HEALTH Is an essential quality ol life measure When one considers I Im- I wall h of an entire nation over .1 s|Mn of almost 29 years Il IS probably difficult to come up wiili one comprehensive assessment without making It sound too simplistic Nonetheless. it Is not unreasonable Io ask : Are We a healthier nation since 1971? There are innumerable ways of replying to surh a question. Demographic measures, for Instance, make easy reading and are Immediately comparable over time On the other hand, what do they say about the actual quality of life of a people After 25 years are they more able Intellectually, behaviorally. socially, motorically or psychologically? What about secular trends, a phe nomenon by which certain highly developed societies such as Japan ai)d Sweden have Im leased their average height motor performance etc. within the same span of time mentioned above?

There are so many aspects to the health of a nation that one may have to look at it from different points of views to make any valid assumptions.

A question of demograph -

When Bangladesh emerged as a new nation in 1971 how important was the health sector to the policy makers, and Infact to the Informed public in general. In the overall design of building the country? The First Five Year Plan (1973-78) states that 'preexisting health facilities were grossly inadequate both in quality and * in quantity, and services were enjoyed by only a privileged few' It further states that th? total estimated population in 1973 was 74 million, with a growth rate of over 3 per cent. The infant mortality was 140 per 1QOO. crude birth rate 47 per 1000 and death rate 17 per 1000. Based upon all these alarming indices, the amount of resources allocated from public funds was about 5 per cent of the total budget.

More someone two decades later the demographic Information may leave someone with both hope -and despair. Infant mortality has come down to 91 per 1090. crude birth rale to 31.5 per 1000, and crude death rate to 11.2 per 1000. Less Infants and children are dying today and that Is surely something to acknowledge and be thankful about, although it would have been more heartening to see at least a halving of the deaths In so many years. What Is of more concern is the total estimated population of 116 million (1993) people. By the turn of the century the population is expected to be double that of 1971 (Fourth Five Year Han). Resource allocation from public funds have also seen a reversal. with the health sector receiving 2.5 per cent and family planning 4.08 per cent.

Less food for more people. ■ or lack of equity?

Calorie intake of the average Bangladeshi has come down to 1850 kilocalorie, much less than the required amount. Nutritional deficiency in children has risen from 60 per cent in 1971 to 75 per cent in 1995. It may well be that pauperiza-

tion is leading to such drastic stales in dur children. and there are many hypotheses for this phenomenon that-, economists often make conjectures about. Even more drastic f* to compare the affluence and waste that Is seen within the urban middle and upper classes, especially in the wedding ceremonies taking place everyday of thejrear Ui various community centre. Senakunja etc. How many mouths would that kind of money and food feed? If mass starvation is a ' mailer of wealth and resources living concentrated in the hands of the privileged and powerful few. such iiian-made' . epidemics must certainly lie confronted at the economic and, political level.

Health service infrastructure : a success story marred by poor quality of service?

Thjs is one aspect where in 25 years we have made considerable strides. Over two-thirds of the total Thanas have a Thana Health Complex (THC), most of them equipped with specialized services such as medical specialist, gynaecologist. and surgeon. .Each is also supplied with essential drugs arid vaccine. Paramedical health personnel are also posted to each union to provide antenatal care to mothers.

reproductive services to women, Immunization and treatment for common - ail-" merits Ail thia compared to almost no services 25 years ago. The fatal flaw In this apparent success story' Is that very lew people avail the services of the THC. most going to the very same doctors inthe loeiU bazaar and pharmacies.

Service 'without a MiiHe?

Firstly, who is responsilite for this informal (not illegal) privatization' of services? This Is a question that needs to be addressed. Secondly, the diagnostic aids available to any Thana or even District hospital is rudimentary, obsolete and inadequate by any modern standards. The scientific and rational practice of medicine today leaves very little scope for empirical prescription of drugs, a method practised by most doctors, having for example no availability of a blood or urine culture at hand. If the question Is an appropriate transfer of technology' and training of genuine technicians. then it is another important issue to be addressed, and a service that the general public have a right to. The third flaw is a lack of accounl-ablTlty of the service-provider. Finaliy. health deliver is a service industry, and ihe motto

service with a smile is some thing We have failed to provide Health education institutions are points where changing at t Hudes needs to be addressed

Commitment to international mandates and the inte-graUori of social factors into

Today the health rhetoric, and some practices, is very much geared to Health for AU by the Year 2000 universal Immunization of children within the EPI programme. The Cairo Declaration. The Social Summit in Copenhagen etc. The positive aspects of such commitments are being seen In the numbers of Immunized children in Bangladesh today, which has risen to over 80 per emt in moot areas availing of antenatal care which Is over 60 per cent. etc. A caveat is that some areas such as Chittagong still remain low by such statistics The social phenomenon of health practices by area need to be investigated esp in such vulnerable area Reproductive health has come a long way. but perhaps only In rhetorics, from mere cafeteria dlstribu Bon of contraceptives to better health provision all through a girls life span, starting from the safety wellbeing and rights of the glrl-chlld. the indepen dent working woman, the single parent, and the aging woman, and also the Inclusion of men and women in the practice of safe sex. The public health sectors Inclusion of various womens groups Into their policy-planning cells is an important step forward, one presumes.

A concerted effort to be healthier in body and mind?'

Millions of malnourished children, abandoned single mothers, small girls having hHlacs. mask pauperl/iimn. ex-imIhs. ipfo llu polluted metropolis. hunger nervation, beggary — Is That iiow we visualize the slate of health of our nation? What future lor these children who are born maimed, undergo deprivation of all varieties, and still manage to stay alive. Soniegllm-mer of' hBpe Is seen where health. economies irf daily living. Iluiiiaii rights, functional edueaiion anti rudimentary I it x tit 111 lotmI support are combing efforts. Today one may riyti ^iv i fiat'the policy maki-r? aii‘"no longer unaware of Ilic strengths in combining efforts. i.e make health multisectoral. iHversc. and pari of the Social ikwelopmenl. After 25 years ol struggle, this is definitely a victory of the people. One only hopes that it Is directed toward a healthier nation.

In the words of a small girl of 12 who sells flowers in the streets of Dhaka, whom 1 spoke to the other day — "Apa. I want to study hard, make lots of money, and be healthy and beautiful" — a simple demand from a child with dreams in her eyes. This beautiful country which has given us many joys, is hers as much as Ours, and one hopes that she has the strength to keep lighting for it.

The writer is a child specialist and Associate Professor of Child Development and Neurology Unit Dhaka Shtshu Hospital.