Preface to Essential Drugs for the Poor
Essential Drugs for the Poor. The Makings of a Successful Health Strategy. Lessons from Bangladesh
Zed Press, London, 1995
I went to Bangladesh for the first and only time in 1982 and have stayed in rather tenuous touch with Dr. Zafrullah Chowdhury since. He is the pioneer of village 'barefoot doctor'-type health care and with his trained doctors and paramedics has done wonders, particularly for poor rural women in the Savar District. When he decided to build a pharmaceuticals factory to escape dependency on transnational corporate suppliers, the reactions were predictable. He tells that story, both harrowing and heroic, in the book, published by Zed Press in 1995, to which this piece is the preface.
Achieving anything simple is always complicated. It's usually exhausting, sometimes heroic as well. Essential Drugs for the Poor provides an excellent case in point. At first blush, one might assume that the provision of safe, effective, low-cost medicines to the population would rank high among any nation's health priorities and enjoy the favour of the authorities of Bangladesh or anywhere else. One would be wrong.
It's not enough that the most effective essential drugs have been repeatedly identified nor that the technology to produce them efficiently and cheaply exists; it doesn't even matter that the financial savings to the nation would be huge and countless lives could be saved. The country as a whole would benefit immensely, yes, but - here the tale becomes drearily familiar - when Transnational Corporations and cosseted professional interests risk the merest loss, then prepare for the energy-draining, nerve-fraying, patience-of-a-saint-trying long haul.
While Zafrullah Chowdhury's patience has surely been tried, he would just as surely resist anyone's attempting to thrust a halo upon him. Perhaps he will, however, let it be said that he has maintained his energy and kept his nerve in the face of obstacles as devious in their underhandedness as they have been baroque in their complexity. This book chronicles a long, as-yet-unfinished struggle to design a rational drugs policy for his country.
The first part of Essential Drugs for the Poor is just the sort of summary needed by non-specialists in order to bring them up to speed. If, like me, you knew that the worldwide health and pharmaceuticals situation is bad but you weren't sure how bad, you will be enlightened, if that's the word. The drug scene (the legal drug scene, that is) is nothing short of scandalous, even in the presumably law-abiding, antiseptic and carefully regulated societies of the North. Though the message of this chapter is not, perhaps, a Dantesque placard bidding us Abandon Hope, we should still recognise the exorbitant privileges already forfeited to the TNCs and the difficulties of clawing them back.
In the so-called third world - this vast realm of the under-regulated and the over-exploited, the sway of the drug companies is virtually beyond belief. As becomes abundantly clear in these pages, they will do whatever it takes to make sure it remains so. No country is too poor, no market too insignificant: the pharmaceuticals giants defend their interests on every front, against all comers.
Part of Chowdhury's description of these manoeuvres may strike some readers as overly detailed: it did me, at first, but then I recognised that I should beware of this initial reaction. His careful rendering of the intricate machinations of the interests aligned against any reasonable outcome of a National Drugs Policy is a primer for the forgetful: only transpose, and you will see in his text the names of your own local potentates, in full cry against the humane or the rational.
Do not presume, then, that because you are not a Bangladeshi, you have no need to know what this Minister or national Commission did when; how the press reacted, informed or pressured by interest X or Y, under such or such conditions and circumstances. Chowdury's narrative stands for every country; the pages you may be tempted to skip concern every patriot who intends to try, now or in future, to buck the system and to put the people's interests before those of the venal and the powerful; to prefer the lives of his compatriots to the profits of strangers.
The devil, they say, is in the details, and so is international capitalism. We can only understand the mechanics of its relentless drive for profits when given, as we are given here, chapter and verse of its incredible will to prevent a useful, benevolent allocation of a poor country's meagre resources. These must not, at all costs, be mobilised in the service of the poor.
Chowdhury doesn't leave anyone out; no one escapes from these pages unscathed: neither the American Ambassador as leader of the storm-troopers defending the turf of the TNCS, nor the traditional rip-off artists practising spurious and lucrative versions of 'Ayurvedic' medicine on the backs of poor and illiterate people. Doctors are not spared, though some may be simply innocent victims themselves. They get no training whatsoever in the economics of the drug trade, and are constantly plied by the companies with a plethora of juicy inducements in many forms: free travel, stipends, gifts, opportunities for publication, for which the encompassing word is bribes.
Most members of the medical professions are willing middle-men and women for drug companies whose attitude can be summarised as 'what they don't know won't hurt them' - although it may be devastating for their patients. The World Health Organisation - which should be the international refuge of the virtuous - hasn't helped, or not much, and has sometimes harmed. Et tu, WHO, which must also look to its bottom line and avoid offense to its top contributors, the United States first among them.
Let me now, at the end, declare an interest. It happens that, at the invitation of Zafrullah Chowdhury, I made my first and only visit to Bangladesh to participate in a conference on 'Transfer of Technology' at his Savar Centre and visit the resplendent new GK pharmaceuticals factory at its official consecration in January 1982. I had the opportunity to witness some of the aspects of an alternative health policy at first hand, following, for example, one itinerant Savar health worker in her daily rounds, including a tubal ligature performed under perfectly hygienic conditions in a simple village clinic on a woman who had borne all the children she wanted.
I also witnessed, from a distance, a pitched battle between the hired thugs of local landowners - on whom it had suddenly dawned that the land they had ceded to GK was actually worth something - and the staff of the Savar Centre. I wasn't there, but I wasn't surprised either when the arson attempt was made on the pharmaceuticals plant. I'm afraid Chowdhury describes the courage and heroism of the staff (not to mention his own), many of whom were wounded defending the factory, far too briefly and modestly here. This may be because physical and political violence is the daily bread of the health professionals trying to institute another kind of care; just as it is the lot of those trying to inscribe an alternative drug policy in the national statute books.
Depressing reading, this book? Yes and no. Considering the odds, a tremendous amount has been accomplished. Sisyphus's boulder must ever be pushed up the mountain, but still, it seems slowly to be wearing a groove to the summit. Chowdhury knows as much as anyone about this unending, upward push. His book told me once more what I know to be true, but of which, like most of us, I must be constantly reminded. Decent people (and I count myself self-indulgently among them) sometimes simply cannot grasp the lengths to which corporations and those who support them are prepared to go in the pursuit of power and profit. Study this exceptionally fertile case. It will stand you in good stead when you struggle for simple justice in the field of health or any other, wherever you may live.