
keeping vital statistics of the village
organization of pure water sup sly and sewage disposal surveillance
curative: treatment of diarrhoea and shock
GONOSHASTHAYA PHARMACEUTICALS
INTRODUCTION
The scientists who developed the first antibiotic, penicillin, at Oxford
University dttring the Second World War, took a clear decision not tn pro
tect their work by patents, because they believed that it was unethical
to patent the outcome of pure research work, especially when it was of
such great medical significance. But later, when the financial potential
'
of penicillin became evident, it was felt that academic unworldliness
had cost British industry dearly in lost profits and subsequent dis
coveries and developments were always patented. Professor E.Po Abraham,
one of the Oxford penicillin workers, expressed this years later in his
’’Memoir of Lord Florey**: ’’Thus nothing was done (about patenting penicillin),
for reasons which might have been admirable in a wofrld withdifferent
economics, but seem almost irrelevant in the society in which we live.”
It was in fact penicillin and the other antibiotics which brought the
modern drug industry into existence. Up to that time, very few medical
chemicals were manufactured on a large scale, exceptions were aspirin,
phenacetin, arsenics and, from the mid—1930’s, sulfa drugs.
Most insulin
and vaccines ’Were still prepared by research departments. While in the mid—
1930’s total sales of the UoS. drug industry amounted to 250 million U.S.
dollars annually, sales had reached 8.3 billion for the first quarter of
1981 alone, and this only for the largest 15 companies.
During the 1970’s, a number of studies began to draw attention to the pro
duction and marketing practises of the pharmaceutical industry, especially
the large multinational companies, both in industrialized and underdeveloped
countries (cf. Select Bibliography). At the same time, the World Health
Organisation developed an ’essential drugs list’ containing 209 items 032 of
are not essential, but useful as alternatives or for rare disorders) and'some
J.'hird World governments (including India, Sri Lanka, and Pakistan) tried to
curb the industry by legislation. Unfortunately, the power of the drug
companies and their hold ovor the elites of such countries was too great for
these efforts to be successful, while- so far WHO policy has remained a paper
concept.
Observing th^ effect of the free hand given to the multinational drug com
panies in Third World countries, it scorns, in hindsight', that the ethical
instincts of the Oxford scientists at the beginning of the pharmaceutical
revolution had much to recommend them even on a practical level.
Pharmaceuticala in Bangladesh
At a conservative estimate, Bangladesh has an annual drug market of Tk. 1250
million (approx. 8j million U.S. dollars), Only a negligible proportion of
this is available free of cost in government health centres, the- rest is sold
commercially. In a country with one of the lowest per capita incomes in the
’ t^A°ad
cc^v\aor^>
660
2
world (70 dollars a year)c this means that after food, clothing and shelter,
medicines are a major part of the remaining expenditure.
Often, a little
medicine may be bought in extreme neec(, but not enough to cure the illness,
and the public are left in ignorance of the detrimental effects of breaking off
treatment prematurely. Most importantly, due to poverty and the high cost of
drugs, at best 15^ of the people ever buy any modern medicine.
Inadequate information and the common habit of self-prescription (because
doctors are unavailable or too expensive and because all drugs can be freely
bought over the counter) have led to a situation where 70% of the annual drug
sales go on drugs described as useless or therapeutically insignificant by the
British National Formulary the National Research Council' (USA) or the Federal
Drug Administration (USA).
The bulk of these unnecessary medicines.arc vita
mins, tonics, enaymos ard ^ough mixtures o
Drugs worth an avarage of Tz, 150 million are imported annually into Bangladesh
by small local firms and also by voluntary and U.N. organisations. The re
maining medicines, worth about Tk.1100 million, are produced in Bangladesh.
There are over 150 registered drug companies, but most of these exist on paper
only, having been created to take advantage of the fact that raw and packaging
materials for pharmaceutical cpmpanies - which are considered essential indus
tries - can be imported with enormously reduced customs duties and are then
resold to, e.g, cosmetics factories.o Tk. SgO-million worth of drugs (= 8l%
of drugs produced in Bangladesh) are pz oduced by eight multinational companies.
The rest is shared by a number of smaller multinationals and 22 local comapnies.
The table below shows the situation in greater detail:
Multinationals:
2e Local Companies.
Name o,f Company
Annual Production in Taka
P fzer
I ■' sons
& Becker (BPI)
Hoechst
G1 axo
S’f ub
I JI
Organon
Others
200 million
it
140
it 120
it
115
11
110
it
105
it
50
it
50
u
15
905 million
Square*
Gaco
Albert David
Pharmadesh
Jayson
Others
70 million
st
40
1!
35
It
30
tl
10
It
10
“195 riillion
Imported:
150 million
Grand Total:
1250 million
‘Square manufactures drugs mainly under third party license (from Janssen)
- 3 Looking at the types of medicines available, we find about 2300 bran-d-named
drugs containing 150 different active ingredients •
Only about 2^0 of these,
about 10% are therapeutically significant or essntial drugs according to the
sources named above
All the rest are promoted solely for the purpose of fin-
ancial gain®
Proliferation of products and their promotion is, of course,, a ubiquitous
feature of capitalism, but in a country like Bangladesh the situation is worse
because it diverts desperately scarce resources and many people will deny them- selves food in the hope that some aggressively advertised, but useless, tonic
will do them more good®
But it is not only a confidence trick: substances
which have actually been identified as harmful and banned in developed
countries continue to be marketed and manufactured in Bangladesh®
The pressure
that can be exerted by foreign companies on the government was shown again
recently when dipyrone (Hoechst brand names ’Novalgin’,’Baralgin1), which can
cause fatal agranulocytosis, was again cleared for manufacture, even with an
increase in the permitted quantities (Bangladesh Gazette, Pt®I, Feb® 29, 19Sl)*
The decision was taken despite strong representation from groups of local
doctors and pharmacists®
Other products banned elsewhere, but still available
here, include phenacetin and clioquinol®
A quotation from the Managing Director
of Fisons (Bangladesh), Mr® A® Wahid, may sum up the attitude of the multi.•. nationals: nWe are businessmen first, first of all we want profits©®oWe are
oversensitive about reports from WHO®
Restrictions on drugs and pesticides
imposed in the U.S® and Canada should not be applied in our country because
our people are ethnically and biologically different from others®11
This is the background to the involvement of Gonoshasthaya Kendra in the product,
tion of medicinese
GKP
Gonoshasthaya Kendra (GK) is a charitable trust which was set up in 1972 by a
group of health workers who had been involved in the Bangladesh liberation
struggle of 1971®
The first objective was to establish a health service in
Savar thana with an emphasis on preventive and primary care®
In the course of
this work, it was realized that health care by itself could not be an answer
to the problem of poverty, and the project became involved in a wide range of
community development work (cfo Progress Report No® 7)a
The project experience, -and especially the problem of how to get good and cheap
medicines to the people, also led to thinking about a pharmaceutical factory
based on four principles; viz® low prices, quality, manufacture of essential
drugs only, .and responsible marketing practises®
The factory is a joint stock
company, but all shares are owned by the GK Charitable Trust and cannot be
bought or sold©
Policy is determined by a Board of Directors, consisting at
present of eight members, with representatives from government (Ministries
of Health and Industries), the Bangladesh Shilpa (Industrial) Bank (BSB) , the
GK Board of Trustees, Savar GK and NOVIB, a Dutch voluntary agency®
- 4 '
i
•
'
.
'■
The cost of establishing the factory has been:as follows
Building including air conditioning: US dollars 1o2 million
n
K5
i 11
Training of managers and business travel: !!
0o1
it
Working capital incl© raw materials for
four months:
1*2
II
Transport and miscellaneous:
0«2
11
Machinery and equipment:
■i
’
US dollars 4C2 million
?
Contributions from:
US dollars 2©62 million
NOVIB (Holland)
Oxfam (UoKo)
ti
O©33
it
Christian Aid (U®K>)
H
0*16
it
BSB, GK Trust and others
II
1o00
II
US dollars 4O11 million
‘Technical expertise has been provided by the International Dispensary Asso-
ciation, Holland, who also organised training for managers and the architectt
as well as the procurement of machinery and raw materials© All managers are
Bangladeshis
.........
GKP is designed to supply 15 - 20% of the present Bangladesh market in essential
drugs once it is in full production©
Retail prices will be 35 - 50% lower than
those of equivalent drugs on the market, and are calculated to leave GKP with
an overall profit of 10 - 15%, after deductions for all production cost, deprecia
tion© and bank charges©
Profits will be invested in expansion, medical and
Part of it must be spent on chari
'social research, and in new enterprises©
table purposes©
Marketing of GKP products will be partly through bulk purchase by the govern
ment for their rural health centres (initially 60 - 70%)? --nd partly through
a chain of special retail shops©
Conclusion
It took nearly seven years to progress, from the first ideas discussed among’
friends to production of the first batches of the. first two drugs (paracetamol
and ampicillin) in May 198To
Many problems had-to be overcome©
The three
main areas of difficulties were:
1O Problems connected with the transfer of technology -,eoga lack of infra
structure, lack of expertise among Bangladeshis from architects to refridgeration engineers to laboratory technicians
,i
i
2e political: an indifferent government and hostile multinationals
3o relationship to donor agencies
A problem which we are only just beginning to face is that of distribution:
how to hand on the benefits of cheap, quality production' to the consumer;
how to eliminate profiteering by middlemen©
f '
f.
■
.
’
•
v--
•
?
■
•
’
- 5 To take a wider view: GK is not only interested in proving its ability to set
up this particular pharmaceutical factory, but sees this effort as a learning
situation for a genuine transfer of technology to the Thrid World*
This is
not achieved by multinationals bringing in complete blueprints which give no
opportunity for training and experience of local manpower*
Further, a
genuine transfer of technology on a large scale needs a more favourable pblitical environment than is given in Bangladesh at present*
We hope that our
work will demonstrate possibilities for such self-reliance and so contribute
to the change needed.,
Most important of all, transfer of technology does not
in itself mean improvement for the poor*
To find ways which guarantee that
industrialization can be controlled by the poor masses of Bangladesh rather
than becoming an instrument of oppression, is one of the main goals of GKP*
Select Bibliography:
Following is a very small selection of the many important books and articles
on the subject*
1. Ho Sjostrom and R o Nilsson, Thalidomide and the Power of the Drug Companies,
Penguins 1972
2. M© Silverman and P©R©Lee, Pills, Profits and Politics, Berkeley and Los
Angeles, 197^
3. RoWo Lang, The Politics of Drugs: The British and Canadian Pharmaceutical
Industry, Saxon House, 197^
Haslemere Group, War on Want, Third World First, Who Needs the Drug Companies?
(undated)
5
Sanjaya Lail, The International Pharmaceutical Industry and Less Developed
Countries with Special Reference to India, Oxford Bulletin of Economics and
Statistics 56, 145 - 172, 197^
6
Sanjaya Lail and Senaka Bibile, The Political Economy of Controlling Trans
nationals: The Pharmaceutical Industry of Sri Lanka (1972 - 76), World
Development 1977> vol*5» no*8, 677 - 697
7. Repofct of the Committee on Drugs and Pharmaceutical Industry (the •Hathi
Committee1 on the Indian drug industry), New Delhi, 1975
8. John Yudkin, Provision of Medicines in a Developing country, Lancet, April 15>
1978, 810 - 812
9* John Yudkin, Drugs and Underdevelopment, New Scientist, 14 December 1978
Sonoshasthaya Kendra
PoO© Nayarhat via Dhamrai
District Dacca
Bangladesh
q/> 7
VOLUNTARY HE..UH .UiCCL.TION OP INDIA
GO^CG/L 1ST
KEffiU
(PEOPLES HEAITH CEim)
In 1971 when th liberation w^r. shook Bangladesh there emerged
a
T group
-----... of idealists.
cu*.—mJ, who believed in freedom, bell^wd in a fre^
independent?Banglad-csh and w^xv willing to fight for it and continue
working for th ir Bangaid'sh. brethren even after Independence in this
venture. These idr clists had vision, courCig?, social consciousness
and concern for.the- deprived. Many of th doctors involved in this
restructuring ,of health work had. abandoned th&ir stqdies in U.K.
and. oth--;r countrL s.
In 1972, th? Bang] adcsh Hospital which was s -t up at th war
front to deal wxth wounded. Pbikti Bjhinls was converted as G onos ast hya
KLndra or th’- Peoples Health G:.ntr? and mov.-d to Savar.
The pioneers of this nead-based ^nd integx*aiod health work w-t»r«>
young m*n and wermn, som. with formal qualifications and others wluh
skills picked up on th? job. Th-^y b^gan th-tr work in th rural areas
of Savar about 30 mil's from Dhaka. Her#-'- the bass hospital was s^t up
to cater tc th« referral- needs of the numerous satellite, sub c^ntr* s »
and to provide health care assistance which was non-existent.
Th' initial health education and immunization prograrom--- was
carrx-d out by about 100 volunteers recruited on part tim^ basis, wl^u
worr senior students from school.
G.K. believed in integrating prevent Ito programmes with activi
ties such as nutrition, agriculture and family planning, socio jacoaanic
programme's which have gr,;at bearing on health. Right from the onset
G.K. was cl^ar abpt$ its .’’alt^rnativ health care approach”, which was
. not based on c>-urtraliz.-d curative oriented ‘drug doctor disease centres
called hospitals - but on d'c; ntralizf-d demystified basis health car?;..
By 1973 G.K. d^cid d to haw full time paid param£i.ic workers,
instead of part time workers, for more effective work. Most of tha
param' dics recruited, were-girls betw«^.n th? agvs of 17-25 years,
interest id in health car. wdrk and from th? local communit les to SOFTO
s~r
th- vulnerabl. population constituting of woimni and children better.
Each paramedic of Savar tak s car; of about 3,000 population i.o.
about 3 villages.
Thes< young worn n are s-nsitiv*- to th ir own peoples no? ds
.arv fortunat.f
fortunate to g,
g-t
tli; support,
support guidance- and supervision from
and .ar?
t th?
doctors such as Dr. Zafraullah Chowdhury and Qasim Chowdhury who
b^lievi? in thfe potential ability of the paramedics to undertake: health
r-lat d tasks w.xth gre-at. r efft-ctivonc-ss than many city based highly
qualified doctors. This is so because unfortunately their medical
-due.:Lion4nsl ad of providing th- m with th? diagnostic, therapeutic,
organizational and communication skills requir'd, to sorv.-. th<-ir own
peopl and inculcation of the right attitudes do exactly the opposite
and air. nat them from th- :ir own people, d^s^nsitis^ them from their
real health
ds and h-lps in development of a valu- system which
focuses, on the comm rcial pct ntial of health cai’e rather than the
service aspect, an aspect that focuses on attempts of resolution
of the actual h.alth or obi-ms.
,
‘W-1BrNW°O^5iW"
‘”
. 5^u
dOl
2.
—
:2:
of th.
vi^s‘rs «•' delved in the selection
view thP ca-ididnt^s rfT
®ld®r^ frQm tte Poorer section intssrTh tr.nqnn^
i*M. 44 paramedics of Savar most of th-m arr women
aid i
b1^1- - « -volutS^T
d by th.- paramedics 13
iv xiocrating sr^p f^ th^SG young Muslim wem^n.
tb> worfer. „ n. c<m„nltv, Th. TO.k
or
“ oPP°rfcunitJr to serv^ their
own ccmmunitt-s but ais^h
fi'e^dom
fma. and
niz.d thv^ffoj'hroviio^ of1^^ 3 3 hi.alth Program* has rc-cogprovision
maternal, and child health care
seryic&rs before
-e of
,•-!?.good
„? matinal
exuvq c at ing fam ily plaim ing,
in the hXl3KhFX&a£
"^tal -T seriCGS ar : pr^ed
from ths concept of a clu+t«3ri ^»P+ <b?T’. Thl® ls ^’ry different
and wait for hours imnatie-ntlv t °1?nxc?' where waw--n line up
impatient medical pex-sonnel^
’ ch6cfcsd by’ h^3^- and. an equally
time. balS.-^Sr^w^i ’ acfciTOy fnvolwd in G.K's work on part
more specialized car -nd distrihJy'i8
and doing a regSu^foSt^
°f
411,10 natal patients requiring
“utrae^iv, pills
inst-itiFSS,ytrS'^BSSw-a1 h G-K' Was
gates it.
-nKin.
the first health
The Bangladesh uovernmenb still propa-
ttet =ompl-s1~F■®’s^
wom^n
. Thu
~x8.
»paramedics
<^s 3H£^J?Sgte
and doctors
The Bar-maidir^
tr““^ “f ««•
simpl.. iab tX IS
b-n tra^
foripal lectures by senior
heaith problems, diagnosing and early rpf-r^l^thtX^^1 —b C°“
specialized care; and heln +h«
O1 thos® requiring more
care of the relate vSy
r
hospitals to .take
ShimiiLi^aFkm flo^sX'Ir^v^hoIT'T’'1103 WfS
d°
«hrdered in
interfered with by the
rZt 3
was b<^
who was there to set up a w"ll mn e\ our^geous paramedic lik1 Nizam,
th. local quack who 3Iort d to 3233
Kizam.^s
threat to
th« ignorant people
Th locU ?^,Piact'lc--s for profits and exploitatad
efforts of th TOedics
n3 i
c°°^ive was started by the
of his bodyw--,rs found 10 ,^313 3 bih‘;S'u,'!i and th- d.ism-.mbered parts
Off his-health m^agBsd2^^a^r^rkWb!?Oifo^s 51* pills and rattles
begin to help communities to
and political factors leading to Ul
workers is not that much anm-XS’
teStf
+3^
i XS Wh'E'‘n healtn workers
C£USa-tiv:- socio-economic
’ W ^le of tha to5alfch
w^kers, tho mor; thr^v^d^^^
^ntr-ibiH
the produc ;rs of
BanglaAesh and fSlipS.Guabemala’3 Nicargua, Mexico,
3.
(
•i'71
• .c.
’
:3:
Insurance Schema: This service
'
based
on the economic conditions
of th p?opl- from th7 community being isserved.
They ar-; divided into 3
groups :
Cat-gory 1
Thos'■ that cannot afford from any source even
two meals throughout the y^ar for family members;
Cat . gory 2 - Thos- who ha,v . land upto 5
acr s arable or
unarablrj
Cat--gory 3 - Thos'- with land upto mor
than 5 acres.
For Category 1, registration card is given free and payment
mt
made
i±■*’?•. ™“ 9.5°
(£”«1
25 Lidian p.K
o.x > x-rays,
rays, operations,
op-rd.uians, admissions ar^
ar' ■ included
inc 11iHl
tn
izr\
togy^
in~thls^50^^
propoShoSfc ee
tO
• ‘° ‘b
th
b. ing 10aSrT v ^S“tr.ation ch+arS‘- is 12 taka with rental charges
sidif-d co? J
CO3t P£ r Pati< nfc P; r visit is 2 taka - the subsiaiz^d. cosu of other services is also borne.
per Vis^is°7f4 RegFrati°n Chargfe' is 13 taka- Cost'prr patent
■than th* 2nd
gr°Up
a highf r rat® for oth' r s«-vic~s
PO°1' ^avC!
f
s ac^ardfn^n th
‘-cco.o.j.ng to th
the minimum amount for health care
F Pi’ogrammss wr< m-1 by .insurance
1930 annual report.
. 1980 the
Immunization - The.s« are given free to all
and. in
!
^c
.>v<
rag©
of
DPTX, Tetanus immun.Lzation was between
60-?0 in 1980, signn icantlyBCG,
higher than other non-proj- ct aiVcts.
f
&*** Saltation: In G.K. scheme 1 tub-- wll smres 15-25
thHtub^lJs.aS JonS
Tho^
b»™. by th. c„™a f„4 „x„ 4^5X4 Syf™00?'t
?
f
for tte maintenance of the tube wall and all the ™= =1
iinancio,! contribution monopolize thp use.
&
A wrench and training for simple repairs Is givmi so that thhand pumps do not 11
- ;■ — — out of order for mor than 48 hours.
" the Int-grat^.Rural
womrn fr
from
Devel opm-.'- nt Pr ogram
•■ dlcal Stud.,*» from 3
ooll.
co"it->' '““h «■* at O.K.
St
dealing with th. conmon health probl-^ of rmilkXdpT
each group c^. to th- similar conclusion th^ th^^dK^ Xo°fquip
m to 9fX8Ctiv^
that 3tXtXiaC2kSV™^iri'E
an effort it. charging th- situation. ' '
»«' tMoal <X>11»S«
P
ncouiag. uh.m to make
4.
:4j
sect i Id,
: Fiald practice dissertation
ducted ir*G K ^h? ^■8'flnS fcO a DxPll>m 1X1 Community medicine was conF1’
G,£; e
Diploe.cours- IS run by th National Institute of
mv-ntiv und social M^<Ucxne in Canmunity Health.
Problems
. , facM.
. . w'
iil r'-la't-ori to NIPSQvi professors not accompanying the jstud^nts
’ “ ’ to th. f?>ld and centx-e. as had bc^n agreed upon
earlier; LoW salaries
------- j - .krof-ssors to undertake privat- practice.
giv.A 3 month training has bwn
gxv^n to JN1CEF trc.me. s. Traditional midwives have also b^ii trained
to link up h.alth and nutrition programmes.
framed
N^rik-ridra. ~ Cunti% for Wom-rPs TVocational
’
~ ‘
" Z_
Training: Narikr-ndra
activit s ar; bas'd on’ a simpl. ’ philosophy that includ^
-------------that
; fundamental
f
cl^sks and oth r teaching; in broader t^rms
which
-------- can
h Ip tn.m •unaerfetanu the causes of their
own under -devclopiiK'.nt and what
to do to bring about th chang .
S w-i
'ri?ining programme s for th worn n in metal work, c-jrp iitry,
hnlp tfem dev lo/skilL both
m-'-n ' W=t 4'T!lthis0Hbh%tht? Gan d° th‘ job i'’t'cluirGd
as w 11 as
C,J
;+ S1!
Rd+
th w«»'n trainu. s th; ms.lv.s is significorr from ’</
do 3 to th<: ofcI1'cir women and communities they
t^aff 44+m°1V 3^nlfxcailt ^ill. This of cours applies equally
women J ro> if sSstT’
C°nCCPt
tr -ditioilal musl™
<y •
wom-n
= ~(P'TPlf5 WorkshoP>- Trainees her-.- are mostly
4+ 4d
d d
t0
cat'sg^ s - skill., d and unskilled. The workoS^t ior -4? Pr°dUC'\a'- corfl^itiv« F™s hospital beds, simple
Sils wi^±4 ^’volviiig chairs, simpl pip- frames for chaS,
o -Ils, winuow frames, ste-1 racks, agricultural instruments, etc.
bunch ofcoiifSSS^3 on;~ 'SthC m0St iascinating sights to watch
a
o^icn oi conf ids nt young girls dressed in blue shirts and navsmas
Stt or SS4S b4?d
away at a metallic
bucket,>
railing, cutting and welding the pipe frame cf a chair with their ors plugg d to prevent deufnt ss due to noise pollution.
At ^carix ntry workshops there; Wore women at work making windows
and ' do dr f ram.. s. xh- women trainees learn how to make wooden furtniture
too.
Gono Paduka (People*s Shop)* Tn iQ7^ n 4^^
work'-rs st
\ n ■ -t
, 19/8 a ^01nb cooperative of skill-d
u^illiiJ i fl ?o
\
Shoe industry; there wf-rn problems ^.g.
work
y
* woik Witn wetuen workers,unwillingness to do agricultural
shoes'for'tht r'icT
aX1 <rapl°^! s’ P^feKneo in making stylish
is f-1-i-r?On° 1?^d^a display Shop near.thnear th canteen
canteen facing
the main
main road
facing the
road
fairly well stocked with inexpensive shoes and sandals made of leather.
5.
:5:
Gono Patshala (R-opl fs ■School^ : One of th--- most innovative
programme-s of G.K, was start'd in 1977. Th' education for th^ children
of the pour is a privilege denied .net, because of .ignorance and stupidity
of parents but due to th. rr cd of their contribution to family work,
wh thfr this is in minding small r children, coll-cting cowdung, fire
wood, fu 1 or wat. r, taking cattl for grazing, washing utensils,
clothes r- it mor ly means that education is not s- -.'n as a priority.
Understanding of this anal rol. of village children i.r. as ‘Hom^
help1 as well as a rstudent1 has to be respected.
Class;-s at Gono Patshala ar- h Id 5 days a week instead of
th- usual 6. Old-r children and teachers holi classes at th- villages
for th-- children who ara unable to come. The school is glared to
fulfil th v-ducational ne ds of th* landless and marginal farmers.
The old. r childr en !.■ . 10-12 y^ars olds In school gc^t vocational
training for 2-3 hours p-,r day and in a matter of 2-3 months they art
capable of making effective contribution, The school prepares the
children for their own communiti* s.
School children are involved in poultry breeding, -Loca.l hems
are cross br^d with ar Australian Cock and 12‘we^k old chicfem aro
tak.-'-n hom$ by th** stud. • nts, Wh^n their chicks hatch 2 of thrm are
returned to the school for other kids.
One of the most br!autifulduring my visit in Jan. 1982
was to watch a class of littl children being conducted in little- groups
with one of th children doing th supervision and teaching of each
gi’oup, a most touching -xampl-! of what children thins?-Ivos can do fox*
on another. On 2 occasions during my 2 visits to 2 different villages
with Sandhya Di -Senior parami.-dic. Co-ordinator of Nari Nikrtan - and
David vl-rn? r, we ebsurv d classes of a group of adult men and women
involv d. in a. learning session. -What was probably the most outstanding
fatur- was that the teacher was * an
enthusiastic young child from
Goho Pathshala,
Gono Krishi Khamar(People fs Farm): Mandatory participation by
all G.K. Staff in th^ projects internal agricultural programmes is
expectxI. Th-< aim is to expose: thoses not actively involved in agri
culture to understand, th'-, skills and th6 rnanua^/lm the level of
technology, labour involved in agriculture and to realize the extent
of u , exploitation and underpayment to the farmer for his contribu
tion in providing this vital technology.
Reforestation is b< ing promoted and. so is fish cultivation.
BhatsaJa Project is 120 mil s to the north of Savar situated
in Shapnarx village of the Jamalpur Dist and is a ’daughter’ project
of G.K. working along the same lines. Geata. Chakravai*ty was the
Director of this project in the initial years.
G.K. !'armaceuticals: Aft-, r 3 y- ars of planning and preparation
in 1978j G.K. got clc-arancfrom Bangladesh Govt to product drugs.
In Nov. 1978th- G.K. Phurmac <.. ut ic als b uildings c out ruct ion b ■ gan. It
set up a first class quality control and Fl'eduction Development
laboratory.
The building d.sign, th-, installation of the central air-condi
tioning, the setting up of hb equipments has been don- by the
Bangladeshis thomsvlvcs. Top manag"' nrmt staff were, recruited from
Bangladesh but sent abroad for training.
G.K. Pharmac uticals is owned 100$ by the G.K. Charitable Trust
and by its charter; 50$ of the profits are to be ploughed back
for the factory expansion and the otht r 50% is to help voluntcoi'
programm s in th' country with emphasis on social sciences and indi
genous herbal medicine research.
6.
:6:
Gone Publications: G.K. has translat d David Wern-r’s ,fbihexvThere is No Doctor11 into Bengali. It also brings out a Bengali monthly
called. Gonosasthya monthly - it is designed to giVi information on
all aspects of basic h .alth care and promote tho use of quality generic
drugs.
Organization: G.K. project staff are divided into mix<d groups
which me ext w-ry we -k for discussions and sharing reading reports.
G.K. staff me^ts . v*.-ry month at staff meetings whor^ major decisions
G.K..
are taken. Th Executive Committee- is elected by workers @ach year.
All staf '-‘contribute IQo of their salaries towards th.- staff
w^lfai^ fund. Food is Sv.-rv? d in th^ mass and m^ss contrib 11ions is
scaled according to salary but same for al 1 .
Conference on Technology Transfer: In Jan. 1932 G.K. > host ad
this int rnational conference on th occasion of th*j- inauguration of
thParmac^uticals. Many individuals who have, made an outstanding
contribution towards drugs and. health work had been invited. G.K.
provided this oppox*tunity fui- many like minded concarn d individuals
to come and share, l&arn and contribute views and experiences related
to drugs. I had the opportunity of b^ing present there and meeting
sem of th*? most consist ?nt support--rs of our drug work.
'
In April 1983 G.K. hosted another international Conference on
Alternative Medical Education with th& aim of having a meaningful
discussion by various authorities and individuals on various experi
ences outside Bangladesh on alternative m dical education.
Dr. bathyamala and I participated'in this very educative
exchange.
- MIRA SHIVA M.D.
Co-ordinator
Cost Drugs and Rational Therapeutics
•
' f f-a
, ■
'
./, ffc
VOLUNTARY HEALTH ASSOCIATION <F INDIA
Community Centro, SDA
Ncw telhi i 11001g
COMMUNITY HEALTH CELL
47/1 (First Floor)St. Marks Hoad
BANGAlO
- 56U 001
74-/^
RESUME: CRITERIA USED IN EVALUATING
DRUGS ON THE MARKET IN BANGLADESH
— Government of Bangladesh
The Expert Committee constituted which are of little or no therapeutic will not be allowed to be combined with
by Government Order No. S-DA/ value.
non-vitamins, e.g. minerals, glycero
D-D-20/82/74 dated 17 April 1982 met
It is unanimously decided that the phosphate, etc. Vitamins shall be in
at 10:00am on 28 April 1982 in the following criteria will serve as the tablet, capsule and injectable forms
Office of the Director, IPGM&R, Dacca, guidelines in evaluating all the only. The reason why no liquid forms
under the Chairmanship of Professor registered/licensed pharmaceutical pro will be permitted is the wastage of
Nurul Islam to begin evaluation of the ducts manufactured and/or imported in financial resources and the tremendous
pharmaceutical products available in the Bangladesh. Therefore:—
misuse that has occurred. An exception
country and to draft a National Drug
I. In general combination drugs will will be made for paediatric liquid single
Policy, keeping in view the health needs be accepted only where no alternative and multivitamin (without Bl2, E, K
of the country.
single drug is available for the purpose and/or minerals) preparations in bottles
Consistent with the declared guide or where the single drug is not of up to 15ml with droppers.
lines of Government to provide basic cost-effective.
VI. No multiple ingredient cough
needs of life to the majority of the
Exceptions will be made for oral mixtures, throat lozenges, gripe water,
people through austerity and to improve rehydration salts, certain anti-malarials, anti-acids etc. will be accepted (either
economy of the country, wastage of co-trimoxazole, iron with folic acid for locally manufactured or imported) as
foreign exchange through the produc use in pregnancy, combined oral con these offer no therapeutic advantages to
tion and/or importation of unnecessary traceptives (containing up to 35mcg out-weigh their cost.
drugs or drugs of marginal value have to oestrogen), and formulations specified
VII. The sale of tonics, enzyme
be stopped.
by the licensing authority for a mixtures/preparations and so-called
Almost any drug may produce multivitamin (B Complex) tablet and restorative products flourishes on con
unwanted or adverse reactions. The paediatric drops; hydrocortisone with sumer ignorance. Most are habit-forming
combination of two (2) or more active antibiotic skin preparations; and a and, with the exception of pancreatin
ingredients not only makes the product haemorrhoid preparation.
and lactese, they are of no therapeutic
costlier, it also increases the possibility
II. The combination of an anti value. Henceforth local manufacture or
of adverse reaction without increasing biotic with another antibiotic or anti importation of such products will be
the efficacy over a single ingredient biotic with corticosteroids or other discontinued. However, pancreatin and
product. Hence, as a general rule, active substances will be . prohibited. lactase will be allowed to be m anu
combinations of similar or dis-similar Antibiotics harmful to children (e.g. factured and/or imported as single
drugs will be prohibited.
Tetracyclines) will not be allowed to be ingredient products.
Combination drugs could be manufactured in liquid form.
VIII. Some medicines are being
approved if the Drug Company can give
III. The combination of analgesics manufactured
with
only
trivial
definitive, approved scientific proof (i.e. in any form is unacceptable as there is difference in composition from other
WHO publications, British National no, or only trivial therapeutic advantage products but having similar action. Such
Formulary,
British
Pharmacopeia, and such combinations increase duplication confuses both patients and
European Pharmacopeia, USP or other toxicity, especially in the case of kidney doctors and will not be acceptable in
authorative guidelines like Goodman & damage and overdose. The combination future.
Gilman’s ‘The Pharmacological Basis of of analgesics with iron, vitamins or
IX. Products whose therapeutic
Therapeutics’,
‘Current
Medical alcohol is irrational and unacceptable. value is doubtful, trivial or absent and
Diagnosis & Treatment’, etc.) of the
IV. The use of codeine in any products that are judged harmful or
drugs’ synergistic action and increased combination form is not acceptable as it subject to misuse will be banned.
efficacy. They also have to prove carries no advantage and may be subject
X. Prescription medicines and
conclusively that combining the ele to abuse.
galencal preparations not included in
ments creates no increase of toxicity or
V. Vitamins should be prepared as the latest edition of the British Phar
side effects nor instability of the single ingredient products with the macopeia or the gritish Pharmaceutical
compound or shortening of the life of exception of Vitamin B Complex. Codex will be prohibited unless there is
the product.
Vitamins of the B Complex, with the strong evidence of need and of efficacy.
One of the greatest sources of exception of Bl2, may be combined
XI. Certain drugs, in spite of known
drainage on the country’s financial into one product. Bl2 shall always be serious side-effects and possibility of
resources is the irresponsible prescribing produced as a single ingredient inject misuse, having favourable risk-benefit
and marketing and inappropriate self able product for use by Specialists only. ratio will be permitted for restricted use
use of vitamins. Another great wastage Other members of B Complex may also by Specialists.
of meager resources is cough mixtures, be produced as a single ingredient
gripe water and alkali preparations product (e.g. Bl; B2; B6; etc.). Vitamins
J
combinations. Schedule III are those
that must be taken from sales by
December 31, 1982 which includes
cough syrups, tonics and the like.
lacking its own factory in the country,
it has these products made by a
Bangladeshi company on a toll basis.
These restriction in addition to the
drastically reduced list of drugs allowed
The drug ordinance lists each drug are not designed to make the TNCs
This list was presented by WHO to and its manufacturer and explicitedly happy.
its member countries and although most states the reasons for its ban. For
The TNCs are brandishing their
agreed with both content and spirit, few example, a vitamin tonic made by a
had the courage of their convictions to local company is prohibited because the weapons. It has been reported that the
act to limit drug purchases and produc tonic contains alcohol which provokes American government has begun to use
tion in their own country. An out liver ailments and is one of the most pressure on Bangladesh to modify the
standing example, however, of a abused drugs on the market. Another laws so that they prove more conducive
government that chose to act upon product is said to have “no proven to US business interests. The companies
these recommendations in Bangladesh. value; placebo effect only; waste of themselves are attempting to find ways
foreign exchange”. An ointment made of getting the laws changed or
In Bangladesh, the annual drug under license from an American TNC is rescinded.
market is US$83 million per year. Of called “useless”. Still another drug is
this, 81% of drugs sold are produced by labelled “no therapeutic value; waste of
The TNCs may find allies in their
8 TNCs. In a country where the per money by the poor people of the efforts in the national drug people.
capita income is less than $70 per country”.
Local manufacturers have expressed
person, at best, 15% of the people can
concern that their own fledging
ever afford to buy modern medicine. In
Many groups throughout the world factories also are being badly hurt by
an attempt to change this state of have hailed the Bangladesh decision as a this new law. One Bangladeshi manager
affairs, in April 1982, an Expert courageous attempt to come to terms has said that the damage done to local
Committee was appointed by the with some of its most pressing health industry might be the most serious
government to evaluate the drug pro problems. The Asian Community Health consequence of this law because these
ducts available in the country and to Action Network, an organization based companies also must limit their pro
draft a national drug policy which in Hong Kong comprised of several ducts. Some of those medicines which
reflected the health needs of 72 million programmes and individuals working in bring the highest profits necessary to
people, 80% of whom live in the non-govemment community health pro run their plants are no longer allowed
countryside. The result was the Drugs grammes, has endorsed this effort as a on the market.
Control Ordinance, 1982 which has far good attempt to re-allocate resources so
reaching effects on both the local and those in poor communites have access
The battle against the TNC drug
the TNC market in the country.
to drugs and care. Others, health companies is not only a Bangladesh
planners in England and America, fight. It has far reaching implications for
Essentially, the Bangladesh drug recognize this policy as one which will and support from other Third World
ordinance permits only the 220 essential rationalize health expenditures and countries. India and Sri Lanka have had
drugs recommended by WHO to remain provide more cost-effective use of both similar fights in their attempts to
on the market. Explicitedly, the law local resources and foreign supplies in centralize drug purchasing for their
includes the banning of combination the provision of medicines.
countries. If the Bangladesh laws stand,
drugs where a single drug is available,
many countries will have a model by
effective and less costly, the marketing
However, others, especially the which to rationalize their drug expendi
of vitamins in a combination pill or TNCs have been less than enthusiastic. tures. Individuals and Third World
liquid with the exception of vitamin B The reasons for their cool reception are governments are placing high hopes that
complex; the sale of tonics which claim easy to find. The law specifically Bangladesh will succeed in making good
restorative powers but prey on the addresses the role of the TNCs in the its intentions. The country that has
consumers ignorance and of drugs where country. While gratefully acknowledging been called world’s “basket case” is now
therapeutic value is questionable; and their assistance to date, the ordinance becoming a symbol of courage and
the use of medicine except by goes on to limit their future contribu conviction to those in Third World
Specialists where side-effects are known. tion. It states that all antiacids and countries who suffer from an inter
The three schedules were promulgated vitamins, a highly profitable enterprise national marketing system which
in the law to dictate the time which for these companies, now will be appears to deny them medicine to both
these drugs must be off the market. produced by national companies. It prevent and cure their illnesses.
states that no TNC medicine can be
Schedule I requires immediate stoppage made in Bangladesh if a national
and includes such medicine as gripe company can produce the same as it
water for babies. Schedule II are drugs leads to overpricing and payment of
requiring immediate reformulation royalities. Finally, it says that no TNC
which includes many of the vitamin can sell its products in the country if,
needs to be subject to the interests of
the TNCs pharmaceutical companies
which place on the market numerous
trade name drugs which they price
according to profit.
COMMUNITY HEALTH CELL
47/1,(First Floor)St. Marks Road
BANGALORE - 560 OUl
BANGLADESH:
The successes and failures of a small
pharmaceutical firm
Gonoshasthaya Pharmaceuticals Ltd.
(GPL), a small company near Dacca, is
struggling to provide Bangladesh with
high quality, essential drugs at com
petitive prices. The goal is to capture
15 to 20 percent of the Bangladeshi
market. The road to the goal is proving
long and rocky.
Bangladesh is a textbook case of a
country that has no significant nation
al or local production of drugs. Eight
multinational companies control 80
percent of the drug market. The re
maining 20 percent is shared among
many small, Bangladeshi firms.
Production is heavy on antibiotics
which make high profits for the com
panies. Companies are reluctant to
produce vital necessities such as dis
tilled water and basic drugs that bring
in low profits. There are about 2,300
brand names available; 70 percent of
them are judged therapeutically
questionable.
To boost sales, there is an estimated
one drug salesman for every doctor. (In
the United Kingdom, there is one
salesman for every 20 doctors.)
The number of drugs available in
government health centers is negligi
ble. Currently, legislation is inade
quate to effectively control the sale of
potent drugs. Many people cannot
afford a doctor and self-prescribe med
icine, often potent antibiotics that are
sold over the counter. In a country
where the average annual income is
about $70, many families go deep into
debt to buy medication.
Against this background, the Peo
ple’s Health Center, a successful prim
ary health care project in Savar,
decided to build its own pharmaceuti
cal processing unit. It took seven years
to complete the $4.2 million project.
Funding agencies had to be convinced
that such a bold idea could work and
work with Bangladeshi experts and
personnel—architects, chemists, man
agers, and plant workers. Three years
4
SALUBRITAS
July 1982
fl
wp' 'T
■X J
•
were needed to complete the feasibility
and other studies required by the
bureaucracy.
Now, with funding from Oxfam,
NOVIB, a Dutch voluntary agency,
Christian Aid, and commercial loans,
GPL has been operating for one year
and has made a start toward producing
in bulk 30 basic drugs, preparations,
and antibiotics, including aspirin,
ampicillin, tetracycline, penicillin,
vitamin C, sterile water for injections,
and oral rehydration salts.
As planned, most of the factory
workers are rural women who have
received training in vocational skills
and literacy from GPL. All instructions
in the drug packages are in Bengali.
Drugs are sold at prices 30 to 50 percent
lower than equivalents produced by
the larger companies. When GPL, a
charitable trust, begins to make a
profit, 50 percent will be reinvested in
voluntary development programs.
But the first year of production has
been fraught with problems. It has
been difficult to find skilled personnel
in Bangladesh, and GPL has had to call
on more outside expertise than plan
ned. The proper machinery has not
always been available. And GPL
recently lost a bid to provide the
government with eleven drugs.
More problems lie ahead. GPL plans
to rely on selected pharmacists to dis
tribute its generic drugs. But will the
firm find pharmacists willing to give
up their profits on brand names? And
will companies continue to success
fully underbid GPL for big, govern
ment contracts? These are just some of
the problems that face the bold exper
imenters at GPL.
This article is based on newsletters pub
lished periodically by the People’s Health
Center, and reports by Dr. Zafarullah
Chowdhury, Director of the People’s
Health Center, and researchers Sally
Bachman and John Yudkin.
i
i
HOW TO . . . teach testing for respiratory problems
I
I
I
i
I
I
I
I
I
I
I
I
I
I
I
When teaching about physical exam or respiratory problems,
you probably will want to explain where the lungs are and
how they work. For this, it helps to draw the lungs on a
student. Draw them on both the chest and the back.
Fo determine the size of the lungs, show the students how
to thump or percuss the back, listening for the hollow sound
of air in the lungs. Draw the bottom line of the lungs first
when they are as empty as possible, and then when they are
full. Students will see how the movement of the diaphragm (a
muscular sheet below the lungs) affects breathing and lung
size.
By doing this, students not only learn about the position,
size, and work of the lungs, but they also learn a useful skill
r
for physical examination—thumping the lungs to listen for
relative hollowness. This can help them spot signs of disease.
To help students understand the different sounds they hear
when thumping, have them determine the level of water (or
gasoline) in a large drum or barrel. Then thump the chest of a
student.
IT’S FULL UP TO HERE.}
Next, compare with a person who has a solid (diseased)
area or liquid lung. If possible, also show the students X-rays
of normal and diseased lungs.
n
t- \
&\
^*/
BREATHE OUT
AND HOLD
IT,
FHE LUNGS
REACH ONLY
TO HERE.
7
I
v
BREATHE IN
DEEP AND HOLD
YOUR BREATH.
NOW HIS LUNGS
REACH WAT
DOWN HERE. ,
I
WILL THIS PART
SOUND HOLLOW ?
The above article is reprinted with permission from the new book,
HELPING HEALTH WORKERS LEARN: A book of methods, aids, and
ideas for instructors at the village level, by David Werner and Bill
Bower. The illustrated book is available in English (Spanish trans
lation in preparation) from: The Hesperian Foundation, PO Box
1692, Palo Alto, CA 94302, USA. Price: $6.50: discounts for bulk
orders.
SALUBRITAS
July 1982
3
commoniiY h^lth ceu.
<7H,(First i- loor)
Marks Row*
BANGALOftfc - 560 001
ZAFRULLAH CHOWDHURY
Bangladesh Drug Policy
A Comprehensive Review
(April through September 1982)
Background
An eight-member Expert Committee constituted by
the present Martial Law Government of Bangladesh
was commissioned to evaluate ail the pharmaceutical
products available in the country and draft a National
Drug Policy with a view to the real health needs of
the people. This committee held its first meeting on
April 28, 1982.
They first laid down 16 criteria by which they in
tended to evaluate all products—12 of these were on
a scientific basis, four on a political/economic basis.
The result of their deliberation on 4140 products then
available was to ban (in 3 categories/schedules) 1707
items.
Drugs from Schedule—I were deemed positively
harmful and to be banned immediately and withdrawn
from the market in one month's time. This Schedule
included 265 locally manufactured products and 40
imported. Drugs in Schedule II required reformulation
as they were combinations of similar or dis-similar in
gredients (antibiotics, analgesics, steroids, etc.) and as
such were of no increased therapeutic value, were a
cause of possible increased toxicity and an unnecessary
expense. This Schedule included 134 locally manu
factured products. Six months were allowed for dis
posal of existing stocks and submission of recipes for
reformulation. Drugs in Schedule III fell into two
distinct sections —either they were: (a) again com
bination products with littie or no proven therapeutic
value or (b) they were useful products which were :
(1) being manufactured under licence by a multina
tional company with no factory in the country; (2) im
ported drugs which were already being manufactured
locally or; (3) simple vitamin, antacid, etc. preparations
which were to be the manufacturing responsibility of
local companies. The purpose of banning under
Schedule III was to safeguard and promote the deve
lopment of the national drug industry by not allowing
multinationals to manufacture/import products either
HEALTH FOR THE MILLIONs/dECEMBER 1982
already locally available or those of simple formulation
(vitamins, antacids, etc.) which required no special,
sophisticated machinery and technical know-how. In
this Schedule, there were 742 locally manufactured
and 526 imported drugs. The time allowed in this
Schedule was six months.
The Expert Committee's report was submitted on
May 12, 1982 and the Chief Martial Law Administrator
and his Council of Ministers approved it (changing the
banning date of Schedule I from one to three months
and Schedule III from six to nine months) on May 29.
The government made a formal declaration of the new
policy on June 7 and the Drug (Control) Ordinance
1982 was promulgated on June 12, 1982.
Anti-Policy Activity
The first headline news story broke before the
official government declaration (of June 7) and was
the signal for beginning maneuvers by the US Amba
ssador to Bangladesh, Mrs. Jane Coon, on behalf of US
multinational vested interests, to have the policy
foRMULA
E3C
EXPERT 5CIENW
COMMITTEE
Contains UnodoltraH
trade Commission
Morfetad in Bangladesh
Ln tm intarestd erttnsv
“The First World Prescription”
1
amended if not rescinded. The drama intensified
with all multinationals and some nationals mounting
a campaign of anti-government criticism (punishable
by 7 years imprisonment under martial law, but in
terestingly enough, no cases were filed in this context)
in desperate attempts to sway the government from
its decision. The US Ambassador was soon joined by
British, Dutch and German Embassies in their pressure
on the government. With apparent failure of their
anti-government campaign, the multinationals turned
their venomous outcry against the Expert Committee.,
against two members in particular.
The spokesman went on to say, "The State Depart'
ment has a statutory responsibility for assisting Ameri
can interests abroad. In this particular case, the US
Government is also concerned that these regulations
may inhibit further foreign investment in Bangladesh."
In late July, the US Embassy brought in four mem
bers of various pharmaceutical manufacturing compa
nies, passing them off as an 'Expert Scientific Com
mittee.' In actual fact, they were little other than a
'trade commission' whose aim was to further pressurise
government's reconsideration. The US State Depart
ment, in the August 19, 1982 edition of The Washing
ton Post, openly acknowledged that the Pharmaceuti
cal Manufacturers Association (PMA), a trade organi
zation for the drug industry, asked it to bring pressure
on the Bangladesh government, to delay implementing
the law pending discussion with the manufactuters''.
Ordinance Amendment
In this same respect, the Bangladesh Medical Asso
ciation proved itself a mockery of the science it pur
ports to practice and it was readily seen that a good
number of registered doctors in the country could
easily be swayed and bribed by drug manufacturing
representatives.
With great confusion having been created by the
multinationals and their
concerned governments,
the Chief Martial Law Administrator set up a Review
Committee (consisting of six military doctors) whose
report was subsequently submitted to the Government
on August 12, 1982. Studying together the Expert and
Review Committee's reports, the Bangladesh govern
ment, on Septembers, 1982, .announced the Drugs
Ordinance Amendment, 1982.
Referring to the (original) Schedule I drugs, only
one item of importance had its ban lifted —imodium
(an anti-diarrhoeal). The other six items which were
reinstated were misused/abused dental remedies/cures.
The time limit for withdrawing the banned drugs of
Schedule I from the market remained three months and
became effective from September 12, 1982.
TMV
Transnational Masters’ Voice
also known as
^—Medical association”
2
Of drugs in (original) Schedule II, four eye prepara
tions were allowed which contain combination antibio
tics and steroids (disallowed under the Expert Com
mittee's criteria). Heptuna-plus, an iron supplement
which fails to meet the original criteria was also allow
ed to remain in this Schedule. The time limit for re
formulation under this Schedule was extended from
6 months to 12 months.
Under (original) Schedule III, 27 drugs (manufac
tured under licence) were allowed to remain, honouring
existing contracts between Bangladesh government
and various multinationals. A further 88 balms and
vaporubs of small national companies (less than 1 %
of the drug market) were put into a (new) Schedule
IV. These were allowed to manufacture and for
18 months.
HEALTH FOR THE MILLIONs/dECEMBER 1982
nao
Karnataka
x>m
West Bengal
Training Incentives
New Secretary
Ms. Usha S, B.Sc., M.B.A. is the new VHAK Pro
motional Secretary.
A nutrition kit comprising of 5 charts and a booklet on nutrition
Rs. 35/- plus postage. Write to Hony. Secretary, VHAK,
St. John's Medical College Hospital, Sarjapur Road,
Bangalore 560 034.
WBVHA has initiated a monthly training in Com- Gujarat
munity Health Development for village health workers
and supervisors at Seva Kendra, Calcutta, from
November 1, 1982. This training will lead to the
Gujarat VHA Evaluated
growth of "teamwork spirit". The training programme
GVHA Annual Convention and General Body meet
includes human relations, communications, com
munity approach, health education, mother and iing was held on 27th/28th November. The theme was
child care, prevention of diseases, environmental sani- IEvaluation of GVHA with a view to planning future
and activities.
tation, socio-political analysis, income generating pro- programmes
|
jects and management concepts.
Bihar
Field training was given at Child in Need Institute
(CINI) and the Ramakrishna Mission.
Mobile Help for Bengal
The St. John's Ambulance Association has taken
up the M.M.U-cum-Ambulance Project for providing
medical help to a total village population of 12 lakhs
through eighteen M.M.U-cum-Ambulance Units. The
E.Z.E. West Germany has underwritten three-fourths
of the cost.
Drought Crisis Shared
BVHA is on the Flood's Relief Committee to meet
the crisis due to drought.
BVHA newsletter October highlights the drug
menace and circulates the list of drugs which should
be banned in voluntary institutions.
BVHA has been also involved in flood relief work
in the state.
Madhya Pradesh
The Government of West Bengal will pay staff
salaries,
Membership Rush
This project originated in a meeting at the Raj
Niwasin Calcutta in July 1980. Dr. S.N. Chaudhuri
(CINI), Mr. J.B. Singh (AFPRO) and Father Tong were
present at the invitation of the then governor, Shri
T.N. Singh. The governor was anxious that some of
the more neglected districts of West Bengal be served
by mobile medical health units. At the meeting,
Fr, Tong had urged that there should be a good mea
sure of people's participation built into the project.
St. John's Ambulance Association agreed to undertake
'
i
the project and to raise one fourth of* the cost from
loca^ sources such as government grants and private
donations.
Several new applications for membership are re
ported in the MPVHA newsletter.
Two workshops on Community Health will be
held in early 1983.
A survey of extent of eye problems in the areas
around Dhani, Dhar District, is completed. A special
program for prevention of nutritional blindness is
contemplated.
An opthalmic nursing course giving general nurses
theoretical and practical knowledge about eye surgery
will be held in March 1983. At the last one conducted at Amarkantak by Dr.V.K. Ali of Christian Hospital,
Shahdol, 171 eye operations were performed.
HEALTH FOR THE MILLIONS/dECEMBER 1982
15
Delhi
AFORD (Aids for the Disabled)
Training Programme
VHAI will work with Dr. P.K. Sethi, to formulate
training programmes for the diffusion of work done at
the Rehabilitation Research, Centre, S.M.S. hospital,
Jaipur. A small workshop was held from November 12
to 14, 1982 to define and develop training courses at
Jaipur.
Salus —India
An annotated bibliography and information system
of low cost health care and manpower training, on the
lines of SALUS of International Development and
Research Centre, Canada, is proposed to be set up in
India. VHAI and CENDIT (Centre for Development of
Instructional Technology) will collaborate on this
project.
*
*
*
Correspondence Course in
Financial Management
A 16 months correspondence course in Financial
Management for Voluntary Health Care Institiutions is
being started by Voluntary Health Association of India.
The opening seminar of this course will be from
February 3rd 1983. The aim of the course is to train
accounts personnel in health care institutions in all
aspects of accounting and financial management.
Only persons with commerce background i.e., educa
tion in commerce or working experience in the accounts
department of a heallh care institution are eligible to
apply for this course.
For the prospectus, application form and for any
further information, please write to : Ravi Srinivasan,
Course Coordinator FINMAN, VHAI, C-14 Community
Centre, S.D.A, New Delhi-110016.
Free accommodation will be provided.
WE
NEED
YOU
Wanted People
Wanted immediately Christian personnel to work
in a rural hospital:
1. General Surgeon: M.S.
Salary
-2100-100-2500-125-3125-150-3875
2. Junior Doctor: M.B.B.S.
Salary
- 825-50-1075-75-1450-100-1950
3. Pharmacist: D. Pharma
Salary
-330-15-405-20-505-30-655-40-855
4. Male Nurses: R.N.
Salary
—330-15-405-20-505-30-655-40-855
5. Staff Nurses R.N., R,M.
Salary
-345-15-420-20-520-30-670-40-870
6. Auxiliary Nurses: A.N.M.
Salary
—220-10-270-15-345-20-445-30-595
7. Driver-cum-Mechanic
-250-10-300-15-375-20-465-30-625
Salary
8. Clerk
Salary
16
Apply to the Medical Superintendent, Swedish Mission
Hospital, P.O. Khurai, Dist. Sagar, M.P. 470 117
Nurse
A qualified nurse for community health work.
Must be willing to live in the village and to work with
villagers. If married, husband's qualification. Apply
with biodata and testimonials to Superintendent,
Ashwood Memorial Hospital, P.O. Box No. 4 Daund,
413 801, Dist. Pune.
2 A.N.Ms. Apply with Biodata and testimonials to
Superintendent, Ashwood Memorial Hospital, P.O. Box
4, Daund 413 801, District Pune.
Consultant
Senior/Junior Consultant for Nuclear Medicine
Department equipped with computerised Tomographic
Camera and Radio Immuno Assay Laboratory. Salary
and terms negotiable. Apply to the Hospital Adminis
trator ; Choithram Hospital and Research Centre
P.B. No. 131, Manik Bagh Road, Indore-452001 (M.P)
YOUR SUBSCRIPTION TO
PLEASE RENEW
HEALTH FOR
THE MILLIONS. IT IS STILL
RS. 12/- PER YEAR.
-250-10-300-15-375-20-465-30-625
HEALTH FOR THE MILLIONS/dECEMBER 1982
■
I.
1
:
----------------------------------------- —------------ ------------------------------- -
HEALTH
FCJRTHE IVllL_l_IOfXJS
Vol. VIII
No. 6
A
Bimonthly
of
the
Voluntary
Health
Association
of
India
DECEMBER 1982
-
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Bangladesh
finds
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FRESCRiniON
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HEALTH FOR THE MILLIONS
COMT/i -'iv
a
• ■ - ALTH CELL
1
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BAMGAtOrib • §60 001
No. 6
Vol. VIII
)
December 1982
Bangladesh Shows the Way
CONTENTS
1
Bangladesh Drug Policy
5
Operation Sidestep
8
Gonoshasthaya
Pharmaceuticals
10
An Indian Low Cost Drug
Project
A small developing country has taken a big, bold step in the right
direction. Bangladesh has banned 1707 drugs dealing with 4140 drug
products. Multinational companies and their governments have expressed
great resentment and resistance to this move. That is expected because
they control 80% of the drug sales in Bangladesh and their market in
developing countries runs into many, many m'llions of dollars.
The multinational and national companies affected, succeeded in
pressurising the Bangladesh government to review and postpone the ban.
These few months are therefore very crucial—because all kinds of pres
sures are being exerted to dilute the ban.
12
Drugs Workshop at Jaipur
13
Manila Declaration
14
Health Workers' Convention
15
News from the States
16
Correspondence Course
16
We need You
17
Just Released
This is where all of us in India concerned with drug issues, have a
vital role. We need to study all information on this issue. We pub
lished in the last issue the criteria adopted by the Bangladesh Govern
ment for the ban. In this issue, there are articles by Zafrullah, Susanne
Chowdhury and Andy Chetley. Other related informations are available
with VHAI. Thanks to the work of Mira and Sathya.
And then act. Write to newspapers. Write to the Bangladesh Health
Minister (C/o Bangladesh High Commission, 56 Mahatma Gandhi Road,
Lajpat Nagar III, New Delhi-110024). Write to Zafrullah Chowdhury,
expressing solidarity and support. They need it. With lack of inter
national support, a bold step is likely to be backtracked by the Bangla
desh Government under multinational pressure.
Editor
: S. Srinivasan
Executive Editor : Augustine J.
Veliath
News & Events : Purabi Pandey
Production
: P. P. Khanna
Assistance
: P. George
Circulation
: L. K. Murthy
There are some who believe that supporting the ban means support
ing a military government. On the contrary, it means supporting people like
Zafrullah Chowdhury and his friends—people who are working hard
to promote social justice and equality in health. Supporting the ban means
supporting a major decision in favour of the poor.
We need to do even better. We have to stop similar irrational and
dangerous practices. We have to demand a similar ban from our own
government. Write to the Drugs Controller of India, Nirman Bhavan,
New Delhi-110011. It is a tough struggle to promote justice and fight
oppression. But if Bangladesh, a small country which is more dependent
on foreign aid for its drugsand development than India can do it, why
can't we ? Bangladesh has shown us the way.
—S. SRINIVASAN
Owned and
published by the
Voluntary Health Association of
India, C-14, Community Centre,
Safdarjung Development
Area,
New Delhi-110016, and printed
at Printsman, New Delhi.
$
?»-
r
newspapers to publicize the aims of own retail shops at least in the 62
subdivisions,, which would enable us to
GPL.
keep a tighter control over sales
3. Retail sale
For an efficient retail sale through practices.
out the country, a network of depots,
agents and transport has to be set up. So
far, this is only in the beginning stages.
At present, we sell to shops in Dacca
and Chittagong. A Dacca depot is about
to be opened depots for other district
cities are being prepared. As we
anticipated, selling through existing
pharmacies has its problems. We have
heard of cases where a much higher
price than the MRP indicated on the
package has been charged. A lack of
confidence in anything that comes from
Bangladesh itself is part of our sad
colonial heritage, and pharmacists,
having heard something of Dutch
financing, charge excessive prices
claiming that this is a new ‘Bitali’
(European) medicine. We hope that, in
future, we will be able to establish our
Sales to government
Each year, the government calls a
large tender for medicines to rural
health centres. In 1979, the govern
ment, after proper calculation, put
pressure on the government-owned
Albert David company to sell them their
ampicillin at a price of 95 paisa per
capsule. In 1980, the Albert David
management contended that due to
rising cost they could not supply at a
price lower than 99 paisa. In 1981, we
bid for the tender of 10 million
ampicillin capsules at 93 paisa basing
our calculation on the raw price cited
by one of the leading trading houses and
considering our high overheads. The day
after submitting our bid, we were
informed by the trading company that
they could now quote a better raw
4.
material price: the previous quotation
had been for US dollars 95-120 per kg.,
the new price was US dollars 86-100.
This cheaper price would have resulted
in a lowering of the per capsule price by
5-17 paisa. We later learned that the
trading house in question is owned by
the wives of the managing directors of
three large pharmaceutical companies,
one multinational and two national, one
of the latter also collaborates closely
with a multinational. Later on we also
learned that some multinational com
panies and 3 top-selling national com
panies had a meeting before the tender.
We did not win the tender. It went to a
national company which had bid at 80
paisa per capsule. The retail price of the
same company’s ampicillin is 159 paisa.
For the government this was the
cheapest ampicillin they had evei
purchased and giving credit where credit
is due, some officials thanked us,
requesting us to keep up the good work.
□
CHART ONE
Prices in paisa (100=1 taka)l for drugs in Bangladesh, 1982.
Drug:
Raw material Packaging Overhead
Unit cost
Profits
GPL
Others
Maximum Retail Prices (MRP)
Gonoshasthaya Pharmaceuticals Ltd.
Ampicillin
(250 mg)
Trade Prices
Ampicillin
(250 mg)
58.3
1.5
16.7
76.2p
5p
(6.57%)
85p
100
Hoechst
Square
Tetracycline
(250 mg)
21.2
1.5
15.7
38.4p
2p.
(5.26%)
42.5p
50
Squibb
11C
106
Pfizer
Albert David 77
Metronidazol
(200 mg)
9.5
8
12.5
30p
2p
(6.7%)
34p
40
BPI
Square
79
65
Paracetamol
(500 mg)
4.8
0.7
6.2
11.7p
0.04p
(3.41%)
12.7p
15
Fisons
Square
24
25
Aspirin
(300 mg)
1.4
0.7
3.2
5.3p
O.Olp
(1.88%)
6.4p
7.5
BPI
Fisons
12
9
Antacid Tab
3.5
0.7
7
11.2p
4p
(35.7%)
17p
20
27
Nicholas
Albert David 18
Diazepam
(5 mg)
0.9
1.6
4.6
7.Ip
2.6
(36.6%)
10.6
12.5
Roche
Square
55
30
Frusemide
(40 mg)
5.2
7.2
13.6
26p
22
(85.6%)
51 p
60
Hoechst
125
1US$1.OO = Taka 21.50
186
175
COMMUNn*
■ rf'
CF.U
47/1.(First lie . >2 ■
BANG-- - ' ■ .-CG
4.
Dosages in Tender Price.
Central Medical Stores, Dacca.
Government of People’s Republic of Bangladesh
Prices in Taka per 1000
Drugs:
1980-81
1981-82
1. Ampicillin Capsule
(250 mg)
Tk. 995
(Albert David)
Tk. 800 (Pharmadesh)
840 (Albert David)
2. Tetracycline Cap
(250 mg)
.440
380 (GACO)
3. Antacid Tab.
170 (Albert David)
31.5 (Fison)
4. Ferrous Fumerate
with Folic Acid
39.45 (Fisons)
31.45 (Fison)
5. Frusemide Tab.
1040 (Hoechst)
510 (GPL)
Jelect Bibliography:
2.
Following is a very small selection
of the many important books and
articles on the subject.
3.
1. H. Sjostrom and R. Nilsson,
Thalidomide and the Power of the
Drug Companies, Penguins 1972
Haslemere Group, War on Want,
Third World First, Who Needs the
Drug Companies? (undated)
5. Sanjay a Lail, The International
Pharmaceutical Industry and Less
Developed Countries with Special
Reference to India, Oxford Bulletin
of Economics and Statistics 36, 143
- 172, 1974
6. Sanjay a Lail and Senaka Bibile, The
Political Economy of Controlling
Transnationals: The Pharmaceutical
Industry of Sri Lanka (1972 - 76),
World Development 1977, vol.5,
no.8,677-697
7. Report of the Committee on Drugs
and Pharmaceutical Industry (the
‘Hath! Committee’ on the Indian
drug industry), New Delhi, 1975
M. Silverman and P.R. Lee, Pills, 8.
Profits and Politics, Berkeley and
Los Angeles, 1974
R.W. Lang, The Politics of Drugs: 9.
The British and Canadian Phar
maceutical Industry, Saxon House,
1974
John
Yudkin,
Provision
of
Medicines in a Developing country,
Lancet, April 15, 1978, 810 -812
John Yudkin, Drugs and Under
development, New Scientist, 14
December 1978
THE NEW BANGLADESH DRUG ORDINANCE AN OVERVIEW
— Susan B. Rifkin
It is no secret that the phar
maceutical TNCs (transnational corpora
tions) present a big barrier to the World
Health Organization’s (WHO) goal of
“health for all by the year 2000”. These
companies, headquartered in the West,
hold patents on some of the most
effective and thus the most demanded
medicines. Through a strong in
frastructure of manufacturing, mar
keting and distribution, the drug TNCs
are in a position to hold prices high thus
assuring their own profits but causing
hardship among consumers especially in
the Third World.
The TNCs have been accused of
preventing rather than contributing to
good health care on several grounds.
Firstly, through their hold on patents,
they stop local companies from pro
ducing the same drug at lower costs.
Not only do they charge the local
company much more to buy the
ingredients to manufacture the medicine
but also they block the company from
selling the product at a lower price. In
addition, TNCs sell by trade name
rather than the generic (descriptive
name) thus forcing the consumer to
demand the higher priced commodity
(i.e. asking for Penbritin — brand name
— rather than penicillin — generic
name). Also many drug companies
market products of questionable value.
They are more a result of good
advertising than of good quality. These
accusations as well as those related to
drug dumping and marketing medicines
in the Third World which have been
banned in the West have focused
attention on the adverse role of the drug
companies in Third World health pro
motion.
In the mid 1970’s, many groups
including the UN began to seek
solutions which would allow Third
World governments to counter the
TNCs’ control to use scarce financial
resources to purchase medicines which
would do the most good for the most
number of purple. Five UN agencies
including WHO (World Health Organiza
tion), United Nations Conference on
Trade and Development (UNCTAD),
United Nations Industrial Development
Organization (UNIDO), United Nations
Development Programme and United
Nations Children’s Fund (UNICEF)
collaborated on a strategy which, among
other things, recommended a list of 190
essential and 30 complementary drugs
which third world governments need to
deal with their major disease problems.
Armed with this list, no government
GONOSHASTHAYA PHARMACEUTICALS
— Zafarullah Chowdhury & Susanne Chowdhury1
Gonoshasthaya Kendra (GK) is a
charitable trust which was set up in
1972 by a group of health workers who
had been involved in the Bangladesh
Liberation struggle of 1971. The first
objective was to establish a health
service in Savar thana with an emphasis
on preventive and primary care. In the
course of this work, it was realized that
health care by itself could not be an
answer to the problem of poverty, and
the project became involved in a wide
range of community development work
(of. Progress Report No. 7).
The project experience, and
especially the problem of how to get
good and cheap medicines to the
people, also led to thinking about a
pharmaceutical factory based on four
principles; viz. low prices, quality,
manufacture of essential drugs only, and
responsible marketing practises. The
factory is a joint stock company, but all
shares are owned by the GK Charitable
Trust and cannot be bought or sold.
Policy is determined by a Board of
Directors, consisting at present of eight
members, with representatives from
• government (Ministries of Health and
Industries), the Bangladesh Shilpa
(Industrial) Bank (BSB), the GK Board
of Trustees, Savar GK and NOVIB, a
Dutch voluntary agency.
Technical expertise has been pro
vided by the International Dispensary
Association,
Holland,
who
also
organised training for managers and the
architect, as well as the procurement of
machinery and raw materials. All
managers are Bangladeshi.
GKP is designed to supply 15 20% of the present Bangladesh market
in essential drugs once it is in full
production. Retail prices will be 35-50%
lower than those of equivalent drugs on
the market, and are calculated to leave
GKP with an overall profit of 10-15%,
after deductions for all production cost,
depreciation, and bank charges. Profits
will be invested in expansion, medical
and social research, and in new enter
prises. Part of it must be spent on
charitable purposes.
Marketing of GKP products will be
partly through bulk purchase by the
government for their rural health
centres (initially 60 — 70%), and partly
through a chain of special retail shops.
1.
Problems:
of the necessary equipment. During the
construction phase, one of our problems
was the lack of expertise in our
architectural
firm.
Pharmaceutical
factories had been built before in
Bangladesh, but either they did not
correspond to the rules laid down in
Good Manufacturing Practise (GMP) or
they were built according to blueprints
brought in complete by multinational
companies which had given no
opportunity for local experience. We
therefore sent our architect abroad for a
tour of pharmaceutical factories. Our
factory is connected to the general
electricity supply. This is quite un
reliable and production losses result
from power failures. Even more serious
are the current fluctuations which
damage equipment and are unknown in
the more sophisticated net works of
industrialized countries. This creates
problems of maintenance, all the more
so, since the standard spare parts for
machinery sent by equipments manu
facturers, consist mainly of mechanical
items, while we are mainly in need of
electrical spare parts.
Any attempt to establish a high
technology project in an under
developed country will suffer from the 2. Personnel:
lack of infrastructure, and the problems
which arise from having to import much
a) Unskilled
Jobs with regular incomes, however
low, are scarce in Bangladesh and the
object of intense competition. This
applies even to unskilled labourer’s jobs
The cost of establishing the factory has been as follows:
in factories. As a result, getting such
Building including air conditioning:
US dollars 1.2 million
jobs depends on the ability to give
Machinery and equipment:
US dollars 1.5 million
bribes, and often also on absurdly high
Training of managers and business travel:
US dollars 0.1 million
levels of formal education. Therefore
Working capital incl. raw materials for four months: US dollars 1.2 million
only families with some property will
US dollars 0.2 million
Transport and miscellaneous:
have members working in industry; and
their wages are often a surplus cash
US dollars 4.2 million
income which is used to buy up land
from less fortunate families of marginal
US dollars 2.62 million
Contributions from NOVIB (Holland)
farmers.
US dollars 0.33 million
Oxfam (U.K.)
US dollars 0.16 million
Christian Aid (U.K.)
1 Paper presented to a Conference on
US dollars 1.00 million
BSB, GK Trust and others
Technology Transfer to the Third
US dollars 4.11 million
World, 10-12 January, 1982 at
Kend ra,
Gonoshasthaya
Bangladesh
Edited
Version.,
/<-
COMMUMTY HEALTH CEll
47/1,(.Fi„r„St ’ lo°ri3i:. M3i'!<s^oad
PHARMACEUTICALS IN BANGLADESH
- Gonoshasthaya Kendra - Bangladesh
At
a conservative estimate,
Bangladesh has an annual drug market
of Tk. 1250 million (approx. 83 million
U.S. dollars). Only a negligible propor
tion of this is available free of cost in
government health centres, the rest is
sold commercially. In a country with
one of the lowest per capita incomes in
the world (70 dollars a year), this means
that after food, clothing and shelter,
medicines are a major part of the
remaining expenditure. Often, a little
medicine may be bought in extreme
need, but not enough to cure the illness,
and the public are left in ignorance of
the detrimental effects of breaking off
treatment prematurely. Most im
portantly, due to poverty and the high
cost of drugs, at best 15% of the people
ever buy any modern medicine.
Inadequate information and the
common habit of self-prescription
(because doctors are unavailable or- too
expensive and because all drugs can be
freely bought over the counter) have led
to a situation where 70% of the annual
drug sales go on drugs described as
useless or therapeutically insignificant
by the British National Formulary, the
National Research Council (USA) or the
Federal Drug Administration (USA).
The bulk of these unnecessary medi
cines are vitamins, tonics, enzymes and
cough mixtures.
Drugs worth an average of Tk. 150
million are imported annually into
Bangladesh by small local firms and also
by voluntary and U.N. organisations.
The remaining medicines, worth about
Tk.1100 million, are produced in
Bangladesh. There are over 150 re
gistered drug companies, but most of
these exist on paper only having been
created to take advantage of the fact
that raw and packaging materials for
pharmaceutical companies — which are
considered essential industries — can be
imported with enormously reduced
customs duties and are then resold to,
e.g. cosmetics factories. Tk. 890 million
worth of drugs (= 81% of drugs
produced in Bangladesh) are produced
by eight multinational companies. The
rest is shared by a number of smaller
multinationals and 22 local companies.
The table below shows the situation in
greater detail:
&
Name of Company
1. Multinationals:
Pfizer
Fisons
May & Becker (BPI)
Hoechst
Glaxo
Squibb
ICI
Organon
Others
Annual Production in Taka
200 million
140 million
120 million
115 million
110 million
105 million
50 million
50 million
15 million
905 million
2. Local Companies:
Square*
70 million
40 million
35 million
30 million
10 million
10 million
Gaco
Albert David
Pharmadesh
Jayson
Others
195 million
3. Imported:
150 million
Grand Total:
1250 million
*Square manufactures drugs mainly under third party license (from Janssen)
Looking at the types of medicines
available, we find about 2300 brandnamed drugs containing 150 different
active ingredients. Only about 250 of
these, about 10% are therapeutically
significant or essential drugs according
to the sources named above. All the rest
are promoted solely for the purpose of
financial gain.
Proliferation of products and their
promotion is, of course, a ubiquitous
feature of capitalism, but in a country
like Bangladesh the situation is worse
because it diverts desperately scarce
resources and many people will deny
themselves food in the hope that some
aggressively advertised, but useless tonic
will do them more good. But it is not
only a confidence trick: substances
which have actually been identified as
harmful and banned in developed
countries continue to be marketed and
manufactured in Bangladesh. The
pressure that can be exerted by foreign
companies on the government was
shown again recently when dipyrone
(Hoechst brand names ‘Novalgin’,
‘Baralgin’),, which can cause fatal
agranulocytosis, was again cleared for
manufacture, even with an increase in
the permitted quantities (Bangladesh
Gazette, Pt.I, Feb. 29, 1981). The
decision was taken despite strong
representation from groups of local
doctors and pharmacists. Other pro
ducts banned elsewhere, but still avail
able here, include phenacetin and
clioquinol. A quotation from the
Managing
Director
of
Fisons
(Bangladesh), Mr. A. Wahid, may sum
up the attitude of the multi-nationals:
up the attitude of the multi-nationals:
“We are businessmen first, first of all we
want profits ... We are oversensitive
about reports from WHO. Restrictions
on drugs and pesticides imposed in the
U.S. and Canada should not be applied
in our country because our people are
ethnically and biologically different
from others.”
* t
COMMO’';
ALTH CP1L
------------- ---
D-9/554 (,1)
a*26.8.82
9^
“ut
VOLUNTARY HEALTH ASSOCIATION OF INDIA
C - 14 Community Centre,
Safdarjung Development Area,
NEW DELHI - 110 016
In Support of Bangladesh1 s Drug Pplicy
On the 7th June 1982, on the recommendation of an eight-member
advi-sory committee, the Government of Bangladesh decided to ban 1707 dztugs*
These constituted about half the drugs sold in Bangladesh (1742 out of 4140
products.licensed for sale)* The guidelines set by WHO’s expert committee on
essential drugs have been followed- Drugs not included in the Pharmaceutical
Codex and British Phaimacopea were also excluded-
Amongst the drugs being banned are tonics, cough mixtures, elixirs, for
dysenteries, restoratives, gripe water and alkali mixtures and combination
antibiotics.
Not only are the hazardous and ineffective drugs being eliminated
but national companies are being encouraged to produce the simpler drugs.
Multinationals would be allowed to manufacture more complicated.drugsAccording to Frontier dated July 1982'some of the other bold steps
taken by the Government to ensure a more people-oriented health care - were:
!• Fixing of the fees of doctors
. 2- Stopping construction of 8 new
medical colleges and,instead,
upgrading the existing medical
colleges.
40 takas for the~first
visit (prescription and
medicines excludedgi
Clinics and nursing homes ~
will need licences and will
have to follow standard
charges.
3. Enforcement of five years
comuplsory rural work before
obtaining a practicing licenceThe decision was taken in the health interest of the people
people of
of
Bangladesh. The policy is aimed at making essential and life-saving drugs
easily available to~the people who most need them- According to Professor
Nurul Islam, Chairman of the Expert Committee, this action would help to
improve health care. "Nobody will die because of the want of medicines in
the country if we stick to only 250 essential drugs including 100 life-saving
drugs"
(A. Chetley)
Bangladesh has had to import the majority of the bulk drugs paying
about Taka 600 million a year - paid for in foreign exchange! a sum equivalent
to 1.7 times the 1979-80 total health budget.
(Dr.H-K-M.A.Hye, Director, Drug Administration, in an interview with
Diana Melrose of Oxfam)The Expert Committee on reviewing the Bangladesh drug market concluded'
that " nearly one-third of this money was spent on unneeessazy and useless
medicines such as vitamin mixtures, tonics, alkatizers, cough mixtures,
digestive enzymes, palliatives, dripe water and hundreds of other sim.ilar
The fact tha^ 'bhree quarters of the population had NO REGULAR
ACCESS TO VITAL DRUGS makes the irrelevance of the abovementioned drugs all
the more jarring.
SALES OF HAZARDOUS AND UNESSENTIAL DRUGS DEPRIVE THE POOR OF
ESSENTIAL AND LIFE SAVING DRUGS.
The pricing of drugs, the promotion and marketing practices, the
methods of sharing of drug infdrmation have all been critically observed.
These observations confirm beyond all doubt that for the drug industry,
profits come before the health of the people and in the absence of a highly
wware and active voluntazy control b the health personnel - one has to
depend on legislation.
'Under the ban, 240 products were to be immediately withdrawn
following the Martial Law Ordinance issued on 7 June 1982 -
--2/-
- 2
D-9/334 (j)
a: 26.8.82
the rest were to be withdrawn by December 1982. Mow there
will be a phased withdrawal of different categories of drugs
within 39 6 and 9 months.
D^ana Melrose in ’Medicines and
the Poor in Bangladesh”.
The.ban.has been supported strongly by various people-oriented groups
and organizations like Health Action International? the OXFAM,International
Organization of Consumer Union, Penang, War on Want, UK, Public Citizens’
Health Group in the USA. We in VHAI also strongly support the ban - who
would not like to see the hazardous and ineffective drugs go out of the
market?
Probably No one except for the drug companies and those higherups whose pockets get lined in allowing the companies to make their profits
out of the people. If this had not been so, we too would have seen some
of the HATHI Commission’s recommendations and other recommendations for
weeding out 23 combination drugs, being put into practice long ago.
The Bangladesh Government has taken a very courageous step. The
mounting pressure on it by the multinationals may result in either the
reversal of the ban under pressure, or, of Bangladesh and its Government
being harassed by the denial of-aid and loans.
The US Government in response to an appeal made by the multinational
drug companies has asked the Bangladesh Government to ’’reconsider the new
national drug policy”. This is being done "even though 70% of the banned
drugs are considered by the US Federal Drug Administration and its counter
parts in Europe to be dangerous and worthless", according to an Express News
Service item in the Indian Express of 20th August 1982.
r^e multinational drug companies who control 80% of the drug sales
in Bangladesh fear that other developing countries may follow Bangladesh’s
example and jeopardise their $ 30 million world .marketThe.Public Citizen Health and Research Group, a Washington based
organization, in a letter to George Schultz, Secretary of State, has saids
"perhaps you are unaware that many of'the US-based multinational drug
companies are foisting on innocent people in the developing countries, drugs
which our own medical authorities consider worthless and unnecessary".
Sabotage of this ban at this stage by the application of pressure or
by money power will be a blow to all those who sincerely believe in
socially relevant and socially just health care. Consequently, this is not
a question of Bangladeshi’s fighting a ’Bangladesh problem’. It is in fact
a question of a higher premium being placed on profits than on the welfare
of human beings - if the ban is withdrawn under duress. This is therefore
a move against which the public opinion of all nations, particularly the
developing countries, should be raised. It is a cause worthy of global support
specially from those involved in health work.
To prevent- the government from succumbing to pressure by the multi
national drug companies, our support is needed and will be given unflinchingly
•f ftr ths list of banned drugs, criteria used and reasons -contact us.
- Recommended reading:
- A Working Paper by Diana Melrose of OXFAM: "Medicines and the
Poor in Bangladesh".
- "Frontier" July 31,1982: "Tonic or Active Ingredient?"
- Bangladesh Bans more than 1700 Drugs: Andy Chetly International ealth Campaigner for War on Want.
Write your views in support of the ban to counter the pressure by
the multinationals to:
The Chief Martial Law Administrator OR
Health Minister, 'BANGLADESH,
C/o High Commission for Bangladesh,Lajpatnagar III,
New Delhi
w
///
//
Co-Ordinator
Shiva)
Co-Ordinator
Low Cost Drugs & Rational Therapeutics
I
//Ate
•<j>A
XI-S’-SZ.
US asks Bangla to
relax ban on drugs
!
4
By T. V. PARASVRAM
pej/tment action requeafrintf
sladesh to review the ban on cer-’j
Express News Service
tain
drugs,' a spokesman for ‘Werj
WASHINGTON Aug 20
Want’ said in London, ‘encou-j
The United States
has urged on
^apgladesh to reconsider a new raging this review is certainly not,
national policy designed to ban helping the people of Bangladesh’.,
The Public Citizen Health
Re-j
hundreds of drugs, though 70 per
cent of the banned^
banned drugs are concon search Group, a Washingthn-bosed.
sidered by the US Federal
ajetter to_ Secre?|
* * Drug
-■ organisaUon
of State
Administration
and its counter- tary
t—
"-r.t: George
?7_? Shultz called*
... J
“s action
" l
'uncoh-j
parts in Europe to be dangerous or the department
scionabie'. ™
It said:
‘Perhaps you}
worthless.
that many of t^ie US-jf
The State Department acknowl are unaware
multinational drug compa-i
edged Wednesday that its inter based
nies
are
foisting
on innocent peopled
cession with Bangladesh was in in
the developing- countries drugs^
response to an appeal from several ■which
our own medical authorities
multi-national
drug
companies
t?hich fear that other developing consider worthless and unnecessary’!
wic lead of
w* Tlie group expressed ‘dismay’ thai
countries will follow the
allowed
Bangladesh and thiss could under- the State Department had
giani
billion
dollar
world
itself ‘to be used by the giant
fhine their 30
---- —
inarKtsi .
multinational drug comDwnies
companies tw
tJ
market
Bangladesh is playing it in a low promote and protect their exploit
impoverished
citit
key* The economics
attache of tation of the impoverished citf
the' Bangladesh embassy in Wash zens of underdeveloped countries.! .
The Bangladesh government ai>ington said the Bangladesh law
was'.a good steo forward, but the nounced. the new law, prohibitiiw
review requested by the State De- the sale of over 1700 drugs
ai)d
partment “is normal and not im- immediately banning 237 product
Jjortant”. The US consumer groups which are considered dangerous. >11
do not share this benign view of June. Among the US drugs affe’:the US government’s intervention ted are some made by Merck, Pfizer,
and have blasted the administra- Squibb. Searle and Upjohn,
fion.
.
According to the members of the
The Washington Post noted m committee that drew up the new*
a front page despatch that among Bangladesh policy, eight multithe drugs Bangladesh wants ban- natjonal companies including Pfizer
ned. are several that are not per- and Squibb share 75 per cent of
mitted in the US, including clio- Bangladesh’s 100 million dollar-aquinol, a chemical that is known year drug mar
fcet.
Pfizer domimarket.
to cause serious damage to the nates the market with over 10 mil
lion
dollars
in
sales
in. 1981,(
nervous system.
~
A • State Department spokesman Squibb
sold five» million, dollars
acknowledged that the Pharmaceu- ^worth
’’erth +the
h? same year.
tical Manufacturers Association of
•
Nineteen
Pfizer drugs are jpn
the United States (PMA). a trade ithe list of drugs banned in Bangla- ji
organisation of the industry, ask- <desh immediately.
.. ....
They include
eci the department to bring pres- its stericol capsules, which contain
the
22 ~
Squibb
sure on Bangladesh to delay im- clioquinol. Among *’
•
piemen ting the law, pending dis- products affected are quixaling
,
eussions with the manufacturers, tablets and suspension (Q and 3
The Spokesman defended the US caps), both of which also contain;
intercession by saying 'the State clioquinol.
Neither
Pfizer not
Department has a statutory res- Squibb would
comment on the
ponsibilitv ter assisting American new Bangladesh law or the druga
interests abroad. In this particular named in it. They obviously pre*
caseFthe US government is also fer to deal with the matter throconefe-ned that these regulations ugh the state department.
mar inhibit future foreign InvestHowever, a spokesman for th®
meitte in Bangladesh..
industry’s. Pharmaceutical Associa• The’ Carter administration had tion, which recently led a dele•VcStfe-or pesticides banned in the gation to Bangladesh in an unUS!A"'would not be allowed to be successful effort to secure recoiij
exnWd abroad'. One of the first sideration of the law. describe®
acte^of the Reagan administration the new law as precipitous an®
was-to overturn that rule with the prejudicial to public health.
result that drug companies can
PMA argued that blocking th*
now export from the US any item flow of drugs from its member
banned here.
There was never companies could open the market
anv ban on the manufacture of in Bangladesh to uncertified and
sX drugs abroad.
potentially
impure
drugs fronj’
The US act'on lias been con- Uieir sources
»
B®"‘y healtl^budlet S
in the USA. Because
of that
Bangladesh is eager to bring its
drug outlays under control and to
begin to produce some of the less
complex drugs immediately.
The Bangladesh committee ack-^
-.,fc
the companies are marketing. Let's
discuss briefly some ofthe more contro
versial drugs they are marketing. What
sorts of drugs do they promote in
Bangladesh that they would not be
happy to be seen marketing in other
parts of thl* world?
CHOWDHURY: Fake the case of noblyzene—noblyzene is dipvrone. This drug
was banned in the U.S., in 1963. It can
j^^llll be found in Bangladesh. Two years
f
■Z
< v
,-,R~
u. .^H^hjr-
VAIIliv/l - dliuitl
expensive drugs and high-powered pro
motion?
CHOWDHURY: All segments of the
population are affected. You must
realize that because of the exorbitant
prices of drugs, only between 15 percent
and 20 percent of the people can afford
medicines. In the rural areas, because
drugs are so expensive, people cannot
possibly afford them. Number one, the
!
v v cucgoi y A. -
L'f* nAViai-.
fn rx
Jrv
Category B have
never starved
in ♦kz/.f
their Tf l£
lives, but have nev^ .had a surplu:
either. They just manage oh the marg?4*
Category C has surplus; food. surp.„.
income. Under our plan, category A,
the poorest have their health fully
.
covered with one nominal fee. People in
category B have to pay a fee of two taka fy
every time they visit the .health center. | |
For people in category C, the ch.-rge is
five taka. If they need to be admiticd, ? |
♦One taka equals approximately U.S.S.07.
il
they must pay extra money.
For the whole center, about 50
percent of our expenditures are covered
by this insurant sclv>ne'. Besides our
1
main center, we have centers for every
10 or 15 villages, each stafie.
five
“We are trying to tell everybody how
paramedics.
Thev
are
full-timer
I
hev
the drugs are produced. We wanted
provide preventive care, maternal and
to advertise to everyone the economics
child welfare, family planning and
of drug production. ”
nutrition advice. They are also involved
in education in a broader sense. The
E
subcenters are used as community
centers. We feel strongly that you €
cannot simply deal with' health care in
the narrow sense; in the rural areas.,
i
h !th care must be part of an overall
d. • clopment scheme. Our people deal
t
••/'th.'
1f
i, •• - t
tar* ? ' ?
Ar* .
:
directly
with cultivatio
” in fthe
vdk’r*gcs',
ZAFIWLLAH CHOWDHURY
thev do extensive-1 agrk u >i u rafcx^ntizZ ■
. . ......1........y .^^jdJnless you are really ■part of
!S ; ,i3
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I
BIODATA OF
Dr. Zafrullah Choudhary,
■■
Directorz Gonosasthya Kendra
People's
Health Centre
Savar, Dhakaz Bangladesh
Gx3<0?
'*^0
©a/
BORN 27th January 19 41
1964
Passed MBBS with Distinction in
Surgery.
1965-71
Trained as general and vascular
surgeon in England. Returned to
Bangladesh to join the liberation
struggle and helped establish the
Bangladesh hospital for the War
victims on the war front.
1972
Bangladesh hospital transformed to
Gonosasthya Kendra, also known as
the People's Health Centre, or the
Savar Project, in Community health
circles of which he was the
” Coordinator/Director.
1974
Awarded the Swedish Youth Peace Prize.
1978
Awarded the highest Bangladesh National Award —
The Independence A;?ard.
1982 Jan,
Along with his team in GK organized an international
Conference on "Transfer of Technology" and inagurated
the famous "GK Pharmaceuticals" producing reasonably
priced, essential quality drugs - run by a cooperative.
1982 June
As member of the "Bangladesh Drug Expert Committee"
was instrumental in formulation and passing of the
internationally acclaimed National Drug Policy - based
in its entity
on WHO's recommendations and concept
of Essential Drug List.
1983 April
Along with GK team organized an international
workshop on 'Alternative Medical Education' to focus
on the need for appropriate need based medical edu
cation for a third world country like Bangladesh.
The aim being initiation of an innovative alter
native medical school in Bangladesh. Both these
conferences were also aimed at bringing together
like minded groups and individuals from the third
world together, for building mutual support systems
for demands for Rational Drug Policies and relevant
medical education.
Member British Medical Association and Bangladesh
Medical Association.
Has contributed actively to international scientific
and social journals - a few of the outstanding
papers be in gJRe search -a method of Colonization"
"Tubectemy by Para-professionals"/'tinder the law in
Bangladesh”. ’’Essential drugs for the poor a myth and reality in Bangladesh."
*************
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RF_DR_19_SUDHA.pdf
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