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Broken limbs, broken lives: Ethnography of a hospital ward in Bangladesh

Zaman, S.

Publication date
2003

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Citation for published version (APA):

Zaman, S. (2003). Broken limbs, broken lives: Ethnography of a hospital ward in Bangladesh.
[Thesis, fully internal, Universiteit van Amsterdam].

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Download date:22 Jan 2024
 Chapterr III

BANGLADESH:: A LAND OF HOPE AND DESPAIR

Thee worldfrequentlyreceives bad news about Bangladesh. However, a land of heroic
accomplishmentss and rich culture hides behind the images of cyclones, floods and
famine.. By briefly discussing the political history, society, health, education and
economicss of Bangladesh, this chapter touches on some of Bangladesh's
accomplishmentss as well as obstacles to achieving further undertakings2.

Politicall history
EarlyEarly history

Travellers,, conquerors, missionaries, princely rulers and peasants wrote the earliest
accountss of Bengalis. To Ibne Batuta, a fourteenth century traveller from Africa,
Bengall was a 'hall full of bounties and wealthiest and cheapest land of the world'. The
seventeenthh century French physician and traveller Bernier was so charmed by Bengal
thatt he wrote, 'Bengal has a hundred gates open for entrance but not one for departure'.
Bengalis'' forefathers were Aryan, Dravidian, West Asian, Tibetan and
Burmese.. This rich ethnic background is partially the result of the geographic location
off Bangladesh; Bengalis live on the periphery of Indian and Chinese cultures. Their
homee on the rich soil and well-watered plains of the Ganges and Brahmaputra enabled
ann agrarian existence.
Originally,, Bengalis were Buddhist and Hindu, but in the twelfth century,
Muslimm soldiers and Sufi missionaries from West Asia converted most of them to
Islam.. The pious Sufis found their greatest response among the Untouchables, who
weree generally ostracisedfromthe Hindu caste system.
Withh the coming of Mogul Emperor Akhbar to the Delhi throne in the
sixteenthh century, Bengal became part of the Mogul Empire until the British took over
severall hundred years later. Bengal, which was a peaceful and prosperous kingdom,
contributedd to the stability of the Mogul throne.
Thee European interest in Bengal began with the Portuguese who, during the
lastt quarter of the fifteenth century, established trading posts and Christian missions.
Theyy were soon displaced by the Dutch East India Company, which established indigo
plantationss on the shore of the Bengali Ganges. Bangladesh was also known in the
Westt for its Muslin, which was considered the finest fabric the world has ever
produced.. At the end of seventeenth century the British secured themselves in Calcutta,
byy that time Bengal's largest, most important city. With the nearly concomitant decline

2
Sources:: Ashraf, Chowdhury & Streefland 1982, Heitzman & Worden 1989, Streefland &
Chowdhuryy 1990, Novak 1993, Van Schendel 1995, Alam 1995, Grieve 1995, Baxter 1997,
Howladerr 1997, Khondker 1997, Ahmed 1997, Ahmed & Chowdhury 1999, UN Report 2000,
Perryy 2000, MOHFW 2001, Jahan 2002, Anisuzzaman 2002, Van Schendel 2002, Abdullah
2002,, Khan 2002, http://sanisoft.tripodxom/bdeshedu/introduction.html accessed on 12/02/03.
Basicc information with political map of Bangladesh and Indian Subcontinent is provided in
Annexx 1.

33 3
off Mogul power, the British East India Company effectively became the ruler of
easternn India. The British hold on Bengal was confirmed when the British defeated the
locall ruler in Bengal at Plassy, a few miles north of Calcutta, in 1757. From that time
onn the British extended their rule to all of India.

BritishBritish period

Inn 1857, Indian soldiers of the British Indian Army, drawn mostly from Muslim units
fromfrom Bengal, mutinied at the Meerat cantonment near Delhi, starting a yearlong
insurrectionn against the British. The mutineers then marched to Delhi and offered their
servicess to the Mogul emperor, whose predecessors had suffered an ignoble defeat 100
yearss earlier at Plassy. The 1857 uprising seriously threatened British rule in India.
Whenn mutinous units finally surrendered one year later, in 1858, the British exiled the
Mogull Emperor to Burma, thereby formally ending the Mogul Empire. As a direct
consequencee of the revolt, the British also dissolved the British East India Company
andd assumed direct rule over India. British India was thereafter headed by a governor
general.. The transfer of the control from East India Company to the British crown
acceleratedd the pace of development in India and greatly altered political conditions
withinn the subcontinent.
Inn education, commerce and government services, the Muslims of India lagged
behindd the Hindus, who more quickly adapted themselves to rapidly changing socio-
economicc conditions. Moreover, after the mutiny, the British favoured Hindus, as the
mutineerss were mostly Muslim soldiers. Furthermore, during British rule in India, most
industryy was Hindu owned and operated. Access to land by the Muslim population was
alsoo limited due to the Land Lease Act of Lord Cornwallis in 1793. Under the new
system,, the revenue collecting rights were often auctioned to the highest bidders,
whetherr or not they had any knowledge of rural conditions or agriculture. Thus,
agriculturee became a matter of speculation among urbanfinanciers,who were mostly
Hindu.. The traditional personal link between resident Zaminders (landlords) and the
peasantss was broken. To poor peasant Muslim tenants, the Hindu landlord, merchant
andd moneylender, often combined in a single person, became an object of fear and
resentment.. As a result, as the prospect of independence from British rule grew, the
majorityy of Muslims desired a complete breakfromIndia with its Hindu majority.
Twoo major political parties in undivided India came to represent the movement
forr independence from British rule: the Indian National Congress and the Muslim
League.. The Indian National Congress, formed in 1885, which was initially broadly
basedd with many influential Muslim leaders, finally came to reflect the aspirations of
thee Hindu majority in the country. The Muslim League, founded in 1906, was
essentiallyy a political party to protect the interests of Indian Muslims. It was within
thesee two parties that the alternative schemes for structuring an independent India were
argued. .
Ultimatelyy two independent states were created in 1947, India and Pakistan,
endingg nearly 200 years of British colonial rule. Because Bengal's western portion is
mostlyy Hindu, when the British left it chose to remain part of India, which is also
predominantlyy Hindu. Today it is called West Bengal state, whose capital is Kolkata
(Calcutta).. East Bengal, with a largely Muslim population, voted to become part of the
newlyy formed Pakistan, whose people were mostly Muslim. Pakistan's two halves,
Westt and East Pakistan, were divided by eleven hundred miles of India. After the

34 4
partition,, a large portion of the Hindu population of the then East Pakistan migrated to
India.. In East Pakistan the Hindu population dwindled from 28% in 1941, to 18.5% in
1961.. The India- Pakistan partition also resulted several religious communal riots.

PakistaniPakistani period

Beginningg in August 1947, the Bengalis in East Pakistan were ruled by West
Pakistaniss based in Pakistan's capital, Karachi, even though Bengalis were the
majorityy in all of Pakistan. Though the Pakistanis were Muslim, they were not of
Bengalii ethnic origin but were instead Punjabis, Pathans, Sindhis and Beluchis. West
Pakistaniss dominated Bengalis in all political, economic and cultural spheres of life.
Bengaliss were not even allowed to use their native Bangla language, but were forced to
learnn Urdu, the language of the West Pakistani elite that had been chosen as Pakistan's
statee language for its supposed 'Islamic' character. The Bengalis viewed this
prohibitionn as a symbol of West Pakistan's disregard for Bengali culture and identity.
Thoughh the Bengalis had decided for themselves to join the new nation of Pakistan, a
countryy that they themselves had helped found when India was partitioned, they soon
becamee disenchanted with the union. They discovered that they had thrown off one
coloniall ruler for another. In the ensuing years the situation became increasingly
intolerablee for the Bengalis, as the West Pakistani elite, which has dominated Pakistani
politicss since independence, gave itself the best jobs and most of the development
funds. .

BirthBirth of Bangladesh

Whenn the Bengalis of East Pakistan began agitating for greater autonomy in the
Pakistanii state, and their leader, Sheikh Mujibur Rahman, won an election that would
havee made him Pakistan's Prime Minister, the Pakistan Army, controlled by West
Pakistanis,, rolled into action. On the night March 26, 1971, a civil war began when
armyy tanks appeared in various parts of Dhaka city, the capital of East Pakistan,
particularlyy around Dhaka University, and began shooting Bengali students,
intellectuals,, civilians and politicians. All told, 3 million civilians were murdered, over
250,0000 women were raped and over 20 million Benglis became refugees in this brutal
civill war. The genocide ended on December 16, 1971 when the Pakistani Army
surrenderedd to an advancing Indian Army, which was assisted by millions of
Bangladeshii Freedom Fighters. What had began as an attempt by the East to gain
greaterr autonomy ended with the birth of a new nation: Bangladesh. After centuries of
foreignn domination and wealth depletion by outside rulers, Bangladesh emerged as one
off the least developed nations on earth, a sorry category for what had once been the
richestrichest province of India.

AfterAfter Independence

Inn the years after independence from Pakistan, a number of regimes rose and fell in the
coursee of violent Bangladeshi politics. Sheikh Mujib, the leader of the war of
independence,, returned to a very different country after being released from Pakistani
jail.. Bangladesh was scarred by its civil war; a huge number of people had been killed,
rapedd and displaced. The task of economic rehabilitation, and specifically the

35 5
immediatee goal of food distribution to a hungry populace, was disrupted by crippled
communicationn and transportation systems. Despite substantial foreign aid, mostly
fromfrom India, the Soviet Union, the World Food Programme (WFP) and UNICEF, food
suppliess were scarce. There was rampant corruption and black marketeering. The new
nationn faced many other seemingly insurmountable problems that inhibited its
reconstruction.. One of the most glaring was the establishment of law and order.
Thee political landscape was complicated; numerous bands of guerrilla freedom
fighters,fighters, remainders of the independence war, roamed around the countryside, fully
armedd and outside the control of the government. Many freedom fighters joined the
Bangladeshh army and thus legally retained their weapons, but many others ignored
Mujib'ss plea to surrender their weapons. Some armed groups took the law into their
ownn hands and set up territories under their own jurisdiction. Some leftist groups who
favouredd armed struggle against Mujib's regime were also active. The countryside was
eventuallyy pacified by counter-insurgency 'National Defence Force' (Rakhkhi Bahini)
whichh was established from the ranks of freedom fighters.
Thee departure of the Pakistanis after the war also left a disorganised civil
service.. Within the army there were also opposing interests. Bengali military officers
whoo did not escape from West Pakistan during the war and those who remained at their
postss in East Pakistan were denied promotions and were assigned functionless jobs, to
theirr great consternation. The formation of paramilitary National Defence Force also
disappointedd the army as they started to share resources and power of the regular army.
AA radical leftist organisation called the National Socialist Party (or JSD, Jatio
ShamajtanrikShamajtanrik dal) demanded a 'People's Army'.
Mujib'ss inability to restore law and order and limit corruption in the country
triggeredd Bangladesh's first bloody military coup in August 1975. Mujib was
assassinatedd and military control of politics was established. The army began to play a
muchh more important and visible role in Bangladeshi politics. In the three decades
sincee then, Bangladeshi rulers have assumed power in the aftermath of extraordinary
andd often bloody events, such as civil war, a military coup or the assassination of his
predecessor.. In the first twenty years of independence, there were four successful
coups,, in addition to a string of uprisings by soldiers, assassination plots and abortive
rebellions.. Sixteen of Bangladesh's 31 years of independence have passed under non-
democraticc rule. Public and political life in Bangladesh has thus largely been
characterisedd by violent dislocation and non-democratic governance. During the
dictatoriall rule the economy was ruined. Productivity, efficiency and the morale of
publicc servants deteriorated sharply. Lack of discipline and mismanagement in the
publicc sector were widespread and there was serious misuse of public office and state
power. .
However,, the struggle for democracy remained alive in Bangladesh.
Oppositionn parties, although they represented conflicting views and were as unwilling
ass the ruling regime to share power, remained a vital force that commanded the
loyaltiess of a large proportion of the population. Socialist and communist parties,
centristt parties and conservative Islamic parties, each with their own visions of the path
thatt Bangladesh should follow, became united in the late 1980s and forced the last
militaryy ruler to resign in 1990. Democratic government has been established in
Bangladeshh since the early 1990s. The Bangladesh constitution provides for a
unicamerall legislature called Jatiya Sangsad, or the national parliament. It comprises
3300 members of whom 300 are directly elected by adult franchise, and 30 are

36 6
exclusivelyy female members elected by the national parliament. The parliamentary
formm of government has the president as the head of state and the Prime Minister as the
chieff executive. After many years of autocratic rule, the first elected government was
formedd by Bangladesh Nationalist Party (BNP) in 1990. This government was
succeededd by the Awami League in 1996 election. A historical twist took place in the
mostt recent national election in 2001, when the Bangladesh Nationalist Party formed a
coalitionn government with Jamat-e-Islam, a fundamentalist Islamic group that opposed
thee independence of Bangladesh. The rise of fundamentalist parties is a recent
phenomenon;; they play a more and more important role in some parts of Bangladesh,
mostlyy in the border areas.
Itt is estimated that there are over 125 political parties in Bangladesh. However,
thee majority of these parties are based solely in urban areas and have tiny
constituencies.. The five or six major political parties maintain their respective mass
organisationss of workers, students, farmers, women, and so forth. Of these, the student
frontfront generally occupies the most prominent position. Although more than a decade
hass passed under a democratically elected government, the problems of governance
havee occupied the centre stage of national debate. The two democratically elected
governmentss headed by two different parties have been characterised by weak
governance.. Weak governance is indicated by poor accountability within the
governmentt institutions, ineffective co-ordination between departments, corruption and
poorr work ethic. There are also conflicts between national and local level politics,
whichh result in frequent violence and political killings. In recent years, on many
occasionss elected leaders pose challenges to the community level traditional leaders
basedd on family lineage or religious authority. Because of the fierce nature of rivalry in
Bangladeshii politics, the democratic practice is also frequently hampered, as the
oppositionn party usually rejects the election result and refuses to join the parliament
session.. The current Bangladeshi political scene is full of frequent hartals (strikes),
demonstrationss and political murders.

Societyy and people

Ethnicity,Ethnicity, language and religion

Bangladeshh is the most densely populated country in the world. Over ninety-eight
percentt of the people in Bangladesh are Bengalis, a branch of Indo-Aryans that
migratedd into the eastern reaches of India after the movement of the parent group from
Centrall Asia during the second millennium before Christ. Bangladesh's minority tribal
populationn comprises just over one percent of the total population. They live primarily
inn Chittagong Hills and in some north and north-eastern part of Bangladesh. Most
triball people are of Sino-Tibetan descent and have distinctive Mongoloid features.
Bangladeshh is unique among the countries of South Asia in that one language,
Bengali,, is shared by almost all citizens. The Biharis and tribal communities value
theirr own language, though they also speak Bengali. Bengali is the most easterly of the
Indo-Europeann languages derived from Sanskrit. It evolved through Prakrit and, to an
extentt resulting from the Buddhist influence, Pali. It is written in a modified Sanskrit
script,, unlike Urdu, which uses an Arabic script. The Bengali language has a major
literaryy tradition, which is exemplified in the work of Rabinrdranath Tagore, a Noble
laureatee in 1913.

37 7
 Aboutt eighty-eight percent of the population of Bangladesh is Muslim, giving
thee country one of the largest concentrations of Muslims in the world. Most of the
remainingg twelve percent are Hindu, the majority of them members of lower castes,
formerlyy Untouchables, who were designated by Gandhi as Harijons (Children of the
God).. The majority of the upper-caste Hindus fled to India in the early 1950s and
duringg the 1971 civil war. The Muslim community in the Bengal region developed
independentlyy of the dominant Islamic trends in India. The preservation of pre-Islamic
culturall elements from Buddhist and Hindu periods made the commitment to Islam
uniquelyy Bangladeshi. Christian missions have contributed much to the educational,
medicall and social infrastructure of the country. The religion of the tribal groups in
Bangladeshh is either Buddhist, Christian or traditional.
Althoughh the independence movement of Bangladesh was inspired by a non-
communal,, Bengali identity, with the advent of the military rule in 1975, the Muslim
identityy was re-emphasised, and the citizens were renamed 'Bangladeshi'. The secular
nationalistt ideology that was embodied in Bangladesh's Constitution was subsequently
replacedd by a commitment to an Islamic way of life through a series of constitutional
amendments.. This created a new debate concerning the identity of the people.
Questionss were asked whether people of Bangladesh should be called 'Bangali',
'Bangladeshi',, or 'Muslim', which generated a sense of separation from the Hindus in
thee country. These debates spurned a number of religious-based communal riots took
placee in the 1980s and 1990s.
Theree is another major debate concerning the identity of the non-Bengalis in
Bangladesh,, particularly the indigenous population of Chittagong Hill Tracks. Though
theyy form less than two percent of the population, they are nevertheless citizens of
Bangladesh,, who are neither Bengali nor Muslim. After the independence of
Bangladesh,, the ruling government overlooked the rights of the indigenous people and
suppressedd their quest for identity and autonomy. This in turn generated an armed
resistancee by the indigenous people of Chittagong Hill Tracks, which came to an end
inn the late 1990s after about three decades. A peace accord was signed by the
governmentt and the representatives of the indigenous people. The implementation of
thee accord however still remains questionable. As a whole the issue of nationalism is in
aa deep crisis in present-day Bangladesh.

Living Living

Bangladeshh is predominantly agricultural. About eighty percent of the people in

Bangladeshh live in villages and depend on agriculture for their livelihood. However,
nearlyy half (48%) of the country's rural population is landless, owning at most 0.05
acres;; social inequality in the rural society is determined by access to land. Because of
theirr landlessness, a large portion of the population must work as agricultural labourers
andd sharecroppers.
Bangladeshii villages, all 68,000 of them, are small and close-knit
communities.. A typical village is home to 400 to 1000 persons comprising a group of
homess called para. Each para has its own name. Since the late seventies, NGOs have
generatedd new dynamics in rural life. Although a small percentage of villagers have
alwayss been involved in non-farm related activities, through their micro-credit
programmes,, NGOs have created new options for various non-agricultural employment
inn villages, including poultry, transport and small trading.

38 8
 Althoughh farming has traditionally ranked among the most desirable
occupations,, villagers in recent years have begun to encourage their children to leave
thee increasingly overcrowded countryside to seek more secure employment in the
(evenn more crowded) cities. Traditional sources of prestige, such as landholding, a
distinguishedd lineage and religious piety are beginning to be replaced by modern
education,, higher income and steadier work as sources of prestige. However,
Bangladeshh is still largely an agricultural society.
Aboutt twenty percent of the population lives in urban areas. Urban centres
greww in numbers and population during the 1980s as a result of an administrative
decentralisationn programme that featured the creation of sub-districts. Of all the
expandingg cities, Dhaka, the national capital and the principal seat of culture, has had
thee biggest gain in population, growing from 3.4 million in 1981 to 9.9 million in
2001.. A majority of other urban areas are relatively small cities that have grown
becausee of their function as administrative centres or geographically suitable localities
forr inland transportation and commercial facilities. These small urban areas are
generallyy shabby in appearance. Most of the urban population congregate in
ramshacklee structures with poor sanitation and few to no modem amenities. Urban
areass are populated mostly by government and private functionaries, merchants and
otherr business personnel. There are some textile, jute, sugar and chemical industries
mostlyy built during the Pakistan period. There is also an increasing number of garment
manufacturingg factories because of the availability of cheap labour force in the
country.. These garment factories were built during recent decades and have generated
neww employment opportunities, particularly for women.
Inn Dhaka, about half of the population are poverty and disaster-related (e.g.
flood,, cyclone) migrants from both the countryside and from urban areas. They live far
beloww the poverty line. In the post-independence period, permanent net migration is
highestt in Dhaka, because the importance of the capital city tremendously increased
afterr independence. A major consequence of such migration is the rapid growth of
slumss and squatter settlements in and around the city.
Inn addition to the rural to urban migration, considerable migration has also
beenn taking place within the rural areas of the region. People from the areas of
relativelyy less developed agriculture and less cropping intensity migrate for one or
moree seasons to areas where agriculture is more developed. There is also seasonal
migration,, depending on the crops in different areas. Inter-district migration also takes
placee because of urbanisation, population density and job prospects. Since the late
seventies,, a large number of people have also migrated to foreign countries, mostly to
Middlee East, in search of employment. The unprecedented efforts of oil-rich but
manpower-poorr countries to attract workers to build infrastructure help to explain this
emigration.. Out-migration of Hindu population is also a politico-historical reality.
Theree is also a recent tendency of the middle and upper middle class citizens to
emigratee to America, Canada and European countries.
Thee influence of globalisation is manifested in the household use of satellite
TV,, mobile telephone and rapidly growing number of cyber cafes in the major cities of
thee country. This has created a visible change in people's lifestyles, particularly in
mainn cities like Dhaka, Chittagong and Khulna. These changes are affecting people's
values,, family structures and other aspects of life.

FamilyFamily and kinship

39 9
Familyy and kinship are the core of social life in Bangladesh. The family in Bangladeshi
societyy has more functions and plays a much more important role than the family in the
Westernn world does. In both rural and urban areas of Bangladesh, a substantial portion
off families are extended families. Husband, wife, unmarried children, elderly parents,
marriedd but unemployed sons, divorced or separated daughters and sisters and
physicallyy or mentally handicapped brothers and sisters are all members of the
extendedd family. Children learn to show unquestioned obedience to parents during
childhoodd and later maintain their parents with all possible care and affection. The
familyy behaves as one integrated unit in social and economic activities.
Anyy vital decision in the life of an individual, like a decision regarding
marriage,, education, purchasing property, career choice and choice of treatment of
diseasee is made with the consultation and consent of other family members. For
example,, marriage is a civil contract rather a religious sacrament in Islam, and the
partiess involved in the contract represent the interests of families rather than the direct
personall interests of the perspective spouses. In Bangladesh, parents ordinarily select
spousess for their children, although men exercise some influence over the choice of
theirr spouses. Only in the most sophisticated elite class does a women participate in
herr own marriage arrangements. Marriage is generally arranged between families of
similarr social standing. Marriage functions to ensure the continuity of families rather
thann provide companionship to individuals, and the new bride's relationship with her
mother-in-laww is probably more important to her well-being than her frequently
impersonall relationship with her husband. A woman begins to gain respect and
securityy in her husband's or father-in-law's house only after giving birth to a son.
Motherss therefore cherish and indulge their sons, while daughters are frequently more
strictlyy disciplined and are assigned heavy household chores from an early age. In
manyy families the closest and most enduring emotional relationship is that between
motherr and son. The father is a more distantfigure,worthy of formal respect.
Duee to rapid population growth, considerable development efforts of the
governmentt and NGOs and the increased influence of modem values, enormous
changess have taken place in the economy and the society of Bangladesh over the past
feww decades, especially during the post-independence period. The rapid population
growthh has caused high population density, with a concomitant rapid decline in the
land-to-mann ratio and landlessness. There has been increased rural-urban migration,
growthh of urban slums, unemployment and incidence of poverty. As a result of the
developmentt efforts, adoption of modem technology in agriculture and agricultural
productivityy has increased, literacy rate in general and female education in particular
hass increased, the mobility and role of women in the economy and the society have
beenn enhanced and traditional values and beliefs have been disintegrating. Alongside
thesee changes, a huge out-migration of labour and influx of foreign aid and capital
havee increased interaction between Bangladesh and the outside world, raising the
exposuree of the people of Bangladesh to modern ideas and modes of living. All of
thesee have, in turn, caused structural change in the economy and a shift in the
traditionall balance of social life, affecting all institutions, including that of the family.
Thee number of extended families is rapidly declining; nuclear families are
becomingg more common. Married youths are increasingly reluctant to maintain their
elderlyy parents and hence, are seceding from their parents to form their own nuclear
family.. The employment of women in the formal economic activities has significantly

40 0
increased.. As both husbands and wives are increasingly becoming engaged in
economicc activities, and in many cases have to work in separate places, formal and
informall separations between them have become more commonplace. Divorce and
separationn of couples is on the rise. However, as there is no other alternative support
systemm (such as a government welfare program), the family still plays the key role in
individual'ss life in case of crisis.

StatusStatus of women

Thee life of a woman in Bangladesh is largely shaped by the patriarchal social system.
Availablee data on health, nutrition, education and economic performance indicate that
thee status of women in Bangladesh is considerably inferior to that of men. Women, in
bothh custom and practice, remain subordinate to men in almost all aspects of their
lives;; greater autonomy is the privilege of the rich or the necessity of the very poor.
Women'ss lives remain centred around their traditional roles of mother and housewife.
Theyy have limited access to markets, employment, education, health care and local
government. .
Thee practice of purdah (the traditional seclusion of Muslim women) varies
widelyy by social milieu, but even in relatively sophisticated urban circles the
segregationn of sexes persists. For most rural families the importance of women's
labourr makes full seclusion impossible, although the attempt is made. In some areas,
forr example, women go unveiled within the core of the village but wear the veil or
outerr garments for trips farther from the community. In all cases, contact with men
outsidee the immediate family is avoided. Purdah is more maintained in certain regions
off Bangladesh like Sylhet or Noakhali, than in other areas. In general, women are less
visiblee in public spheres of Bangladeshi life than they are in many other cultures.
However,, over the years, through education and modernisation, changes have
takenn place. These changes have mostly happened in middle class women's lives; their
solee traditional role of mother and housewife has been expanded. Changes have also
takenn place in poorer women's lives, particularly through female-centred activities of
NGOss and through involvement of women as labourers in large-scale garment
factories.. These changes have brought women more into the mainstream of events in
Bangladesh,, though the position of women in general lags far behind men. The UNDP
gender-relatedd development index (GDI) ranks Bangladesh 123rd out of 174 countries.
Thiss poor ranking is primarily the result of the low literacy rate and the small share of
earnedd income of women compared to that of men.

SocialSocial hierarchy

Muslimm Bengalis often maintain social distinctions that can be important in family
matterss and in political and social mobility. A common differentiation made is between
twoo hereditary groups: ashraf and atraf. The ashraf (noble) are those of high status
whoo served in the government or the military during periods of Muslim rule by
northernn India, and who are supposedly descendants of Arab families associated with
thee Prophet Mohammed. The nobility includes people from syed and sheikh lineages.
Thee atraf are the bulk of Bengali Muslims who were converted to Islam in Bengal. The
Hinduu community has its own ways of making social distinctions in the form of status

41 1
differencee between different castes. In this system people are categorised according to
endogamouss social groups of families with the same professional background.
Thiss hierarchy according to family lineage is, however, weakening in
Bangladesh.. Society is becoming divided into classes based on wealth and political
influence.. The proscription against marriage between individuals of high borne and
loww borne families, once an indicator of the social gap between the two groups, has
mostlyy disappeared. Now most matrimonial alliances are based on wealth and power
andd not on family distinction. Social distance based on lineage has been replaced by
sociall distance based on wealth and power. Bangladeshis usually use a distinct
dichotomouss model of social stratification, corresponding to gorib (poor), chotolok
(lesserr people), or murkhu (ignorant) on one side and dhoni (opulently rich), borolok
(bigg shot) or bhodrolok (noble people) on the other. The first category generally
includess those with inferior social status such as landless peasants, small traders, day
labourerss and all kinds of manual workers. The second category implies higher status,
andd refers to landlords, businessmen, government and private service holders,
academicianss and political leaders. However, there are various layers and shades
withinn these categories. A person's ranking also depends on his or her reputation and
variouss aspects of lifestyles.
Afterr the creation of Bangladesh, opportunities for employment, business and
education,, which had formally been controlled by non-Bengali Pakistanis, became
availablee to Bengali Muslims. As a result, a new elite class that upset the traditional
classs relationship based on land ownership and lineage emerged in Bangladesh.
However,, although the traditional pattern of hierarchy has changed, the principle of
hierarchyy in interpersonal relations remains as morally correct and necessary. There
remainss a clear tendency among Bangladeshis to categorise and rank people. Indication
off rank is displayed in both casual conversations and official inquiries in which
personss are categorised by reference to such indices as income, academic degree, skin
colourr and birth order within the family

Health h

HealthHealth services

Thee government is the main provider of health services in the country, though the
privatee sector plays an increasingly bigger role. Bangladesh inherited a weak
infrastructuree from Pakistan, but within the first decade of independence it successfully
managedd to develop an extensive, multi-tiered public health care infrastructure.
(Organogramm of Health Ministry is included in the annex). At the top level, there are
teachingg and specialist hospitals. Below them is a network of district hospitals. Under
thesee are Thana (an administrative unit below the district level) Health Complexes
(THCs)) which provide primary health care, and at the Union (administrative unit below
Thanaa level) Health and Family Welfare Centres (UHFWCs), which provide out-
patientt services only. A referral system is meant to operate, whereby patients first
approachh a primary care centre. If their case cannot be adequately dealt with at that
level,, they should then be referred upwards for specialized treatment at the secondary
orr tertiary levels. At the village level, domiciliary services provided by field workers
fromm the Thana and union centres are intended to bring health services to the doorstep
off the people.

42 2
 Fromm 1974 onwards, the Ministry of Health and Family Welfare (MOHFW)
hass had a bifurcated organisational structurefromthe top down to the grassroots level,
withh one cadre of workers in family planning activities and another cadre in health
activities.. Developed at the insistence of the donors who wanted to aggressively pursue
familyy planning activities, it led to the duplication of management and service delivery
staff,, and inefficiencies and difficulties of co-ordination at all levels. Currently,
attemptss are being made to integrate these two services and improve management for
efficientt and cost-effective delivery of an essential package of health care services.
Governmentt health service delivery is seriously hampered by the inadequate
andd insufficient supply of equipment, pharmaceuticals and other medical supplies.
Apathyy of the medical personnel who provide the services and a lack of adequate
trainingg and experience of the medical personnel do as well. Some of the personnel
problemss arise from the reluctance of government staff to be posted in rural areas
wheree facilities such as schools and housing are scarce and also where the potential for
privatee practice is limited. Almost all qualified practitioners in government services,
especiallyy in the capital and the major cities, establish their own private practices that
theyy attend after the office hours of their governmental job. The tendency is thus to
frequentlyy refer patients seeking government health services to these private clinics,
wheree they receive better attention but at a much higher cost than in government
facilities.. Thus, as health services are costly in private clinics, they are only accessible
too rich people. Although government services are claimed to be free (with exception of
somee nominal charges in the case of certain facilities) there are various expenditures
thatt patients must make, such as tips to lower level staff and the purchase of medical
supplies.. The exact number of private hospitals and clinics is not known, but these
clinicss are situated mainly in big cities like Dhaka and Chittagong and urban areas.
Becausee of the inadequacy of government services in meeting all the health
andd family planning needs of the population, hundreds of NGOs attempt to fill the gap.
Thee NGOs are mainly involved in the provision of primary health care in both urban
andd rural areas. During the first decade of Bangladesh's existence, the health-related
workk of NGOs contributed greatly to the formation of a national health care delivery
system.. NGOs helped with rehabilitation of war affected people, training of health
personnell as well as the development of new options for rural health care. Presently a
numberr of large international NGOs (e.g. CARE, Save the Children and World
Vision),, large national NGOs (e.g. BRAC, Ganashasthya Kendro, Grameen Health
Programme)) and hundreds of smaller local NGOs are playing a complementary and
supplementaryy role in Bangladesh's health care delivery system. Due to their flexible,
result-orientedd management style, NGOs are able to experiment with innovative ways
off dealing with the health and population problems of Bangladesh, unlike the highly
bureaucratisedd government structures can. Other organisations providing health
servicess include Bangladesh Red Crescent Society, the Lions Club, the Diabetic
Foundationn and International research organisation Centre for Health and Population
Researchh (ICDDRB).
Aparttfromthis biomedical health services, there is also a vast non-biomedical
healthh care system operating in the country that includes traditional Aurvadic Kabirajs,
Unianii Hakims, homeopathic practitioners, practitioners of 'folk' medicine and faith
healers.. There is one government-run institute of indigenous medicine, where Unani
andd Aurvadic practitioners are trained. Unani is more popular than Aurvedic treatment
inn Bangladesh (while in India, the opposite is true), probably because of Unani's

43 3
affiliationn with Islam. The commercialisation of Unani has taken place in recent years
andd packaged Unani medicines are becoming popular. Homeopathy is also a popular
choicee of treatment by the vast majority of poorer people. There are a number of
governmentt affiliated training institutes for homeopathic practitioners.
Althoughh Aurvadic Kabirajes, Unani Hakims and different faith healers are
activee in the informal health care system in rural areas, Bangladesh also has an
extensivee array of local shops and pharmacies where biomedical drugs and other
health-relatedd supplies are sold. By far the single largest group of rural private
practitionerss is the 'unqualified allopathic' practitioners who are the untrained
pharmacists,, market sellers and road-side 'quacks' with little or no professional
trainingg in the use of allopathic drugs. The rural population and the urban poor are the
mainn consumers of this informal health service.

HealthHealth status of the people

Althoughh the conventional demographic indicators measuring the health status of the
Bangladeshii population register improvement in recent decades, the disease pattern has
remainedd unchanged. Infectious and parasitic diseases, arising from malnutrition, lack
off hygiene and poor living conditions continue to dominate. The most common
afflictionss in rural areas are diarrhoeal diseases, skin diseases, intestinal worm
infestations,, peptic ulcers, acute respiratory infection, anaemia, diseases related to
micronutrientt deficiency and eye disease. In addition, pregnancy and childbirth-related
illnesss continue to be major threats to women's health. Although the maternal
mortalityy rate has nearly halved since 1990, the present rate (4.4 per 1000 live births in
1996)) is still a matter of serious concern. The reasons for the high maternal mortality
ratee include the low nutritional status of pregnant women, the lack of access to or
utilisationn of health care services and domestic violence. Only twenty five percent of
pregnantt women receive antenatal care or assistance from trained attendants at
childbirth. .
Non-communicablee diseases such as diabetes, cardiovascular disease, mental
illness,, cancer and rheumatoid arthritis are reportedly increasing. Little is known about
prevalencee and incidence of HIV and AIDS. In 1998, the government of Bangladesh
sett up a surveillance system to track risky behaviour, as well as to look for HIV and
otherr diseases. The results indicated that the prevalence of HIV was still low, but that
riskyy behaviour was common. Villagers visit commercial sex workers in town and
returnn home to infect their wives with various sexually transmitted diseases. It is also
nott known to what extent working in Middle East might have contributed to rates of
HIVV infection. Moreover, culture prohibits open discussion and health education about
sexuallyy transmitted diseases.
AA new threat to people's health has recently emerged: arsenic contamination in
groundd water. It is estimated that 95% of the population relies on ground water for
drinkingg purposes and over a quarter of Bangladesh is affected by arsenic levels above
0.055 mg/litre, the nationally accepted standard. This means that about 30 million
peoplee are potentially at risk of arsenic poisoning.

Achievements Achievements

44 4
Inn last decades some remarkable progress has been made in the health and population
sectorss of Bangladesh. Among these is the outstanding increase in immunization
coveragee over a short period of time. Before the mid-1980s, disease control programs
focusedd mainly on curative services, but in the late 1980s the emphasis shifted towards
aa larger role for prevention. An Expanded Program of Immunization (EPI) was
initiatedd in 1986 with the assistance of the World Health Organisation (WHO) and
Unitedd Nations Children's Fund (UNICEF). The EPI coverage rose from 2% in 1985
too 67% in 1997 among children 12-23 months of age,, and coverage rosefromless than
2%2% to 86% for women with children under one year who obtained at least two tetanus
shots. .
Thee most spectacular progress has been made in the field of family planning.
Bangladeshh is the only country among the poorest 20 countries in the world where
sustainedd fertility reduction has taken place over the past 15 years. Between 1972 and
1996,, the contraceptive prevalence rate rose from 4% to 49%, bringing down the
fertilityy ratefrom6.3 to 3.3 children per woman.
Thee landmark National Drug Policy adopted by Bangladesh in 1982 was one
off the first among developing countries that promoted the use of essential drugs and
restrictedd the use of drugs with no scientifically proven efficacy. It limited the hst of
approvedd drugs to 150 essential drugs and restricted the manufacture and sale of most
drugss to nationalfirms,thus prohibiting exorbitant profits.
Despitee the achievements, at the dawn of new millennium, Bangladesh is
confrontedd with the challenging task of providing equitable, accessible and good
qualityy health care services to the population at large, the majority of whom live at or
beloww the poverty line.

Education n
Bangladeshh has gone through various educational systems. From the time of the
Englishh rule to the Pakistani regime and finally to the present-day Bangladeshi system,
educationn has evolved not only in method but also in fundamental aspects like
languagee of instruction.
Buddhistt monasteries, Sanskrit Tolls, run by Hindu Pundits and Islamic
MadrashasMadrashas are the examples of institutional education in the early history of Bengal.
Att the beginning of the nineteenth century, a system of liberal, English language
schoolss based on the British model was instituted in the region that now constitutes
Bangladesh.. The emphasis on British education led to the growth of an elite class that
providedd clerical and administrative support to the colonial administration but did not
developp practical skills or technical knowledge. The new elite became alienated from
thee masses of the people, who had no access to the new education system. For the
generall masses, the indigenous Sanskrit Tolls and Islamic Madrashas remained as the
mainn institution of education.
Duringg the Pakistani period, there was a general awareness of the need to
restructuree the education system to meet the needs of the new nation. The reforms of
thee educational system included an emphasis on broad-based and technical education.
However,, the impact of such policies was not felt in the then East Pakistan, and with
onlyy a few exceptions, a liberal elite-based education system with very little awareness
off life in the countryside was in place when Bangladesh became independent from

45 5
Pakistan.. After independence, many forms of education were permitted to co-exist.
Evenn so, the formidable British system was, and still is, largely in use.
Presentlyy the Bangladeshi system of education is divided into English
Medium,, Bengali Medium and Religious branches. In English Medium schools,
coursess are taught in English using English books. English Medium schools are mainly
privatee and are thus accessible to the wealthy class. An alternative to the English
Mediumm is the Bengali Medium, which is offered by the government. The tuition fee is
niinimall compared to that of the English Medium schools. Apart from these,
Madrashas,Madrashas, religious institutions are still there, where poor children are genera
sheltered,, fed and taught the ways of Islam by Imams. These children learn the script
fromfrom the Koran and the regular prayers. Madrashas are generally linked to mosques
andd the children usually serve the mosque. As government subsidies for these
institutionss are very low, these establishments often rely on public donations. Islam
generallyy plays a dominant role in the education systems of Bangladesh. In all
branchess of education, it is required to teach Islamic studies. Nevertheless, non-
Muslimm students are excused from Islamic courses. Besides these schools, there are
otherr disciplines such as cadet colleges and boarding schools where children are taught
mainlyy under military regimes.
Thee education system in Bangladesh is divided into 4 levels. 'Primary' is
gradess 1 to 5, 'secondary' is grades 6 to 10, 'higher secondary' is grades 11 and 12,
anddfinally,there is the university level. In Bangladesh the overall literacy rate is about
444 percent (1995); female literacy rate is 28 percent and the male literacy rate is 50
percentt The gap between the literacy rates in urban and rural areas is very wide: 36 %
aree literate in rural areas while 63% are in urban areas. However, with the inception of
Universall Primary Education program, the literacy rates have been increasing. The
Non-Formall Primary Education (NFPE) of the development organisation BRAC has
contributedd to improving female education. Their efforts have helped to reduce the
largee gender gap in education. In 1998 there were about 52,000 primary schools that
enrolledd over 50 million students. Additionally, there are about 11,000 secondary
institutions.. There are 11 government universities and approximately 20 private
universities.. There are thirteen government and four non-government medical colleges.
Theree are four Government Engineering colleges, one leather technology institute and
onee textile technology institute. Specialised universities are the Bangladesh University
off Engineering and Technology (BUET), Bangladesh Agricultural University and Post
Graduatee (PG) Medical University.
Itt is extremely difficult to educate a population as large as that of Bangladesh.
Thee task of educating is even harder when the people of the country are hungry and
sufferr from poor health. As education is a key to a successful nation, the government
andd NGOs in Bangladesh are trying hard to improve the state of education in the
country,, despite the many obstacles.

Economy y

Eastt Bengal, the region that became East Pakistan and later Bangladesh, was a
prosperouss region of South Asia until fairly recently. It had the advantage of a mild,
almostt tropical climate, fertile soil, ample water and an abundance of fish, wildlife and
fruit.fruit. The standard of living compared favourably with other parts of South Asia. As
earlyy as the thirteenth century, the region was developing as an agrarian economy, but

46 6
itt was not entirely without commercial centres. Dhaka in particular grew into an
importantt commercial centre during the Mogul Empire. Upon their arrival in the early
seventeenthh century, however, the British chose to develop Calcutta and not Dhaka as
theirr commercial and adrninistrative centre in South Asia. The development of east
Bengall by the British was thereafter limited to agriculture. The colonial infrastructure
off the eighteenth and nineteenth centuries reinforced East Bengal's function as the
primaryy producer of chiefly of rice and jute for processors and traders in Calcutta and
beyond. .
Theree were deleterious effects of British rule on the economy of Bengal. As
mentionedd before, the Land Lease Act of Lord Cornwallis generated far-reaching
negativee effects on the economy of this region. The act broke the traditional feudal
relationn between the farmer and the land owner, and generated opposing interests
betweenn those owning and those working the land. This hampered agricultural
developmentt Prior to the arrival of the British, textile industries prospered
considerablyy in the eastern part of Bengal, especially in the areas surrounding Dhaka
city.. In fact, a major motive of the British ships for anchoring in India was to export
thee fine Dhaka muslin and other products of silky cotton from Bengal to Europe. But
withh the industrial revolution in Britain in the late eighteenth century, a mechanised
textilee industry developed there and the British rulers sought to eliminate Bengali
competitionn by means of trade restrictions and the imposition of prohibitive duties. Not
onlyy were Bengali textiles shut out of the British market, they were also shut out of the
Indiann market because taxes discriminated against local cloth. As a result, while
industryy developed in Britain, it withered in Bengal.
Thee partition of British India and emergence of India and Pakistan in 1947
disruptedd the former colonial economic systems that had preserved East Bengal (now
Eastt Pakistan) as a producer of jute and rice for the urban industrial economy around
Calcutta.. East Pakistan had to build a new industrial base and modernise agriculture in
thee midst of a population explosion. Pakistan's five-year plans opted for development
strategyy based on industrialisation, but the major share of the development budget went
too West Pakistan, which is now Pakistan. The lack of natural resources meant that East
Pakistann was heavily dependent on imports; this created a balance of payment problem.
Withoutt a substantial industrialisation program or adequate agrarian expansion, the
economyy of East Pakistan steadily declined.
Decadess of skewed development under British rule, followed by neglect under
Pakistann and destruction caused by the 1971 war, left the country prostrate during the
earlyy 1970s. After independence in 1971, the new government under the leadership of
Sheikhh Mujib attempted to carry out a more comprehensive land reform programme
butt failed miserably due to opposition of the landed class from within the ruling party.
Itt pursued a wholesale nationalisation programme, bringing all industrial concerns of
anyy importance in the public sector. But the nationalised sector showed alarmingly
poorr performance mainly due to the inefficiency and corruption of management and
labourr leaders, trade unionism by labourers and the sabotage of mills and factories by
previouss owners.
Nonetheless,, the new government witnessed major accomplishments in
repairingg damage and setting up the basic administrative machinery needed to run the
country.. With few mineral resources, almost no industrial infrastructure and a mostly
unskilledd labour force, Bangladesh depended on imports for most of the basic
requirementss of the nation. Its exports, on the other hand, were agricultural

47 7
commodities,, especially jute, that declined in real value and were subject to
uncontrolledd fluctuations in world demand. Under these circumstances, the economy
dependedd on large annual inputs of foreign aid. In fact, since independence more than
eighty-fivee percent of the annual development budget of Bangladesh relied on receipt
off foreign aid.
Afterr the assassination of Sheikh Mujib, the new military government
abandonedd the nationalisation project and took a clearly capitalist path. Economic
privatisationn and liberalisation were encouraged. A process of withdrawal from the
publicc sector started; the regime also actively sought increase in foreign aid. The
successivee governments gave an increasingly greater role to the private sector. The
privatee sector did grow in Bangladesh, but it was arbitrary state patronage that usually
fuelledd the growth of selected individuals.
Inn rural areas, adoption of modem technology in agriculture has considerably
increased,, which has led to a significant rise in per acre productivity. A large variety of
non-agriculturall income opportunities have emerged in the rural areas, reducing
dependencee of households on agriculture. Export of manpower has significantly
increased,, enabling a sizeable section of rural households to earn remittance income
fromfrom abroad. At the same time, inequity in the distribution of income and assets has
escalated,, and a powerful elite and a large middle class have emerged. A wave of
consumerismm has flooded the economy; the people of even the remotest corner of the
countryy are increasingly consuming various non-traditional items.
Althoughh there has been a reasonable growth of GDP, reduction of absolute
povertyy to a significantly lower level and a decline in the rate of fertility over the last
threee decades, the crucial indicators of development such as savings, investment,
growthh of the industrial sector and the rate of economic growth continued to remain at
extremelyy low levels. The incidence of poverty remains very high.
Nevertheless,, in recent years, large labour exports to Gulf nations (1.85 million
duringg the period between 1976-1996), development of the readymade garment
manufacturingg industry (only 134 factories in 1984 and 3,618 in 2002) as well as the
micro-financee services under government- and NGO-supported programmes (currently
10.22 million people have access to micro-finance programs) have started to create a
positivee impact on Bangladesh's economy. Still, economic development is a precarious
processs because of unstable political conditions.

Thee hospital that I will describe is shaped by as well as manifests these social, cultural,
politicall and historical features of Bangladesh.

48 8