JAMES WOLFENSOHN: Sustainable development is where dealing with degradation of an environment is seen by the people as affecting their health

ASHOK KHOSLA: I believe sustainable development means development in which there's a much greater equity than there is in today's form of development.

HILDE FRAFJORD JOHNSON: Govenance means, to use a very simple analogy, the family. Making sure the decisions are open and people can take part in it - democracy.

CAPTION Chakaria, Bangladesh

DR. MOHAMMED IQBAL, Chakaria Community Health Project: There was a devastating cyclone in 1991. After cyclone, people got a lot of relief, so people had a relief mentality. Everybody was looking to ICDDRB - it's an international organisation, it has come, it will give us relief it will give us drought free, it will give us medical service free - so they had a relief mentality.

COMM In one of the poorest areas of one of the world's poorest countries, the disaster led to a huge aid response. Relief and malnutrition continue to this day.

DR. MOAZZEM HOUSSAIN, Chakaria Community Health Project, 1994-1998: Malnutrition is 14 out of total 81 registered. So 14 out of 75 is malnourished.

COMM: If the problems of health care were going to be solved long-term, then something new had to happen. Thoughts on 'health for all' had been worked out at the UN 'Alma Ata' conference a couple of decades earlier.

DAVID LEGGE, LaTrobe University Alma Ata is terribly significant. In 1978, 150 countries - or whatever it was - got together and said that we had to develop a model of primary health care which delivers generalist services locally - which uses appropriate technology, appropriate labour force models. But very importantly, which involves local communities in thinking about the problems they're facing.

DR. MOAZZEM HOUSSAIN: Primary health care which came at Alma Ata, where community participation is said to be one of the pillar. But since the project started there is not very good example where community participation has been proved to a very successful tool.

SIOBHAN PEATTIE, Save the Children: It was - and still is - a great idea, But I think there's a difference between expecting communities to, all on their own, pay for those services - as opposed to actually getting involved with government systems and trying to improve the quality of that.

COMM. What was needed was a scheme that at least demonstrated a community participation approach. Something that has the potential to reach the vast numbers of rural poor. If the Government of Bangladesh couldn't do it then a non-governmental organisation was going to try. Here in Chakaria, was a chance to try out a new way of doing things. It wasn't the easiest of places to experiment with health care.

First off, the International Centre of Diarrhoeal Disease Research - the NGO that wanted to set new health care precedents - had to measure what was there. Moazzem , a community physician, was charged with setting up the project.

DR. MOAZZEM HOUSSAIN: In the beginning, actually, we just used to come and sit in the tea shops - and sit in different places where people gathered. And the people used to ask, what the people, where from you are coming, and why do you come here? So initially it was responding to the colleagues - rather than telling what we wanted to do.

COMM: The district of Chakaria had a pretty poor record. Most children - 60 per cent - were sick during any two week period. Most were malnourished. Less than half were immunised against measles. There was little family planning. There was high infant and maternal mortality. Diarrhoea was common. Dispensing medicine with unsterile needles was widespread. Few knew about food or water hygiene. Most didn't know the causes of iodine deficiency or night blindness. There was rickets and endemic malaria. People suffered vitamin deficiency, and that left them prone to disease.

But collecting all this information was not easy. Chakaria is very conservative and puritanical. The inrush of aid after the cyclone caused resentment as well as dependency. This is a Muslim dominated area. Clerics were deeply suspicious about a project that talked of community control, modern medicine and female involvement.

MOHAMMED IQBAL: This area was very conservative and fanatic. And people had a mistrust about the NGOs - so they did not believe the health activities of the ICDDRB.

DR. MOAZZEM HOUSSAIN: In the beginning they clearly used tell about the story of the East India Company, and they used to say we have seen the East India Company coming to this country for trades - and then they have taken over the country, so we don't believe NGOs. I mean these are the agents of the foreign foreigners, and donor agencies... So we had to tell them and we had to convince them, I mean, we are here to talk to you and to listen to you and to know from you - to know your health situations, and then if anything in this project in this area, is to be done it you who will be doing it.

COMM: There were community leaders who knew something had to be done.

ISAHAQUE MOHURIPARA, Village Health Committee Chairman: People weren't conscious about health issues - There was no system for sanitation. Wherever you went, there was diarrhoea.

COMM: One of the very first things was health awareness. Villagers got to understand the causes of diarrhoea. They found they could buy latrine parts for about $3. Three hundred villagers subscribed - and saved nearly $850. Three hundred latrines were ordered and, overnight, public defecation disappeared, and the instance of diarrhoea decreased. The next stage was to find somewhere else where community involvement might be fostered. Elders in Mohuripara - about 60 per cent Muslim and 40 per cent Hindu - understood the need for local initiative.

ISAHAQUE MOHURIPARA: Then we took the initiative to gradually develop ways to tackle the health problems we have. It would be better for the village to do things by ourselves. This land is my parents' land. It's been given definitely for free use. And then we decided to have a building there. And then one of my cousins Bashirullah, gave 50 to 60 thousand taka.

COMM: In 1998 the first of five health posts was built, and paramedics went to be trained.

AINUN NAHAR, Chakaria Community Health Project: ICDDRB gave me community paramedic training - and from February 1998 to June, I trained as a midwife at Gonu Shastra in Dhaka.

COMM: With help only to buy stethoscopes and medicines, a mechanism had to be worked out to pay paramedics and doctors. It's complicated.

AINUN NAHAR If she gets this health card for 50 taka, all the members of her family can be listed on the card. And they all can get treatment here. That would include seeing community paramedics, primary treatment for 5 taka and the session day - the BSP session day - when they can see the main doctor. They have to deposit 15 taka to get the treatment.

SAJEDA: If they told to come and get this card we would have done. Everyone in this poor place.

ZILLUR: You don't understand the importance love...

SAJEDA: What do you talking about, not giving it importance?

ZILLUR: How can they treat you without a card?

SAJEDA: For money.

ZILLUR: How much do you pay?

SAJEDA: 55 taka. There's no point going if the medicine doesn't work!

DR. MOHAMMED IQBAL: After one year of activity they found that only the rich people are coming and buying the health card at the cost of taka 50.They identified the poor and the poor must be addressed. So they made a list of the poor, the poor families of this area. And then, in a planning workshop, they have decided they will give the poor families the health card at the rate of taka 10.

SAJEDA BEGUM: For the card, it's 50 taka. It's expensive - how can we afford it? What shall I do ? Pay for the children's medicine, and pay for the card - or buy food to feed ourselves. And this is why we didn't get the card.

ZILLUR RAHMAN, Mohuripara Health Committee Secretary We've told them so often - but they still claim not to know anything. Someone got treatment without a card, for free, and got the medicine and didn't pay for the medicine...And then when we came to collect the money, they said my illness didn't get better why should I pay!.

DR. MOHAMMED IQBAL: Some people are thinking that I am not ill, or somebody of my family is not ill... When I shall get ill, then I shall buy the family health card.

COMM: The concept of saving for health is an alien idea - even in such a disaster-prone area as Bangladesh. Traditionally, 90 per cent of the rural poor pay local and untrained quacks, when they need health care. Suddenly, having to pay large sums in an emergency can be devastating to a family.

INTERVIEWER: What kind of medicine does he give?

ALMAS KHATUN: For fever and malaria, he gives medicine for everything.

INTERVIEWER: How much do you have to pay?

ALMAS KHATUN: A lot of money. 100 to 200 taka, 50 taka, it depends how ill you are.

COMM: Almas, mother of four sons, has malaria.

ALMAS KHATUN: My whole body shivers - fever, I get palpitations of the heart, I feel really dizzy, And I've got really a bad pain in my stomach, heart palpitations...

INTERVIEWER: How do you know you have malaria?

ALMAS KHATUN: From malaria, my whole body shivers.

INTERVIEWER: Did you go the doctor?

ALMAS KHATUN: No.

INTERVIEWER: Why?

ALMAS KHATUN: Haven't got money. How can I go without money?

COMM: Living up in hills, Almas doesn't know about the health post. Neither does her friend Sakina, whose baby isn't well. She's only seen the local quack.

INTERVIEWER: When did you last see the doctor?

SAKINA BEGUM: It's been about 10 to 12 weeks.

INTERVIEWER: How old's the baby?

SAKINA BEGUM: One year.

INTERVIEWER: There are doctors here, do you go?

SAKINA BEGUM: I have no money, sister...

INTERVIEWER: There will be no benefit, they said?

SAKINA BEGUM: They say he will get better.

COMM: When told about the health post, both mothers would set out next day, to walk the five kilometres to see the doctor. The Chakaria Community Health Project isn't supposed to be an alternative to Government health care. Right from the start, Moazzem worked with the nearest hospital and with other community organizations. Health awareness was top priority.

DR. MOAZZEM HOUSSAIN: People believe that the reason for night blindness is - if you kick the chicken's cage... Because the chicken doesn't see well at night, so if you kick that, then you'll also suffer from night blindness... So that was in time when there was extensive vitamin A campaign in the country - that was the knowledge level here...

COMM: There still are difficulties of understanding. Women - not least those in polygamous marriages - still find going out in public intimidating. Husbands have to be there to guard their honour.

DR. NANDITA NAZMA, Chakaria Community Health Project Women in this area, they are very much neglected. They are poor and also they have many children, - they cannot take proper health care for themselves.

COMM: As the health scheme grew, the villagers of Mohuripara realised all the health organisers were male and all the health volunteers were female! At one particular meeting, both sexes attended. It was the first time women had ever been to a public meeting.

AINUN NAHAR, Chakaria Community Health Project: Ladies couldn't talk to ladies. It was very difficult. We had to make them understand. And after getting the female volunteers and setting up the intercluster meeting, it's now changing...

COMM: Where women used to be invisible, there are now public seminars. Hasina holds one in her house.

DR.MOHAMMED IQBAL, Chakaria Community Health Project: The project found that the female health is neglected - so they selected some female health volunteers. They were trained about the female health - What are the health problems, what are the complications of the pregnancy, what to do when a complication arises?

AINUN NAHAR Many pregnant mothers and babies died from delivery. And especially they died from diarrhoea, malaria and pneumonia... Mostly they died from delivery. Problems in delivery, and the bleeding before delivery, and bleeding afterwards. Mothers didn't know about checkups. Or what kind of treatment they have taken and where to go for the treatment.

COMM: Ainun returns to a baby she delivered three days ago. Cutting umbilical chords used to be done with bamboo splints, but messages are getting through.

MOUAZZEM HOUSSAIN: Men have become more sensitive to responding to the women's needs - women have become much more free, courageous, and talking very boldly with their men, and with the men from outside... And this is a smooth transition, I feel - and that was a dream I would say with in this project.

COMM. The Chakaria Health Project now has seven health posts and is setting up 17 'mini-posts' in the isolated hamlets. The number of families buying into the scheme is rising and the annual fee has been reduced. Immunization has increased, there's less diarrhoea, and health awareness is dramatically improved. But without running water, villagers have to risk water-borne diseases, caught from ponds. Skin infections, dysentery and malaria all result from the numerous ponds, streams and ditches. Iodine, antibiotics and impregnated bed nets are all being used, but standing water will always breed malaria-carrying mosquitoes, and malaria can cause major economic crises.

Zillur once raised nearly 2000 taka - about 35 dollars - from his villagers to save the life of a pregnant mother who had malaria and who had been rejected by her husband. After hospitalization and recovery, Zillur was able to bring her back home. There's now a poor fund saved up for emergency cases. But it's not likely to cover the many who have no money.

MOUAZZEM: You've been ill for 2 years, you're so close - why can't the doctor come and see you?

OLD WOMAN: I can't pay, I have no money

MOUAZZEM: Oh, so if you have no money you can't see the doctor?

OLD WOMAN: No.

MOUAZZEM: How do you manage?

OLD MAN: Everyone helps us, and we live like this.

MOUAZZEM: What's wrong?

OLD MAN: Asthma.

MOUAZZEM: How long have you been suffering?

OLD MAN: About a year.

MOUAZZEM: One year?

OLD MAN: Yes.

MOUAZZEM: When did you see the doctor and what other treatment are you having?

OLD MAN: No, I haven't seen anybody.

COMM: Wednesday - doctor's surgery day and anti natal clinic. After seven years, health and attitudes have improved, even if income levels haven't.

MOHAMMED IQBAL: As a doctor, I have a social commitment. I wanted to do something for the society. Here, I found the health is addressed totally - not as part of the problem... All the problems of the health is addressed from the developmental health, preventive health, curative health - everything is addressed properly. And the people's participation, and the self help activities are going on nicely... So I like the job and I am here and I hope I shall be here!

COMM: Zillur shows Almas into the surgery. She's made the five kilometre journey, and she's come with her friend, Farida.

MOHAMMED IQBAL: They are living in a hilly area, and clinically, she is suffering from malaria. And at the same time, she is a smoker, and she is having some bronchitis. And so for both the reasons she has fever. I am giving her anti-malarial drugs. At the same time I am giving antibiotics for bronchitis also.

COMM: Sakina's son can't hear, can't cry and can't hold himself up. He's 12 months old.

NANDITA NAZMA: I think this baby has cerebral palsy. His prognosis is not good. Hold him on your arm.

SAKINA: Everything he eats he vomits it out. He doesn't go to toilet.

COMM. With cerebral palsy, Sakina's son, Shahidullah is always going to be disabled. Sakina faces endless trips to Chittagong Hospital. It's over an hour each way by bus and costs more than she has.

SAKINA: I'm poor, how can I go to hospital?

NANDITA NAZMA: I know what you mean but there's nothing else we can do.

SAKINA: Will it make him get strong?

NANDITA NAZMA: Yes, and make sure you give him this medicine, OK?

SAKINA: Yes.

DAVID LEGGE, LaTrobe University: Look, there is no doubt that there is a huge scope for building more effectively on the creativity and initiative of local communities. But when women have an obstructed labour, we need to have proper operating facilities with all the proper mod-cons of your technical hospital.

SIOBHAN PEATTIE, Save the Children Fund: If everybody is very poor, then there is a limit to the amount of service provision that can come from that... So it is a model that can be scaled up, so it's really an approach, you know, that governments should look at. You really need a lot of input, financial input to make that happen at a population level.

CAPTION Since the filming this programme, Sakina's son Shahidullah has died. The Chakaria Community Health Project continues to provide the only low-cost health care to Mohuripara.

END