health, disease and health-care in rural bangladesh

Sot. SC;. Med. Vol. 16. pp. 2041 to 2054. 1982 Printed in Great Britain. All rights reserved

G277-9536/82/232041-14$03.00/O Copyright 0 1982 pergamOn press Ltd

HEALTH, DISEA$E AND HEALTH-CARE IN RURAL BANGLADESH

ALI ASHRAF, SHAFIQ CHOWDHURY and PIETER STREEFLAND

The Christian Commission for Development in Bangladesh, GPO Box No. 367, Dacca, Bangladesh and the Royal Tropical Institute, Department of Social Research, 63 Mauritskade, Amsterdam,

The Netherlands

Abstract-During two periods of almost 3 months each, a study was done in three villages of Tangail District in Bangladesh. One of the objectives was to find out how the fields of traditional medicine (Ayurveda and Unani), folk medicine and allopathic medicine were related to each other, and which processes could be discerned in these interrelationships. In this respect an important outcome was that traditional medicine had almost disappeared in this area and that Western medicine holds a very strong position. Another objective was to study the illness-behaviour of various economic categories of villagers. Here we found that the poor made much more use of the government facilities than the rich. In fact, these facilities have a large potential, but there are many defects in the way they are operating, so that the potential is not realized at all. We also studied the cures which the practitioners of folk medicine and those of Western medicine are offering to their clients. One of the conclusions was that the practices of the unqualified allopathic practitioners, who hold a strong position in the countryside, are often a hazard to health.

BACKGROUND

Rapid implementation of a modern health-care system in the rural areas is one of the main goals of the Bangladesh government for the present. Using funds supplied by the World Bank, the Asian Development Bank and bilateral donors, many activities in the fields of construction and training are undertaken. The scope of the efforts to bring cheap and reliable health-care to the villagers is enormous. In each of 356 rural thanas there will be a thana health complex (THC), while at the lower administrative level of the union about 4500 union family welfare centres (UFWC) are to be set up [I]. In addition, each village will be provided with a village health worker, the pal- lirchikitchak.

While the new centres are erected and some already existing government facilities are converted and adapted according to the new standards, the personnel who will have to work in these centers are being trained. An important category among them are the medical assistants (MA) who will be in charge of the UFWCs. They are trained at special schools, each of which is connected with a number of UFWCs, where the students can gain some practical experience during their course [Z]. In 1979 the Netherlands Ministry of Development Co-operation, which had then funded four of the schools as well as the sixteen UFWCs connected with them. asked one of the authors to prepare an evaluation of this building programme. In this preliminary stage it became rapidly clear, however, that there were much more important topics for social research available in the field of health and health-care [3]. The giant effort to build up a well- defined health-care delivery system in the rural areas of Bangladesh was, in fact. taking place while hardly any information existed on prevailing facilities and practices. Besides, the government’s attitude was such that. while top-level experts flew into the country to give advice on the planning of the new system, no use

was made of the experience gained in a small number of private innovative medical projects [4].

Because much grass-root level information was found to be lacking, the Netherlands Ministry of De- velopment Co-operation decided to finance a study of the various sources of health-care presently available to villagers. The study was to take place in a region where UFWCs had been operational for some time, so that it would be possible to gauge their importance amidst other health-care facilities to both rich and poor villagers. Bangladesh is one of the poorest coun- tries with about 90% of its inhabitants living in rural areas. Not all villagers are, however, equally poor. In fact, studies of its peasantry show a highly stratified society, with a large and increasing bottom stratum of landless labourers, whose conditions are slowly deter- iorating [S]. As the very poor have to cope with specific health problems and have little or no means to spend on health-care, the socio-economic differen- tiation among the rural population was chosen as an important issue for the study.

THE STUDY

It was clear from the beginning that we did not only want to find out who was using which facilities in which cases, but also how these facilities were operating. We needed, in other words, both quantative and qualitative information, To gather this kind of data it was absolutely necessary for the researchers to spend some time in the village and use methods like in-depth interviewing, observation, and case-studies. We decided to work with two research teams, one male and one female, each of which would study a separate UFWC and one or two villages nearby. The male team consisted of two local researchers, both of. whom had previous experience with quantitative analysis of health behaviour; the female team included both a local and an expatriate researcher, the latter being an experienced nurse, who worked in

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Bangladesh before. and had also been trained as an anthropologist. A Bangladeshi doctor who had long experience in primary health-care and was well acquainted with quantitative research into health behaviour was selected as research director. A Dutch anthropologist who had been working in Bangladesh and other parts of South Asia before acted as part- time advisor, His duties included selection and. training of the research staff, writing of the scenario, and assisting in the writing of the interim and final reports

C61. Before the fieldwork could begin, we had to over-

come two major difficulties. First;there was the selection of the sites. We wanted to study two or three villages in two separate unions, both of which should have an operational UFWC [7]. Though on paper there should have been plenty of operational centres to choose from by spring 1980, in practice this was not the case at all. We found that in reality only a fraction of the planned number could be defined as operational. All of these were situated in the district of Tangail, where early implementation of the plans began. Actually, we would have preferred to avoid Tangail, as the government has undertaken many development activities in this region through the years. As a result one might find a slightly different picture than in the more peripheral districts. After various trips to the area and intensive discussions with district authorities we selected Zamanabad UFWC, which was considered to be the best functioning one by government officials, and Banshari UFWC for the study. The Zamanabad centre is situated near a main road, not far from the district headquarters; Banshari UFWC is located in a remote part of the district, about 35 miles from Tangail town. The female team studied Banshari village (population 1596) the male team the villages Patgram (population 4306) .where the Zamanabad centre stands. and Kaladi (population 1578), about 5 miles away. Still another problem had to be solved, however. It took about 5 months before the Ministry of Health gave us the necessary clear- ance.

The researchers lived in their respective villages during two periods of almost 3 months each. During the first period they tried to build up a picture of the various sources of health-care available to the villagers and to learn about preventive and curative practices. They also attempted to find out the con- cepts behind the villagers’ behaviour. Further, they interviewed the various private practitioners and collected information about the nature of their practice and their relationship with the people. Besides, in each village sixteen households belonging to different economic categories were selected for a survey of illness-episodes. Instead of categorization on the basis of access to land, which is a time-consuming, difficult and precarious operation, we took the capacity of a household to provide a living for its members as point of departure. This way to categorize households had recently been tried out successfully by van Schendel in a study on social mobility in rural Bangladesh. He makes a distinction between the following categories of households [S]:

(A) Households unable to provide for 12 months on a very low level of living during the past year. As it

was impossible for them to get loans. they regularly starved.

(B) Households just managing to provide for I? months at a very low standard during the past year.

(C) Households able to provide for 12. months at a moderate standard of living during the past year. and even from 1 to 3 months in excess of that.

(D) Households able to provide for 12 months at a comfortable standard of living during the past year. and for more than 3 months in excess.

The selection of the sixteen households in each village was done in such a way that six belonged to category ‘A’, five to ‘B’, three to ‘C’ and two to ‘D’. Two ad- ditional criteria were taken into account: each partr (village neighbourhood) should be represented and both Hindu and Muslem households should be selected proportionately. Each of the sample households was visited every week by the researchers. They collected information on vital events. illness-episodes and, particularly, on what had been done in case of an illness. Where possible, the researchers tried to ob- serve the course of actions taken.

During the second phase of the fieldwork the researchers focused more on the activities of the UFWC. while the surveillance of the sample households continued. They were able to establish good rapport with the UFWC staff. Repeatedly, interviews were held with them regarding their training, duties and responsibilities, expectations, working conditions and problems. Twice a week, on different days, the activities of the centres were closely observed and detailed information was collected on the background of the patients, the nature of their ailments and the services they received.

In addition to the usual problems connected with anthropological fieldwork, such as how to face expectations that arise, the researchers had to cope with difficulties related to the specific nature of the study. It took quite some time and effort, for instance, before some of the unqualified allopathic practitioners opened up during interviews and allowed us to ob- serve their practice. Another difficulty concerned the fact that some diseases are not easily discussed with outsiders, because they either are considered to belong to the private sphere, as is the case with female diseases, or may lead to stigmatization if their prevalence becomes generally known as, for example, in the case of TB. Besides, the way in which especially the poorest villagers perceived the seriousness of ailments made it sometimes difficult to record illness-episodes. This occurred when a respondent did not think an ailment important enough to mention, as it was considered to be part of daily life, not worth bothering about as this could not be afforded. Probing was, therefore, a necessary technique for the collection of data on illness-episodes.

As it is important for the reader to be able to judge the value of the material presented, some sources of bias should be mentioned here as well. We already mentioned the fact that Tangail district got more than the average share of government attention as far as development activities are concerned. Next, it is important that the fieldwork took place during the dry season, namely October 1980-January 1981 and February l981-May 198 I. This certainly has

Health, disease and health care in rural Bangladesh 2043

influenced the prevalence and pattern of illness-episodes which could be observed. Another source of bias is the sex-composition of the research team. There may have been, for instance, underreporting of female diseases in the villages where the men worked. On the other hand, the female researchers found it sometimes difficult to collect data on the actual costs of disease. They communicated best with the women, whereas the men generally paid fees and knew most about this.

HEALTH. DISEASE. AND HEALTH-CARE

Perceptions of he&h and disease

Though all villagers, Muslim and Hindu, rich and poor, believe that disease occurs according to the will of God, each illness is thought to have its specific cause. Malnutrition, tetanus, abortion. eclampsia and hysteria are, for instance, often thought to be caused by bad air or by an evil spirit, whereas diarrhoea and dysentry are attributed to a combination of bad air and improper food intake. Almost everybody per- ceives skin disease, particularly scabies, as the conse- quence of blood poisoning. Among the educated a superficial knowledge of the role of germs does exist, but only in relation to a limited number of diseases, such as malaria, dysentry and tuberculosis. Only a minority of the villagers were found to classify diseases according to the influence of kasha (astringent) and rasha (laxity) in the body. According to them one group of ailments, including urinary tract infection. pneumonia. dysentry and leucorrhoea. occur when the bodily system becomes astringent. Too much rasha in the body results in complaints like diarrhoea. common cold. oedema and swelling of joints. As will be clear from these examples. when studying the villagers’ explanations of the causes of various diseases, a picture emerges of a kind of mixed culture in which a variety of influences can be discerned [9]. The heri- tage of folk medicine and common experience still plays a crucial role. Compared to that the influence of allopathic knowledge, as well as of Ayurvedic and Unani ideas appears to be much smaller [lo]. The villagers’ perception of the background of illness is, of course. changing in the course of time, some explanations slowly disappearing, while others are gaining influence. We came to know that Ayurvedic and Unani knowledge and interpretations are on the way out, and have, in fact. for the greater part disappeared from the villages we studied.

All villagers do believe that some diseases can be prevented by observing certain rules and customs. Quite common is. for instance. wearing of a sanctified amulet. It was found that. in general, immunization is not perceived as a means to prevent certain diseases. In one of the villages none of the respondents in the sample households could say whether smallpox vacci- nation was in any way related to the eradication of the disease. But there are also villagers who are con- vinced that smallpox vaccine can prevent chicken pox and measles as well. Cholera vaccine is under large demand during the diarrhoeal disease (rainy) season. as it is believed that this vaccine can prevent those ailments.

Most of the villagers do not relate bad sanitary practices wi!h disease The main use they have for a

latrine, if there is one, is that it offers privacy. Prob- ably due to a radio campaign it is becoming better known that boiling water before drinking it can prevent diarrhoea. Not many people did seem to practice it, however, mainly because of the high costs of fuel. Actually, the study made it quite clear that availability of resources (tubewells, latrines, vaccinations) for everybody, rich and poor, and a sufficient income to be able to afford certain practices (a balanced diet. fuel for boiling water) are both crucial factors as far as the prevention of disease is concerned. Poverty and prevention just do not go together.

Observing and discussing the prevalence of disease in the villages, one discovers that illness is often ignored. Especially the poor try not to worry about the treatment of disease as long as they can tolerate the symptoms and there is no loss of income. Minor ailments like occasional fever, one or two bouts of diarrhoea and a common cold do not receive any special attention. Because of financial constraints also some chronic diseases, like infantile diarrhoea or dysentry, infection of ear and nose, or scabies, may remain untreated for years, in the hope that a cure will ensue naturally. Here we see one of the lesser known sides of poverty: the bitter necessity to con- tinue suffering though possibilities for cure may be available.

The private practitioners

The largest providers of curative care to the villagers are the unqualified allopathic practitioners and drugshops [I I]. Folk medicine, comprising home- remedies, faith-healing and use of herbal medicine. appears to stand in second place. The practitioners of folk medicine are commonly known as kahiraj, a term which in Bangladesh is also used for a graduate in Ayurvedic medicine. There was, however, not a single qualified practitioner of Unani or Ayurvedic medicine to be found in or around the three villages. Only one practitioner somewhat followed the Ayurvedic system, using knowledge he had picked up as an apprentice to a qualified kabiraj. The homeopath is another practitioner who is active in the countryside [IZ]. But in none of the villages did we find any ‘pure’ homeopathic practitioner. Those who consider themselves homeopaths are administering allopathic medicine as well, because that is more in demand and leads to a better income. The villagers prefer homeopathic treatment especially for children and pregnant women and perceive it as a mild and slow working therapy. Besides, it is cheaper than allopathy. We observed that the homeopaths certainly try to influence those who consult them to take homeopathic medicines. b> showing the difference in price and emphasizing that these medicines are sweet, easy to take. and that the) lead to permanent cure. Allopathic medicine. they stress, give quick result, it is true. but this does not mean it will last. Other health-care providers who offer their services to the villagers are the traditional midwives. Often, these dai are only called after a woman has been in labour for some time and the patient’s relatives have failed to deliver the baby. The dui do not follow a system of ante- or post-natal care visits. On the whole, their practices are unhygienic. though some of them are using warm water (though not boiled), a clean blade and clean cloth. None of

2044 ALI ASHRAF et al.

them know why such things should be used. Their services are not well-paid and they have to be satisfied with whatever is offered to them. Finally, we have to mention the services of medical craftsmen like the bone-setter and the tooth-remover. Together with the dai, the various kinds of kabiraj, the homeopath and the unqualified allopaths they form the realm of private health-care from which the villagers have to choose when home-remedy does not suffice. Govern- ment health-care is, of course, another option. In the remaining part of this section we shall elaborate on the background and practices of the two categories of private practitioners who play a major role: the unqualified allopaths and the kabiraj.

The unqualified allopathic practitioners

The unqualified allopaths whose services the inhabitants of Banshari, Kaladi and Patgram are using generally work either from their own drugshop or keep a chamber in somebody else’s. Their formal education ranges from 8th to 12th grade, and they learned their trade via an apprenticeship with a qualified or unqualified practitioner. We observed that in most cases patients are treated without a full record- ing of the case-history. Often, a diagnosis is made and medicine given on the basis of what is told by a relative, as the patient is staying at home. When the patient is present and the complaints are of a serious nature, the practitioner may feel his pulse, record his temperature, examine his tongue and even palpate his abdomen or examine his chest with a stethoscope. But this is usually done in such a way that one gets the feeling it is mainly meant to impress the patient and possible companions. Most of the practitioners pay home visits if needed, unless they deem the case too serious and/or think that their specific medical treatment cannot be of much use. We observed a few cases where practitioners did not attend to emergencies pre- tending that they themselves were ill.

The unqualified allopaths’ treatment mainly con- sists of medicines, which are given out directly from the shop. Allopathic medicines are usually sold per tablet or capsule or, in case of a syrup, per spoon. A fixed treatment scheme is usually not followed. For a specific disease a variety of tablets or liquids may be advised, depending on the severity of the complaint, the economic situation of the patient and the range of available medicines. Which medicines the patient gets is often the outcome of a process of negotiation. If the patient thinks that an advised cure is too costly, the practitioner gives him other options and assures that these other drugs, even though they are cheaper, are just as good as those which he advised in the beginning. Sale of medicine on credit and payment in installments are not uncommon. We also got the impression that a little consideration as to prices is sometimes given to the really poor. For home visits a fee is charged, but when the patient visits them the practitioners do not usually ask a fee, as this is included in the price of the medicines. For special services like giving an injection an extra fee is charged.

The quality of the health-care provided by unqualified allopaths is very much questionable. In this respect the large quantity of drugs which are freely available in the market, their use being propagated by the pharmaceutical companies, is an extremely nega-

tive factor. Prescription of several types of medicine at a time, even of a combination of two or three antibiotics at a time is common practice. Use of very broad spectrum antibiotics like ampicilline, doxicyc- line and of chemotherapeutic agents like Septrin is common as well. In general, drugs are prescribed only for 2-4 days. Because a large number of the diseases are infectious in nature, improvement can be achieved within this time. We also observed that capsules of antibiotics were handed out in only one or two pieces. Like one practitioner put it: “these medicines work magic for them. Quite often they are cured by taking one or two capsules. They don’t need any more”. Though the practitioner advices his client to return when the few drugs he obtains are finished, in practice it turns out that the patients do not come back. Either their condition improves, or they feel that the medicine did not work and consequently look for other treatment. Besides, they often do not have sufficient time and money to pursue a treatment and may decide to live with the ailment. As a result of the practice of the unqualified allopaths not to give full courses of medicines, many illnesses turn chronic and keep showing acute exacerbation repeatedly. Each time, the villagers perceive this as a new episode of illness. Though most practitioners may not be aware of this, it all works, of course, to their advantage, as their. patients come again and again.

The unqualified allopaths are least effective in the treatment of non-infectious diseases. If people come to them with such complaints they either avoid to treat them or experiment with drugs.

The practitioners of folk medicine

In the villages anyone who practices medicine other than allopathy or homeopathy, be it faith-healing, herbal medicine or exorcism, is known as a kabiraj. There is a large variety of these practitioners and they may differ considerably as to their perception of diseases and the nature of their treatment. One important category of kabiraj are illiterate women, who learned their trade from an wad (general term for expert teacher) or from relatives. Their main mode of treatment is to apply sanctified water or oil, or amu- lets made of the bark of trees, jute string or pieces of glass. Occasionally they may use materials like mus- tard oil, garlic spices and a few herbs that are available around the house for the preparation of medicine.

Case No. 1

I&fun Nahar, a very small and fragile woman. has been Practicing as a kabiraj for the last twenty years. She learned her craft partly from her mother, who told her about it shortly before she died, and partly from a moulaui (religious man), who taught her how to cure diseases with the knowledge of the suras (verses from the Holy Quran). According to Lutfun anybody can acquire her knowledge, there being no need of a special power or spirit: “you only need to be honest”. She usually treats patients at her own house, two or three people a day, in the morning and the evening. She does not take money or presents: “to do something for the people is just good”. Men, women and children, mainly Muslems. come to her for treatment. Though rich families consult her as well. most of the patients are from among the poor. Most of her treatments are based on faith-healing, such as jhara (an action-pattern


consisting of different movements with the hands directed at the body of the patient, recital of holy texts and application of, for instance, certain herbs, meant to disturb or chase away bad air or a bad spirit) and pani para (sanctified water). She also uses herbal medicine, which she pre- pares from roots, bark and some ingredients she buys in the market. What exactly she buys she would not tell.

Another category of kabiraj are the specialists, nota- bly the snake-poison remover, and the ojha, who is specialized in removing shape batash (snake air, see Case No. 2) [13]. These specialists generally adhere to strict professional ethics. Among the rules they swear to follow are: not to charge any fee, not to tell anybody the secrets of their art, and to respond to calls immediately. They are, of course, allowed to inform one or two of their trusted followers about their skills before they die, but these will have to take a similar oath. It is firmly believed that a specialist will lose his curative powers, if he breaks the rules.

Case No. 2

Abdul Malek (26) is specialized in treating burns and shapa batash (snake air). His father was also a practitioner and was specialized in the same diseases. He asked his father to teach him the art, but this was refused. He then went to an ustad (expert teacher), stayed there for seven days and learned how to treat the diseases. He also got a book with 101 lines’ quotations ofjhnra verses. He does not have any formal education, hut is able to write his name. He works as a day labourer. As a healer he does not have any income, because he will never take money or even paan (betel leaf, according to Bengali custom the minimal enter- tainment that can be offered to a guest). If he did, his special power will disappear. Most of his patients are from his own neighbourhood, and as this is a Hindu area, the majority of them are Hindus. Men, women and children are among his patients, with women in the majority among those who suffer from shapa batash. When he treats burns directly after the accident he uses coconut oil or egg yolk. When it is an old burn he paints the whole area with writing ink, to stimulate the drying in process. Besides, he gives jhara three times in a day. The dietary restrictions he prescribes regard milk and sour food, as milk makes the burn whitish and sour food delays the drying in process. As to shapa batash: one may get the disease by passing a place where a poisonous snake has been resting and has left its air behind. This air can influence a person who then sud- denly develops the symptoms: extreme heaviness of the head, nausea, restlessness, vertigo, weakness, numbness, slurring speech and sweating. The patient may or may not have diarrhoea, vomiting and mild fever. When the villagers recognize these symptoms, they know they have to go to an ojha immediately and that allopathic medicine is of no use in such a case. To diagnose the illness Abdul Malek pours some water on the mud floor and stirs his hand through the wet mud. After that he puts his hand flat on the floor. If it moves towards the patient, he is sure that he or she has shapa batash. During the whole procedure he recites jhara verses. Immediately after he has detected the disease he begins a vigorous treatment with massage to direct the bad air to one part of the body where he can let it escape via a small wound he makes in, for instance, one of the toes.

Only for one of the kabiraj in the village we studied the practice was a full-time occupation. This was the practitioner who had been trained in Ayurveda and who practiced a mixture of Ayurveda and folk medicine. He charged a high fee, unlike the others, many of whom give medication free of cost, except for the

components which come from the market. Kabiraj who belong to one of the poor households, however, expect and appreciate some gift if the patient gets cured.

During our study of illness-episodes we found that both rich and poor households were seeking the treatment of kabiraj. Sufferers from diseases which according to folk definition are believed to be caused by bad air or bad spirits usually first go to a kabiraj. Besides, the advice of kabiraj is sought when during the course of a disease people have a bad experience with western medicine. These observations may well indi- cate a rather stable position of folk medicine. This will keep as long as the quality of allopathic health- care does not improve considerably and folk defini- tions of illness do not change dramatically because of, for instance, an increase in the educational level.

The Union Family Welfare Centres

Both the centres which we studied became operational at the end of 1979. Though there are some differences between them-one, for instance, is well equipped with furniture while the other is still inade- quately furnished-there are many similarities in the way they operate. In order to show how this source of public health-care is working in practice, we shall present a case-study of one of the centres. After that we shall discuss at some length the problems we observed.

The Banshari VFWC

The background. Soon after it became known that a health centre was to be provided to the area, a committee including government officials and the union chairman was formed which would be responsible for the selection of the site and the construction of the building. Banshari, the main village in the union, with all the offices, a bank and a market (but also with an already functioning government dispensary) was considered to be the best location for the centre. People from Jobar village, however, disagreed and argued that the centre should be in their village, since it is located in the middle of the union and has no public health facilities as yet. Ultimately the union chairman solved this problem to the advantage of Banshari. The building phase took rather a long time due to some financial trouble about which a lot of gossip circu- lated. Finally in October 1980, more than 2 years after the building was started, the staff moved to their new accommodation, where initially they could still only use one room.

The building. The centre is located in the middle of the village. It has six rooms, of which, as yet, only one was available to all the staffio see and treat patients. During the last week of our stay, the FWV (Family Welfare Visitor) could, however, move to her own room. Then only two rooms were-sufficiently-furnished and equipped. But there were no benches for waiting patients, no latrines and drinking water facilities, the nearest tubewell being about 400 yards away. As far as we could see the centre is easily accessible to the villagers: during the winter on foot and in the rainy season by a small boat. At the back of the centre staff accommodation for the MA (Medical As- sistant) and FWV is provided. Although this provision is certainly not a bad one, the low height of the

2046 Arr ASHRAF et al.

separating wall between the units hampers the resi- dent’s privacy. Here a tubewell is lacking as well.

The personnel. The clinic is staffed by four full-time workers: the MA, the FWV, an aya and a peon. Besides. there are two part-time dai (traditional mid- wife). Let us take a closer look at the MA and the FWV, the principal functionaries. The family welfare visitor was transferred to Banshari in September 1980 after completing her 18 months’ training in Dacca and with about half a year’s experience in another union. She enjoyed here training, but tells us she is afraid that she will forget many things she learned, as she is still unable to begin with her own programme of mother and child care. She neither has the space nor the medicines needed. Usually she sits in the MA’s room, where she sometimes gives instructions on taking medicine or attends to a few women. Only when the MA is on leave and she has to run the clinic is she able to attend to the patients, though she then has to treat them with a limited number of medicines, as the MA puts out a small quantity of drugs and takes the key of the store with him. She is not happy with her subordinate position-though she and the MA have a good understanding-as it limits her in her work. From March to May 1980 all FWVs in the country went on strike to enforce their demand to be put in charge of the UFWCs, but the authorities decided the MAs should be in charge, as they have more training. The FWV has not started with her home visits yet, though she says she attends to deli- veries on call.

The MA joined the centre in March 1980, directly after completion of his two years’ theoretical and one year’s practical training. He has little interest in his work and complains that he cannot fully apply what he has learned. His practical training was in a hospital, where he used instruments and medicines which he does not have at his disposal now. He was never trained in a field situation. He never learned how to run a clinic or how to keep the records. Apart from this, he has to buy stationary with his own money because he does not receive any funds for .this purpose. His motivation to join this service had much to do with the hope of getting a good position, a good salary and a motorbike, but none of these hopes were fulfilled. He has found out that there is no career ladder in this job and would prefer to do some more courses and then become a graduate doctor. He goes on house calls in Banshari and neighbouring villages, gives a prescription for medicines and receives lo-20 Taka as a fee, according to distance and nature of illness, unless the patient is very poor. He has recently begun a private practice in a nearby village, where no other allopath is available [ 141. The villagers perceive him as a doctor.

All staff members are interested in having more training, mainly to attain a better position. Their main motivation to take their job was to have permanent employment in the first place. Talking to them one gets the impression that their mind is always occupied with what is not there, like the insufficient medicines, the understaffed centre, the incomplete building. On the other, hand one finds them rather inactive and feels that they have lost any sense of creativity.

The activities. In principle the centre is open from

eight till two. while on Friday it is usually closed around twelve. During our study period it happened several times though. that the staff could not keep these timings because of lack of medicines or construction work at the building. Two days a month the centre is closed completely. as the staff go to the thana health complex to collect their salary and attend meetings. Most of the patients come m the morning. They enter the MA’s room as soon as they arrive and. as no one organizes their flow. sometimes as many as ten patients, both men and women. may be crowding the room. each trying to push ahead. The staff tries, however. to treat patients on a first come first serve basis. There is no screening for serious diseases and no initial registration is done. Only when a patient gets some medicine for his ailment. name. age. gender, village, complaint and treatment are written down in a register. This registration is done quite haphazardly; during twelve observation days we found that in 55 (21”“) out of 256 entries in the book no complaint was mentioned. About 15-20”, of the patients do not get registered. because they leave as soon as they hear there are no medicines for their complaints. Usually medicines are given in too short courses; the patient gets a quick explanation on how to take the medicine, but the elderly among them often get confused. Only in a few cases instructions on how to prevent the disease are given. The staff does not believe in health education. because the patients. in their opinion. are too poor to put the advice. such as improving their diet, into practice. Patients do not get a written slip about the medicines they receive, so that the MA cannot refer to any previous treatment. The register is also not used as a reference. In general very little time is given to the patients to narrate their problems. But when more affluent people pay a visit. they get a better reception and their complaints are attended to more seriously. The other patients do not seem to complain about such a difference in treatment, as it only reflects the situation in their village society.

There are no special provisions for women observing purda (seclusion) [ 151. Moreover. no privacy is possible for those suffering from female diseases. As a result women hesitate to mention such problems. It often happens that a woman, who after a long time decides to pay a visit to the clinic, preparing herself in advance to explain her complaints to an unfamiliar male person, ultimately cannot tell her story because she is interrupted by men who come in and behave as if the MA is there only for them.

As the centre is located near two schools, regular visitors are the school students, who come with minor ailments and at the same time may also ask for some medicine for their relatives at home. This fact, that the patient stays at home and that somebody else comes to narrate the complaints and request for medicine, is rather common. Once in a while they are asked to bring the patient, but usually they are given the medicine-if it is available-according to the complaint.

Medicine supply is very limited and irregular. The centre is supposed to get four UNICEF kits a year. During our stay they received one in October 1980 and another in February 1981. According to the staff, the contents of these kits are usually incomplete and the amount of medicines is insufficient. Moreover,


they get the kits designed for Mother and Child Care, which only contain a limited variety of medicines. By the middle of March only a small number of medicines were left, such as benzyl bezoate. sulphadiazine, piperazine, aspirin, eye ointment and iron tablets. For several diseases, like diarrhoea, hyper acidity, tuberculosis and female diseases, there were no medicines at all. A first-aid box is lacking. Because of the shortage of medicine the MA feels constrained in his activities and does not see the use of examining patients thoroughly, as he cannot treat them properly anyway. Several times he made an effort to discuss the problems with his superiors, but to no avail. One of them pointed out that the UFWC is under the responsibility of the Family Planning Department-unlike the thana health complex which falls under the Health Department-while another stressed the need for preventive work, probably not realizing that many people cannot afford prevention [16].

A proper referral system is lacking; whenever FWV or MA use the term ‘refer’ what they actually mean is ‘advice’. In case of certain ailments, such as acute abdomen, retained placenta, complicated fractures and tuberculosis, the MA advices patients to go to the thana health centre or to the hospitals in Mymen- singh and Tcngail. He does not write any referral letters, since his signature is not recognized by the authorities and an instruction regarding referral is lacking. Sometimes the MA asks the thana medical officer (TMO) for advice. Once we observed that the TMO, who came on a supervisory visit, was seeing a few patients, whom the MA had informed about his arrival in advance.

Once every month a sterilization programme is conducted in the UFWC. A fully equipped team comes for that purpose from the thana health complex. They are assisted by the two part-time midwives on the UFWC’s staff. Women usually stay for l-3 nights after ligation. Though the programme has been going on now for over a year. indoor facilities like beds. food and sanitation are still lacking. Women receive one scrree. which they have to wear before they enter the operation room, and 84 Taka before being discharged. Men receive one lungi (ankle- long skirt, usually worn by the men) and 46 Taka [I 73. Both get Vitamin C and iron tablets. A few women we met thought their menstrual complaints and general weakness to be due to their tubectomy. Others were satisfied. however. During our dis-

cussions in the village, we noticed that, because of its sterilization programme, quite a few people had the impression that the UFWC is there mainly for family planning purposes.

The patients. During the 2 days we visited the centre, the number of registered patients amounted to 256 (as compared to 779 in Zamanabad UFWC). Each day we collected information on about five registered patients, who were chosen randomly. The total sample size was 62. We interviewed these patients either in the room where they were seen and given treatment, or afterwards on the varanda. We found that more men than women are visiting the centre. This is different from the Zamanabad UFWC, where women are clearly in the majority. The discrep ancy is probably due to the relatively high attendance of schoolboys in Banshari and a more active FWV in Zamanabad.

A majority of the patients in the sample (see Table 1) come from within a distance of 2 miles (80%) and more than half of them covered between I and 2 miles. Taking into account that approx. 4 miles is the longest distance which can be covered from any place in the union to the centre, that people who live near the union’s border may well find it easier to visit another centre and that the Banshari centre is known to have a shortage of medicines, this coverage does not seem to be bad at all. On the other hand an average of 25-30 patients a day should be considered rather low for a centre like this.

As could be expected, most diseases were intestinal (see Table 2). Among these diarrhoea and dysentry scored rather low. Besides the fact that, as we already mentioned, these complaints are often neglected by the poor, another influential factor may be the un- availability of medicines, of which the people seem to be well aware. Other important ailments encountered in the centre are respiratory tract infection, eye and ear complaints, minor injuries, skin and. deficiency diseases. The fact that patients with female diseases, urinary tract infections and tuberculosis, complaints which are known to be prevalent in the community, are not commonly encountered in the UFWC, again may be related to the well-known lack of proper medicines. Besides, in case of female diseases, the nature of the disease plays, as we explained earlier, a significant role as well.

Though we could only make a rather superficial assessment of the economic category of the patients in

Table 1. Age. sex and travelling distance of patients visiting Banshari UFWC on twelve ‘observation days’

Distance l-2

< 1 mile miles 32 miles Total Grand Age M F M F M F M F total %

Under 5 1 1 6 4 2 - 9 5 14 22.6 5-14 1 1 5 2 1 - 7 3 10 16.1 1544 3 6 6 6 4 3 13 15 28 45.2 45+ 1 2 5 - 1 7 3 10 16.1 Total 6 10 22 12 k 4 36 26 62 99.9

0 0 25.8 54.8 19.3 58.1 41.9

Source: Sample,Survey Banshari UFWC


Table 2. Distribution of patients of Banshari UFWC according to diseases

Patients Diseases Number “/,

Intestinal disease 1s 24.2 Respiratory disease 10 16.1 ENTIeye disease ' IO 16.1 Deficiency disease 6 9.7 Skin related disease 6 9.7 Unrelated fever (PUO) 2 3.2 Aches and pains 2 3.2 Injury/‘surgery 6 9.7 Gyneacologicaliobstetricdf disease I 1.6 Urinary tract disease 1 1.6 Others 3 4.8

Total 62 99.9

Source: Register of patients Banshari UFWC.

the sample. it was clear that those from ‘A’ and ‘B categories, i.e. the very poor and the poor, were in the majority. Together they seemed to form 74% of the sample (78”/, in the Zamanabad sample). We saw, in fact, only one patient who clearly belonged to ‘D category. Another thing we learn from Table 3 is that over 40% of the patients in the sample came directly to the UFWC with their complaint, without consult- ing another outside source of health-care first. Almost 259, of the patients had already made a visit to the center with the same complaint. Another interesting observation is that more than 10% of the sample had consulted an unqualified allopath before visiting the center. These figures are remarkably similar to those found in Zamanabad.

Prohkms regurding the operation of the UFWCs

The plan to offer basic health services to the rural population through UFWCs is potentially a good one, the more so because these centres were found to be visited most by the poor. Implementation of the plan shows important defects, however. Let us look at these a bit more in detail.

(I) Both the centres are situated almost next to a government dispensary. These facilities, which were

established long ago. are well-known to the people. To the villager the present activities of the UFWC do not differ much from those of the dispensaries. except that the new centres provide family planning services as well. No wonder that many perceive the UFWC primarily as a family planning clinic. As far as amenities are concerned it is striking, that neither of the centres has a drinking water faality. One centre has latrines, it is true. but as there is no sweeper. these remain dirty and are often inaccessible. Obviously the inadequate provision of these basic amenities is the more deplorable because of its negative demon- stration value. An important problem regarding the geography of both buildings is the neglect of any provision reflecting the special position of women in Bangladeshi Muslim society. Hence. women who ob- serve purda are reluctant to come.

(2) Among the most important staff members in the centres, the Medical Assistant and the Family Welfare Visitor, the latter’s background. education and out- look appeared to be most in line with the task to be performed. Though in one of the centres the FWV was rather passive, this was clearly related to the fact that lack of supervision and medicines made it impossible for her to work properly. As to the MAs there was much evidence of lack of a close linkage between their training and attitude. and the work they had to do. Both the MAs had 12th grade general education with 3 years of professional training. Dur- ing their course they touched almost all the major branches of medical science. but only very super- ficially. To us they appeared to be totally oriented towards clinical medicine and we never got the impression that they felt they had any responsibility towards preventive and promotive medicine. When asked about it, they expressed their interest in giving health education classes in schools, but at the same time they explained that they did not do it because the authorities did not encourage them in this regard. Actually, the attitude of the MA is that of a semi- doctor. Both of them made it clear to have taken on their jobs mainly from a career perspective and not to have much commitment to the work as such. They expressed the need for more sophisticated working conditions, so that their education could show to full advantage. The MAs did not consider the FWVs’ 18

Table 3. Sources of prefessional care utilized just before coming to Banshari UFWC; according to economic category

Sources of care Economic category

A B C D Unknown Total O0

No treatment/no professional care* UFWC (Banshari) Unqualified allopath Qualified allopath Kuhiruj Banshari dispensary UFWC (other) Total

“/,

12 8 4

5 7 1 2 3 2

2 1 2 2 1 1

24 22 9 38.7 35.5 14.5

1 2 27 43.5

- 2 15 24.2 - 1 8 12.9

- - 1 11.3 - 1 4 6.5 - 1 1.6 1 6 62 100.0 1.6 9.1 100.0

Source: Sample Survey Banshari UFWC. *Includes those who took home-remedy and/or were attended by non-professional neighbours

Healtir, disease and health care in rural Bangladesh 2049

months training adequate for them to attend to patients by themselves. But to us the FWVs appeared to be more at place in the centre than the highly trained MAs.

(3) Insufficient quantity and quality of medicines obstructs the centres’ activities in two ways. On the one hand, it makes the position of FWV and MA very insecure. In both centres as many as 20% of the patients had to be sent away without any treatment and it is understandable that many of them comp- lained about their pointless journey. Still, it is important to point out that in case of non-availability of medicines the patients do not strongly push their demands. They are unaware of the fact that provision of basic health-care by their government is not a favour but a right. On the other hand, insufficiency of medicines leads to injudicious distribution of what is available, e.g. to incomplete courses and inadequate quantities. This is similar to the practices of the unqualified allopathic practitioners, but for other reasons and with less grave consequences as dan- gerous drugs are lacking in the centres. Another problem is the emphasis on curative medicine. As we saw before, the MAs who are in charge of the UFWC do not feel responsible for preventive and promotive medicine. This is partly because there are personnel with specific tasks in these fields connected with the thana health centre. Here we see an example of a structural bottleneck for the effective implementation of basic health-care. It also emphasizes the isolated position of the UFWC in the governmental health- care system. This isolation is aggravated by the lack of a formal referral system.

THE QUANTITATIVE PICTURE OF ILLNESS-BEHAVIOUR

We shall now present a picture of how the villagers are using the different facilities discussed above. As

was mentioned before, during the fieldwork we collected information on illness-episodes in sixteen households belonging to different economic categories in each of the three villages. AS it was only our inten- tion to give a quantitative indication of the observed prevalence of disease, under the illness-episodes in the respective tables, all kinds of diseases and (minor) ailments have been grouped together. Further, we have counted an illness as incapacitating when the patient was bedridden and not able to work; in cases of children under 1 year of age when they did not laugh and eat; in cases of older children when they did not eat and play. For chronic cases of, for instance, dysentry and peptic ulcer, acute exacerbation as defined by the individual concerned was counted as a separate episode, while a chronic case without significant improvement was counted as a single episode. An illness episode was considered as unreported when the households did not tell the researcher about it spon- taneously.

First, we shall now look at the distribution of the illness-episodes among the economic categories. Table 4 shows the situation in Banshari village during almost 6 months of a reasonable agricultural year. Underreporting of episodes was most frequent in ‘A’ category. Further, the two poorest categories, ‘A’ and ‘B’, scored highest as far as the percentage of incapacitating episodes is concerned. Finally, the tendency to consult outside sources of health-care (either next to or apart from home remedies) is most distinct among households of the categories ‘c’ and ‘D’. Patgram village (Table 5) shows approximately the same picture. Underreporting is highest among the poor and a relatively large number of their episodes were incapacitating. Categories ‘C’ and ‘D’ visited outside sources of health-care most often. Though underreporting is highest among the poorest in Kaladi, surprisingly it is also high in ‘D’ category. The rich also score relatively high on incapacitating episodes, which is differ-

Table 4. Distribution of illness-episodes among sixteen households of different economic categories in Banshari

Unreported Incapacitating No treatment/ Visit outside Economic Number of Number of Total number episodes episodes home remedy case source category households members of episodes No. % No. % No. % No. %

A 6 28 34 I 20.6 4 ‘11.8 24 10.6 10 29.4 B 5 29 28 3 10.7 3 10.7 17 60.7 11 39.2 C 2 10 13 2 15.4 1 7.7 6 46.2 . 7 53.8 D* 3 16 24 2 8.3 1 4.2 5 20.8 19 19.2

Total 16 83 99 14 14.1 9 9.0 52 52.5 47 47.0

Source: Weekly surveillance of sample households. *During the study it became clear that one of the households did belong to ‘D’ category rather than to ‘C’.

Table 5. Distribution of illness-episodes among sixteen households of different economic categories in Patgram

Unreported Incapacitating No treatment/ Visit outside Economic Number of Number of Total number episodes episodes home remedy sources category households members of episodes No. % No. % No. % No. %

A 6 29 27 8 29.6 11 40.7 6 22.2 21 77.8 B 5 29 30 9 30.0 10 33.3 6 20.0 24 80.0 C 3 26 33 5 15.2 6 18.2 4 12.1 29 87.9 D 2 16 21 3 14.3 23.8 4 19.0 17 81.0

Total 16 100 111 25 22.5 3: 28.8 20 18.0 91 82.0

Source: Weekly surveillance of sample households.

2050 ALI ASHRAF rr al.

Table 6. Distribution of illness-episodes among sixteen households of different economic categories in Kaladi

Unreported incapacitating No treatment Visit outside Economic Number of Number of Total number episodes episodes home remedy care source category households members of episodes No. ‘lo No. O,, No. O” No. ‘I,,

A 6 39 83 22 26.5 17 20.5 38 45.8 45 S4.2 B 5 34 71 I2 16.9 II 15.5 26 36.6 35 63.1 C 3 2s 70 6 8.6 I2 17.1 I4 20.0 56 80.0 D 2 22 42 8 19.0 IO 23.8 13 31.0 29 69.0

Total 16 I20 266 48 18.0 SO 18.7 91 34.2 175 65.8

Source: Weekly surveillance of sample households.

Table 7. Distribution of diseases according to sex and economic category in Banshari

A B C D Total Grand Diseases M F M F M F M F M F total ‘”

Intestinal disease Aches and pains Respiratory tract infection Unrelated fever (PNOl Injury and surgery Eye/ENT Deficiency diseases Gynaecological diseases Skin disease Joint pains/arthritis Urinary tract infection Others Total %

1752-112 7 I2 19 19.2 - 4-7-l-2 - I4 I4 14.1

5 3 2 2 I ---8 5 I3 13.1

- 2-3 I I I 3 2 9 II 11.1 - 3--12-21459 9.1 - I-III12257 7.1 - 4----2-42 6 6.1

- 2 -2-l-l-6 6 6. I - 2-,_-l-22 4 4.0 -------___ _

-2-l-3-3 3.0 - _ Ill--4257 7.1 6 28 9 19 8 5 9 IS 34 65 99 I00

18 82 32 68 62 38 38 62 35 65 100

Source: Weekly surveillance of sixteen sample households.

Table 8. Distribution of diseases according to sex and economic category in Patgram

Diseases A B C D Total Grand

M F M F M F M F M F total %

Intestinal diseases I2 I5 17 12 9 5 5 6 43 38 81 30.5 Respiratory tract infection 2 17 6 2 7 3 I - 16 22 38 14.3 Unrelated fever (PUO) 2 6 7 2 4 5 5 - I8 I3 31 II.7 Aches and pains - 6 3 I 5 3 4 9 I 14 23 8.6 Skin diseases 5 22-343 I 13 7 20 7.5 Eye/ENT 2 3 I 3 4 I 3 I IO 8 18 6.8 Injury and surgery I 2 4 I 2 - 3 3 IO 6 I6 6.0 Deficiency diseases l6--I331 5 IO IS 5.6 Gynaecological diseases - I - 4 - 6 - I - I2 I2 4.5 Urinary tract infection - _ I l---l I? 3 I.1 Joint pains/arthritis ---- 2__--2- 2 0.8 Other: - - - 4-3---7 7 2.6 Total 25 58 41 30 37 33 24 I8 127 139 266 100 % 30 70 58 42 53 47 57 43 48 52 I00


ent from the two other villages. Consultation of outside sources is, in Kaladi, like Banshari, highest among the l ’ and ‘KS households.

Tables 7, 8 and 9 give an impression of the morbidity pattern in the villagts. In Banshari, except for ‘C’ category households, women were suffering from considerably more illness episodes than the men, especially among the poorest. Out of the total number

of episodes about 65% occurred among the women. As the researchers in this village were female underreporting of gynaecological and obstetrical problems has probably been less than in the two other villages. There, respectively 52 and 60% of all episodes concerned women. In both villages the poorest households clearly showed the pattern that women suffered most from illnesses and ailments.

Health. disease and health care in rural Bangladesh

Table 9. Distribution of diseases according to sex and economic category in Kaladi

205 1

Diseases A B C D Total

MFMF’MFMFMF Grand total %.

Intestinal diseases Respiratory tract infection Deficiency diseases Skin diseases Aches and pains Joint pains/arthritis Eye/ENT Unrelated fever Gvnaecological diseases In&try and sur8ery Others Total %

- 9 4 7 7 5 4 2 15 23 22471-24 9 13

- 2--32--34 - 4--2-1337 - - - 2-2-2-6 - ll--l--l2

- I --- l- 3321321-96 _ - - - - I--- 1 - - 1 1 I 1 I I 3 3 I_---*---2- 6 21 I2 18 19 14 9 12 46 65

22 78 40 60 ‘58 42 43 57 41 59


38 34.2 22 19.8

7 6.3 IO 9.0 6 5.4 3 2.1 I 0.9

15 13.5 1 0.9 6 5.4 2 1.8

111 99.9 IO0

An extremely important question we tried to answer was: where do people go for treatment when they are ill. In Banshari, in 47 out of 99 illness- episodes, treatment was sought from outside sources, comprising a total of 74 visits. On the aggregate level it is clear that most visits (42%) concerned the unqualified allopaths, with the UFWC in next position and the kabirhj in third place. Among the poorest households, however, the picture is different. There, the UFWC and the government dispensary were frequented most. Together they covered 75% of all visits of people in ‘A’ category. In Patgram we see the same overall tendency: most visits out of a total of 280 regarded the unqualified allopaths (46%) while the UFWC stands second and the kabiraj third. Among the poorest the UFWC is the most frequented source, it is true. but the choice for government care sources is less pronounced here than in Banshari. In Kaladi village a slightly different overall picture emerges. Again, the unqualified allopaths score highest (even more than 507, out of a total of 130 visits), but here the government dispensary stands in second place, followed closely by both UFWC and kabiraj (both just over 1 I’?,,). To the poorest households the UFWC seems most important, however, while both government sources together account for 647; of all visits from ‘A’ category households.

The prominent position of the unqualified allopathic practitioners is a disturbing phenomenon, because, as we have seen, their practices are often harmful for health. Besides, it signifies the strength of allopathic medicine in the countryside of Bangladesh, which is to a large extent responsible for the fading of traditional medical systems [IS]. Another important piece of information is the relative importance of government health-care, especially to the poorest section of the rural population. Finally, we want to point at the lO-15% of the visits which concerned the knbiraj. Together with the high degree of application of home remedies which we found, it implies that folk medicine is still going strong.

The relative importance of various sources of health-care as calculated on the basis of visits does not, of course, tell us anything about the arguments which influence people’s choices nor about the path they follow in their search for adequate treatment. As to the arguments, it seems that consideration of relative costs, distance, trust in a particular practititioner, all have influence, as well as beliefs about the special qualities of medical systems. So, homeopathy appears to be preferred for children, folk medicine for female diseases and ‘bad air’ diseases, and allopathy for respiratory tract infections and dysentry. But this is clearly not a fixed rule. We also got a strong impres-

Table 10. Distribution of visits to different sources of health-care according to economic category (Banshari)

A B C D Total “/,

Unqualified allopathic practitioner 2 IO 7 I2 31 41.9 UFWC I1 4 3 5 23 31.1 &z;trhircrj 3 4 - 4 11 14.9 Govt. dispensary 4 1 - - 5 6.8 Qualified allopathic - - - - practitioner Hospital Homeopath Unknown - 1 - 3 4 5.4 Total 20 20 10 24 74 100.1

Source: Weekly surveillance of sixteen sample households

2052 ALL ASHRAF et al.

Table 1 I. Distribution of visits to different sources of health-care according to economic category (Patgram)

A B C D Total %

Unqualified allopathic practitioner UFWC Kahiraj Homeopath Qualified allopathic practitioner Zamanabad dispensary Hospital Family Welfare Worker Unknown Total

15 37 51 27 130 46.4 23 21 10 2 56 20.0 13.6 4 5 28 10.0 7 2 11 1 21 7.5

- 2 9 5 16 5.7 4 4 1 2 13 4.6 2 5 3 2 I2 4.3

I I 0.4 12-- 3 1.0

65 81 89 45 280 99.9


sion that there is a trend to start with a home-remedy, after which people may keep shifting from one system of health-care to another, changing practitioners on the way, until some relief is achieved. During this process advice given by neighbours and relatives plays an influential role. In fact, decisions on the road to health are the outcome of an ad-hoc process of weighing many different factors and it is virtually impossible to generalize about the routes they take. Some things are clear, however. Improvement of an acute condition is defined as cure and treatment is discontinued as soon as that level is achieved. Further, death is always seen as an act of God and no one can interfere with it. As a result practitioners are never blamed, even if death occurs due to grossly wrong treatment. They will be thought right as long as they have expressed their great concern and interest in the patient.

CONCLUSION

Provision of basic health services in the countryside, as the government of Bangladesh is trying to accomplish at present, should be planned and evalu- ated against the background of health behaviour, morbidity patterns, and existing sources of health- care. Besides, it should always be born in mind that these conditions are not static but changing. Also it is important to differentiate between behaviour, needs and possibilities of rich and poor peasants. The

present study was meant to provide some information about these issues, based on fieldwork in three villages of Tangail district.

The main conclusuons of the study can be summar- ized as follows. First, it was evident that the two traditional medical systems, Unani and Ayurveda, had all but disappeared in the study area. Though this region may not be representative for the whole of Bangladesh, this finding may well signify that in other areas traditional systems of medicine are, at least, on the way out. One reason for this is probably the exodus of Hindus from the country in 1947 and 1971, but this, of course, only holds in the case of Ayurveda. Another reason is the government’s neglect to support the traditional systems and their institutions. How- ever, most decisive has probably been the advance of allopathic medicine into all nooks and corners of the countryside. This fact is most clearly expressed in the powerful position of the unqualified allopathic practitioners. On the aggregate level these were found to be the most often consulted outside source of health- care. If we break the rural population down into various economic categories, the poor appear to opt first for the services of government sources, which are provided free of cost. Unknowingly, in this way they make a wise decision, because the treatment of unqualified allopaths is such that harmful effects on health are quite possible. Folk medicine, in various forms, is still strong in the countryside. It has, in fact, very much its own realm in those ailments where

Table 12. Distribution of visits to different sources of health-care according to economic category (Kaladi)

A B C D Total %

Unqualified allopathic practitioner Zamanabad dispensary UFWC Kahiruj Hospital Homeopath Qualified allopathic practitioner Family Welfare Worker Total

6 18 29 14 67 51.5 9 2 2 5 18 13.8

12 3 - - 15 11.5 6 I

: 1 15 11.5

- 4 8 6.2 - 2 1 I 3 2.3 - 1 1 - 2 1.5 -

37 f 2 1.5

33 26 130 99.8



Western medicine is not, or is thought not to be effective [19]. Finally. though the new source of public health-care in the countryside, the UFWCs. have a great potential for reaching especially poor villagers, the two facilities of this kind which we studied were found not to be functioning smoothly at all. And unless improvements are implemented in due course, credibility may be damaged to the extent that the potential vanishes.

AS we have pointed out in the beginning of this article, the study had an applied angle and was meant to bring forth some recommendations. Their content was as follows. First, we pressed that bonds should be set to the activities of the unqualified allopathic practitioners. This could be done in two ways. There is a need for a policy of registering the practitioners on the basis of certain medical qualifications; only those who have this qualification and are registered should be allowed to practice. In this context short courses for upgrading practitioners have, of course, to be included. Besides. the government has to control availability and free sale of drugs to a much larger extent. Only essential medicines (e.g. the government planned and WHO recommended list of 31 medicines) should be available at the village level, at strictly controlled prices. Second. we recommended that the government financially support the training of Ayurvedic and Unani physicians, as well as stimulate research in the field of traditional medicine. If such a policy is to have any real impact, it has, of course, to be com- bined with the restrictive measures regarding allopathic medicine outlined above. Third, we advised to seriously look into the valuable elements of folk medical practices, These elements should be identified, standardized and incorporated in primary health care services. Finally. we pointed out that for improvement of the functioning of the UFWCs the following measures are absolutely essential. Full staffing and adequate medicine supply of operational centers; more emphasis on the motivation of applicants when selecting personnel : more practical and appropriate training of personnel.

We also made it clear that these recommendations are. in fact. second best. For us the main outcome of the study was the need for an integrated and compre- hensive approach to improving health in rural Bang- ladesh. Such a policy could only be a drastic one and should be directed at the eradication of poverty as this is the root of much illness and stands in the way of preventive measures. Besides. there is the need for more control of health care facilities by a rural pop- lation which has been educated and organized to do so. Obviously. under the prevailing conditions in Bangladesh these far-reaching recommendations would stand no chance at all. Even implementation of the second best measures we advocated will probably be very difficult.

REFERENCES

I. The rhcrmr is an administrative unit comprising approx. 250.000 inhabitants. The artion has about 20.000 population and is run by an elected body under the Union Chairman. Several government programmes have officials at the union level. A thana health complex com-

7.

8. 9.

10.

II.

prises a 31 bed hospital, an outpatients department and some mobile staff, with tasks in the fields of en- vironmental sanitation and communicable diseases control. The two most important staff members at the UFWC are the medical assistant. who is in charge, and the family welfare visitor, whose task is to deliver mother and child care and family planning services. On paper the services of the two health facilities (THC and UFWC) are integrated and complementary; reality is, however, quite different. At present 18 training centres are operational. The obiective is to have one in each of the 20 districts. The training takes 3 years, one of which is a field training in a UFWC. Since 1980 there is a rule that half of the candidates should be recruited from among service holders, e.g. family welfare visitors and sanitary inspec- tors. See Streefland P. Medic&Sociological Research iti Bangladesh. mimeo, Amsterdam, 1979. The most important innovative medical projects in Bangladesh are the Companiganj Health Project in Noakhali District. Gonoshastaya Kendra (GK) in Dacca District, and the Bangladesh Rural Advance- ment Committee (BRAC) in Sylhet District. Further information can be found in the following publications: Evaluation Unit Reports on the Compunigunj Health Project. Christian Commission for Develop- ment in Bangladesh (CCDB). Dacca, 1980. Briscoe ‘J. Are voluntary agencies helping to improve health in Bangladesh? Int. J. Hlth Serv. 10, 1980. Ahmed M. The Savar Project: Meeting the Rural Health Crisis in Bangladesh. In Meeting the Basic Needs of the Rural Poor (Edited by Coombs P. H.), pp. 42-103. New York, 1980. Ahmed M. BRAC: Building Human Infra- structures to Serve the Rural Poor. op. cit. pp. 3622469, 1980. See in this respect the following publications: Arens I. and van Beurden J. Jhagrapur: Poor Peasants and Women iri a I/i/laye ia Bangladesh. Amsterdam, 1977. Hartmann B. and Boyce J. Needless Hunger: Voices from a Bangladesh Village. San Francisco, 1979. van Schendel W. Peasant Mobility: The Odds qf Life in Rural Bangladesh. Assen The Netherlands. I98 1. The research team consisted of the following members: Shafiq Chowdhury (research director); Ali Ashraf (senior researcher); Abdul Hai Khan (researcher); Nur Nabi (steno-typist); Miss Jannat-e-Quanine (researcher); Miss Saskia Delmonte (researcher): Pieter Streefland (research advisor). In June 1981 the Royal Netherlands Embassy in Dacca published the final report on our study under the title “Health, Disease. Care and Cure in Rural Bangladesh”. A short time after the completion of the study Miss Saskia Del- monte died in Dacca. Her sudden death came as a terrible shock to the other team members, who knew her as a dedicated researcher. a great colleague and a very good friend. In our research design we stated three conditions for an operational UFWC: (I) it should have the latest provision of physical facilities like buildings. furniture. etc.; (2) it should be properly equipped with medical and sureical reauisites: (3) it should have a Medical Assistan; and a’ Family Welfare Visitor working and residing there. van Schendel W. op. cit. p. 90. 91. Whether the various explanations together constitute a single cultural system of disease etiology and cure can only be answered when more in-depth research has been done. Information on the Ayurvedic and Unani traditional medical svstems can be found in Leslie C. (Ed.1 .4.5im Medical systems. Berkeley. 1977. ‘Unqualified allopathic practitioners‘ are those private


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practitioners who are practicing allopathic medicine but do not have a formal medical degree. The term ‘unqualified’ is only used here in order to differentiate 17. among private practitioners and is as such not meant in a negative sense. For background information on the position of homeopathy on the sub-continent and on the promi- 18. nent place of Bengal as the “domicile of homeopathic profession through the latter part of the last century”. see: Bhardwaj S. M. Homeopathy in India. In The Social and Cultural Context of Medicine in India New Delhi. 1981 (Edited by Gupta G. R.), pp. 31-55. We heard that in other areas of Bangladesh the term ojha is also used for a snake-poison remover. Both things, asking for money and running a private practice, are against the rules. The quintessence of the purda-system-which exist in many different grades of strictness-is limitation of contact between the sexes; it entails the subordination of women. At its most rigorous purda virtually confines women to concealment at home. An important structural impediment for the realization of high quality public health-care in the country-side is 19. the division of the Ministry of Health into a Family Planning Department and a Health Department, each with its own funds and responsibilities. See for interesting observations in this respect Gish 0. Health and

family planning services in Bangladesh: a study in in- equality. lilt. J. H/t/l Serc. Il. 198 I. US% = 19-21 Taka. depending on the exchange rate. Women receive more money than men. because their operation is more serious and they are unable to work for a longer time. It will be clear from our remarks on the practices of the private allopathic practitioners that our view of their activities, their position in rural society and their potential is quite different from that of Pierre Claquin. who is. in fact. rather positive about them. Probably his view can be understood if we keep in mind that his conclusions are based on a study of the survey-type. which is a much more superficial kind of research than what we have tried to do and which can. of course, also be improved on. Besides, given the nature of the study on which Claquin bases his article and the fact that the local term kabiraj is used for various types of village practitioners, the reliability of the distributional figures he gives seems to be rather questionable. See Claquin P. Private health care providers in rural Bang- ladesh. Sot. Sci. Med. 15B. 153-157. 1981. A recent study of a village in Tamil Nadu. Indta. reaches the same conclusion. See Djurfeldt G. and Lindberg S. Pills Against Povrrry; A Study of the Intro- duction of Western Medicine in a Tarnil Village. Lon- don, 1975.

health, disease and health-care in rural bangladesh

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