• Public Health

The world of public health is bereft with the departure of one of its most passionate practitioners and advocates of health for all. Dr Zafrullah Chowdhury passed away in Dhaka on 11 April 2023 after a protracted kidney disease and after spending an eventful and inspiring life dedicated to the health care and development of poor and voiceless people. He became their protector, developer, health carer and a voice.

Dr Chowdhury embodied and lived the principles and values of primary healthcare. He challenged the profit-oriented healthcare and through his life-long work broke the medical clichés by providing alternate ways of caring for those who cannot pay but have higher healthcare needs due to their poverty and poor living conditions.

Born in Raozan, Chittagong, Eastern Bengal in the Indian subcontinent in 1941, he was 6 years old at the time of the Indian partition. As a young man he saw major political events: East Bengal became part of Pakistan, a new country, as its eastern wing. Then it got itself separated from West Pakistan in 1971 after a bloody war and transformed into Bangladesh. These upheavals and political movements turned Dr Chowdhury into an ardent Bengali nationalist. Spending an active political life as a medical student he proceeded to the UK for training as a vascular surgeon. He was there when the war erupted between East and West Pakistan. He left his training halfway and took the flight to Dhaka as a young doctor to help the freedom fighters.

With the help of other charged doctors and volunteers, he set up a hospital in the war zone, at the border of Tripura state of India, for taking care of injured fighters and refugees. The busy hospital soon swelled to a 480 bedded field hospital. The war ended and Bangladesh came into being in 1971 but this was the beginning of Zafrullah Chowdhury’s more than half-a-century crusade for poor people’s health and development. He relocated the field hospital to Savar, a rural outskirt of Dhaka and never looked back.

In 1972, the field hospital experience and huge unattended healthcare needs of war-torn people led to the establishment of Gonoshasthaya Kendra as a charitable trust, commonly known as GK, meaning People’s Health Centre.1 Zafrullah Chowdhury soon realised that the healthcare needs of the people were too many and too important to be left to the doctors who were not available in enough numbers in any case. He started short trainings of volunteers, predominantly women, who started providing basic healthcare to the people by reaching-out to them as well as at the GK centres.2 Trained paramedics became the mainstay for delivering diverse preventive, promotive, curative and rehabilitative health services. This work never stopped.

Need-based expansion of GK over the last 50 years has resulted in a GK group of health facilities covering the full spectrum of healthcare from community healthcare to tertiary-level advanced hospitals. All with a priority for the poor and vulnerable people. GK healthcare is entirely non-discriminatory with explicit affirmative action and financial protection, through partly community health insurance scheme, for those who cannot pay. And healthcare in GK means healthcare that is needed, from diarrhoea to dialysis and TB to transplants. It also operates a medical university.

Dr Chowdhury remained active at local as well as global levels. The work he started inspired even the International Conference on Primary Health Care held in Union of Soviet Socialist Republics (USSR) in 1978 which resulted in the famous 10 commandments of the Declaration of Alma-Ata.3 Since then, one way or the other, he contributed to all major global milestones on PHC, health-for-all and universal healthcare agendas: WHO’s ‘global strategy for health for all by the year 20004’; ‘Primary healthcare: ‘everybody’s business’,5 the final report of the commission on social determinants of health6; The world health report 2008: primary healthcare—now more than ever7; the WHO framework on integrated, people centred health services8; to name the few important ones. He was a big critique of ‘selective primary healthcare9’ and vertical health programmes.

40 years after Alma-Ata, the Global Conference on Primary Health Care—From Alma-Ata towards universal health coverage and the Sustainable Development Goals, in Astana, Kazakhstan in 2018, produced Declaration of Astana.10 Taking into account the changed world in 21st century, the Declaration of Astana has largely reaffirmed and rephrased and modified the Alma-Ata vision. To achieve the third sustainable development goal, which calls for efforts to ensure healthy lives and promote well-being for all at all ages, the Declaration of Astana put special emphasis on three components of PHC: empowering people and communities; multisectoral policy and action; and primary care and essential public health functions as the core of integrated health services.

Empowering people and communities for their health and development was the sina qua non of Zafarullah’s approach. In that, he especially championed women empowerment. At one time, only women were driving rikshaw, car and trucks in GK, for which he established a driving school. Women community workers were biking their way to work. This was transformative in a conservative society but extremely emancipative for women. A friend remembered him as a feminist long before it was fashionable for men to fight for women’s rights.11

Multisectoral approach and action were another important feature of his projects. Since the work was, and is, needs-driven, it crept out of health domain and embraced other development needs. Water and sanitation, agriculture, nutrition, education, employment generation, manufacturing medicines, are some of the key programmes of GK.

Public health emergencies are caused by frequent cyclones and floods in Bangladesh—almost a regular feature. Every time GK is there, supporting people with shelter, food and healthcare. They have developed an almost automated emergency response mechanisms. GK is a leading healthcare provider to the most marginalised Rohingya refugees.12

In 2000, he founded and hosted a global People’s Health Assembly (PHA)13 14 in Bangladesh and managed to get around 1000 delegates from across the world. PHA came out of the simmering People’s Health Movement. Dissatisfied with World Health Assemblies (WHA) where resourceful private health sector actors were sometimes influencing the WHA outcomes, he launched an alternative global forum in the form of PHA. The first PHA in 2000 at the GK campus near Dhaka was a great event. Despite historical bitterness between Bangladesh and Pakistan, Zafrullah Chowdhury personally welcomed many of us from Pakistan and took our special care. This was one of the most inspiring public health events I have attended. Halfdan Theodor Mahler attended the PHA. In 1978, he was the Director General of WHO and is considered as one of the key architects of the historical International Conference on PHC in Alma-Atta. In his speech, he said and I remember, ‘NGOs played a key role in making the 1978 conference a success and they are the ones who have continued to promote and implement the Declaration of Alma-Atta and I have come here today as my thanksgiving. Thank you all of you for making it possible.’ This was indeed a great testimony and an unforgettable moment. Zafarullah was also among the founders of Health Action International—Asia Pacific.15

Another major event for which Zafrullah Chowdhury will be remembered was his revolutionary work on essential medicines. In 1982, he convinced the Bangladeshi government to implement, the essential medicines concept in letter and spirit through the famous National Drug Policy. In one stroke, 1600 non-essential medicines were deregistered and a list of only 150 essential medicines was adopted. Big pharma industry was up in arms and they threatened to roll back from Bangladesh. Zafarullah responded quickly by setting up a manufacturing company for essential medicines. He has captured these dramatic events in a page-turner book, ‘The Politics of Essential Drugs: The Making of a Successful Health Strategy: Lessons from Bangladesh’.16

He survived a serious attack of COVID-19, suffered renal failure and was on regular dialysis, but till the end, he continued to work and inspire. Ever expanding GK established largest haemodialysis centre in the country which served 300 patients a day,17 one of whom was Zafarullah himself. A dynamo of a man, he continued to blaze for the poor, their healthcare and development and fight against all kinds of local and global injustices in this regard.

The world recognised his contributions and bestowed him with many prestigious honours and awards including the highest civil award by the Bangladesh government; Ramon Magsaysay Award from the Philippines; the Right Livelihood Award from Sweden; the International Health Hero award of the University of Berkeley in the USA and the Ahmed Sharif Memorial Award of Bangladesh.18

Smiling with squeezing eyes, he was a great company. He was soft at heart but stubborn in his commitment. Always attired casually. Once he told me that as a young man he was crazy about expensive cars but once he chose to work with poor people he adopted an ordinary lifestyle, almost ascetic. Through his work, he changed lives and worldviews. He inspired a whole generation of health workers, inside and outside Bangladesh. Anyone who once met him would never forget him. This is how the website of PHM has befittingly announced his departure, ‘…the world lost one of the foremost champions of people’s health rights and primary healthcare that the world has ever known.’ He would live long through his legacy.