«Misfortune is great, but man is greater than his misfortune.» – Rabindranath Tagore, Bengali poet.
In 1970, the Western world received devastating news: The Beatles were breaking up for good. While the European and American public, still in disbelief, tried to recover from such a catastrophe, in November of that same year another event also made an impact: The most devastating tropical cyclone in human history left half a million dead in the Bay of Bengal.
Reaching speeds of 250 km/h, the Bhola disaster had destroyed entire regions, with the majority of victims being young children who couldn’t seek shelter in time from the tidal wave. The stories were documented by war correspondents who couldn’t believe their eyes.
In addition to the horror, this disaster couldn’t have been more untimely.
The growing identity of East Pakistan, now Bangladesh, is considered one of the main causes of the indifference of the central government of West Pakistan. This intentional abandonment further fueled the independence sentiment, leading to the Bangladesh Liberation War months later. After another thirty thousand deaths, the worst was yet to come. The military conflict and violent separation led to the 1971 Bengali genocide perpetrated by Pakistani forces that included systematic rape and targeted killings of scientists and intellectuals. The result of this madness was another half a million deaths in what was the first genocide since the Nazi dementia.
The developed world remained silent and looked the other way, with the brave exception of Archer Blood, the U.S. consul general in Bangladesh, who sent the following message to Washington on April 6, 1971:
“Our government has not denounced the atrocities… Our government has evidenced what many will consider moral bankruptcy.»
Thus, in this bloody birth, Bangladesh was born, the young nation that Henry Kissinger called «a lost cause now and forever.»
Fazle Hasan Abed witnessed the catastrophe of the Bhola cyclone and had to leave Bangladesh during the 1971 war. After the end of the armed conflict, he decided to return from the United Kingdom and instead of continuing with his comfortable position in finance at the Shell oil company, he developed a recovery plan for the devastated country. With money obtained from European donors, he founded BRAC (Bangladesh Rural Advancement Committee) in the Sunamganj district with the aim of allowing the return of war refugees. Building shelters appeared as a direct and apparently suitable strategy, however, it was clear to the organizers that building buildings did not mean building communities.
Development had to come from the people themselves to be sustainable and effective. Following this philosophy, community members were in charge of their own progress, not only building infrastructure but also integrating small industries such as fishing for their own sustenance. The strategy was a resounding success and it was evident that they could be more ambitious. In 1977, BRAC stopped the rhetoric and got to work on health. Inspired by the Chinese barefoot doctors, it revolutionarily adapted the strategy to be based on female community volunteerism. The Shasthya Shebika health worker program had the face of a Bangladeshi woman who was in charge of promoting health and treating common diseases as well as serving as a link with the government health system if required. In a process of continuous learning and strict evaluation, the Shasthya Shebika program demonstrated its invaluable contribution to community health. Starting with the treatment of diarrheal diseases in children, its role expanded to include birth control, registration of health indicators, among others, within the framework of health prevention. Its greatest importance was being the direct voice of the needs of the villages and at the same time, its main actor in development.
The results made a few dozen volunteers become over 100,000 Shasthya Shebikas who make 18 million home visits per month, serving 100 million people in Bangladesh. The numbers themselves are a public health feat, but their successes are even more impressive. In crucial indices such as completion of treatment for tuberculosis, villages with the Shasthya Shebika program have the highest success rates in the world, reducing the prevalence of tuberculosis by half compared to those places without this intervention. In the 1990s, places where BRAC was present were the only ones with universal immunization coverage, in addition to having the highest rate of oral rehydration therapy utilization in the world in case of diarrheal diseases. Bangladesh was one of the few underdeveloped countries in the world that not only met the Millennium Development Goals set for reducing infant mortality by 2015 by the World Health Organization but did so five years earlier.
BRAC is currently the world’s largest non-governmental organization, ranking high in transparency and effectiveness. Its community interventions have shown greater poverty reduction in Bangladesh compared to other government interventions. One indicator that is sometimes overlooked but expresses the advantage of the community approach is that BRAC’s interventions have improved school performance in both boys and girls. For girls, this strategy has allowed them to have twice the opportunities to continue their education since 1995 compared to places with standard interventions. The model has been exported to Afghanistan, Sri Lanka, Pakistan, the Philippines, Nepal, Myanmar, Uganda, Tanzania, Sudan, Liberia, Sierra Leone, and Haiti with different results, some of them not encouraging. Aware that the learning process is long, there is no dismay in the face of failure, but rather the feeling that continuous work has an achievable goal.
The Declaration of Alma Ata was accused of being utopian and futile, ominously marking its birth. On the other hand, the Concert for Bangladesh organized by George Harrison in 1971 in response to the atrocities of war and natural disasters was received with optimism and media attention. Part of the Beatles, along with Bob Dylan and Eric Clapton, gathered at a time when music was not a mass consumption instrument but a countercultural manifestation. The proceeds were donated to the United Nations, and amid criticism, the event became another example of good intentions without achieving real change.»
The community strategy of BRAC shows us that there are success stories that can serve as the true return to the community that Alma Ata proposed. It also tells us that plans must be based on the particular situation of the population, but that community empowerment is a crucial tool. While not ignoring the shortcomings of BRAC (which is very selective to meet Alma Ata’s ideals), it is a starting point for much-needed comprehensive healthcare. If we want a true return to the soul of Primary Care, the challenge is not to allow the community to be ignored by medical or governmental clientelism. It is necessary to remember Carl Taylor, one of the architects behind the Alma Ata Declaration, who stated:
«There are no universal solutions, but there is a universal process of finding solutions.»
El Alma de la Atención Primaria 