Dr. Mohammed Abdul Bari, one of Bangladesh's eighty-six pediatricians trying to serve over fifty million children, has demonstrated how organized mothers can fill much of the health care gap themselves and how to pull the largely unused resources of the government's health system in to help them.
Dr. Bari and his nine siblings grew up in the remote backward area of coastal Patuakhali. He saw very directly what almost nonexistent public health and/or curative services there meant. While still a student at medical school, Dr. Bari assisted the only doctor in a war zone clinic during the Liberation War of 1971. Even then he knew his interests and mission required a broader understanding. After graduation from medical school, Dr. Bari decided to study the social sciences. Accordingly, he enrolled in evening classes and earned a B.A., majoring in economics, philosophy and advanced languages. Later, he devoted himself to psychological medicine during an eighteen-month residency at the only postgraduate intern hospital in Dhaka. In 1985, he earned a postgraduate degree in child health care and became a pediatrician. Early in his professional career, he worked as a physician in several countries of the Middle East. After thus helping his younger siblings pay for their education, he volunteered with the United Nations and was put in charge of an eighty-bed child casualty hospital in the Kampuchean refugee camps. Here he experienced the unecessary suffering and often the death of children caused by adult incompetence or indifference. Since he returned to Bangladesh, Dr. Bari has been committed to overcoming that sort of avoidable suffering and lost potential for millions of young Bangladeshis.
Dr. Bari was born in Patuakhali, part of the coastal belt in southern Bangladesh. One of the most backward areas even by Third World standards, Patuakhali is regularly lashed with cyclones and tidal waves. Transportation and communications facilities are rudimentary, turning a simple six-mile journey into an odyssean task. Dr. Bari grew up accepting as inevitable the squalor and illiteracy that make people, especially children, victims of one avoidable disease after another. Later, when he started medical school at the age of eighteen, he was appalled to realize how much of the suffering was preventable. Unfortunately, as time passed, the situation worsened. The population swelled and nutritional and health problems increased, especially among children. Dr. Bari was shaken to realize that there were few child specialists in the country--a total of seventy-six in 1988 for a juvenile population of nearly fifty million. In his region, he was the first. He knew that to provide more than token help, he would have to find very new ways of practicing medicine. For the foreseeable future, doctors could not do the job alone. What other human resources could be brought to bear? The most obvious possibility was the mothers. He knew how much they cared and how closely they watched their children. When he sought to find out when a child had last urinated (a key question in judging the risk in a diarrhea dehydration case), the mothers alone knew. Over the last five years he has experimented, and now has a powerful local organization of 10,000 local mothers who come together in local groups weekly to discuss health issues and to organize a range of support activities. They are also an organized pressure group that is beginning to hold the formal medical system accountable, notably by demanding government doctors get out of their comfortable central office and get out to the villages. Dr. Bari knows that such pressure alone will not suffice to draw in these doctors: he has got to create a new structure attractive to the doctors. Toward this end, he has persuaded the mothers to pay fifteen taka per patient visit, thus cumulatively adding roughly 3,000 taka to a doctor's monthly salary ($750). To further modify the economics facing these doctors, he has pressed for them to be provided with speedboats, a step that avoids days and revenues being lost in transit. In addition to this and changing the incentives, Dr. Bari has worked skillfully to win the support of the district's senior-most public officer. It has not quite happened yet, but Dr. Bari hopes eventually that one doctor after another at the government health post will begin to go out and serve the villages and that this will become their new group professional norm. Since most of the country's medical capacity is tied up in the government's health system, one that barely reaches the majority, connecting this resource with organized client groups in the villages could, if sustained and spread, have enormous impact. Dr. Bari is now making the transition from developing this model in Patuakhali, even though it still needs further maturing there, to thinking through and beginning the work of changing the national health care system so that it will finally reach the children who need it. He wants to spread the Patuakhali model, with mothers taking charge and thinking through and solving their own problems together and then winning over effective support from the local doctors. Second, he knows he has to train and motivate both the current local doctors and those now coming up in medical school. They must be committed and able to serve the country's tens of millions of children. The Patuakhale model gets at the underlying economic incentives and helps to create an educated group of clients able to carry through once the doctor is gone. For all this work, however, the doctors need to know how to care for children and, more particularly, for the children faced with Bangladesh's health realities, not those of Paris or New York. He hopes to produce over a dozen videos to help bring the current generation of general practitioners up to a good level of competence, self-confidence, and interest. He also wants to initiate reforms in the medical schools. Specifically, he wants to cut one year off the too theoretical course in order to beef up more practical clinical training. He also wants to build a strong child care element into the curriculum with the further goal of ensuring that half the medical graduates will be well equipped to handle the real daily problems that arise in child health care.
The enormity of the problem of mother and child health care in Bangladesh can be fathomed by looking at some basic facts about the country. The population of 113 million lives in an area of 143,998 square kilometers. Children make up approximately fifty percent of the population. Less than twenty-nine percent of the people are literate; only sixteen percent of the women can read or write. Out of a thousand live births, 106 infants die, and sixty percent of the children between the ages of three and four are moderately to severely malnourished. Over 40,000 children become blind due to vitamin deficiency, and ninety to ninety-eight percent of the population is infected with parasites. More than 300,000 people a year die from diarrhea. There are 6,168 people per doctor, 376,666 children per pediatrician, and 152,550 women per obstetrician. Medical school curricula in Bangladesh still follow traditional Western models, which do not cater to the specific problems of the developing world. For example, few deaths result from malnutrition, infectious diseases, and diarrhea in the West, while these problems kill thousands of children in Bangladesh every year. The medical curriculum must be revised to address these pressing local issues. On paper the government has a broad-reaching, moderately acceptable health delivery service system, but in reality the system is poorly managed and dispirited, and suffers from a lack of accountability among health workers. Government doctors generally earn most of their income from their private practices. As a result, only about one-tenth of the population, concentrated in urban areas, benefits from modern health services. Finally, the rural people themselves are unaware of their rights to basic health care. They are illiterate, steeped in traditional beliefs and practices, and deprived of access to clinics due to the poor transportation system. Only the earning members of the family may declare someone ill and in need of medical attention. Most people die without seeing a doctor.
Although Dr. Bari has formulated a far-reaching action plan, he is aware of the deep roots of the problem and the constraints within which he must work. Therefore, his present task has been to focus on his target clientele, the women and children. Dr. Bari chose Mirzagonj, a remote, underdeveloped, underprivileged area in Patuakhali District, to put his first idea, awareness building, into action. Although Mirzagonj is only 300 miles from the capital, it takes about twenty hours to reach this area. Covering an area of about 200 square kilometers, with a population of 150,000, Mirzagonj is largely inundated with water half the year. There is a government health complex offering basic services, but it takes two to eight hours to reach it. Even with the almost constant heavy rains, there is a dearth of safe drinking water. There are serious outbreaks of diarrhea at least twice a year, each habitually claiming many lives. After receiving his postgraduate degree in pediatrics, Dr. Bari started in earnest to improve the maternal and child health situation in this area. He has won key, active support from a religious school leader, a member of a locally leading family, and a female lawyer. With the concept "teach a mother and you teach the child" in mind, Dr. Bari started off by organizing Mothers' Clubs, groups of fifteen to thirty mothers who were given health and sanitation information as well as nonformal education that in part would correct some traditional beliefs and practices. The focus of the health care is on prevention rather that on cure, as most of the common illness can be avoided with proper knowledge and attention. The members meet weekly to discuss problems and to try to find solutions to them. Trained health workers and sometimes a doctor attend the meetings and facilitate their learning. This problem-solving experience and information helps the members develop their problem-solving skills. This first phase of Dr. Bari's work has, after five years, produced a number of encouraging results. The infant mortality rate has dropped from 138 to sixty-seven deaths per 1,000 live births, night blindness has been completely eradicated, and diarrhea has been well controlled. Now, 9,116 mothers in 462 Mothers' Clubs can sign their names. The members' accumulated savings of one taka a day now exceeds 800,000 taka ($25,000). This money is used as a revolving fund for the members' benefit. They have set up local "Fair Price Shops," which sell simple medicines, basic stationery for school, and nonperishable food items. In an emergency, a mother with a health card may buy what she needs on credit, repaying by putting two taka instead of one into the daily savings pool. Bari intends to replicate this successful pilot project in other areas of Bangladesh. Second, Dr. Bari has been working on several different planes to change the norms of the doctors in the district, to free them from the government center and their nearby private offices and get them out to the villages to work with the mothers. The government has now agreed that one doctor will visit the area every day. This is the first time in rural Bangladesh when a registered public doctor has been so dispatched. It is a precedent that should help people and communities in neighboring areas become more aware of the facilities the state has, not to mention the idea that they have a right to access them. Thirdly, Dr. Bari is planning to tackle his plan of training present practitioners whose knowledge of pediatrics is inadequate. He hopes to initiate training workshops and develop a series of video learning materials for them this year. He will draw on the help of other child specialists in doing so. Finally he plans to begin building support for the reforms of the medical curriculum he seeks through seminars, workshops, and discussion groups. He has approached government circles and members of the Bangladesh Pediatric Association, and their responses have been encouraging. He is also lobbying with the Ministry of Health.