COMMENTATOR (COMM.): Previously on Life...

JON ALPERT: Would you please show me how much food you have in the house right now?

AMARTYA SEN: People die needlessly - millions of them - across the world

JAMES WOLFENSOHN: Women are central to the whole issue of development.

FRED SAI: Our social structures have broken down.

ROBERT REICH: If those are our only options: either preserve and protect the old; or usher in the new with no social responsibility at all, then we are in trouble!

COMM: Meet Sam Everington - a doctor in twenty-first century London.

DR EVERINGTON: We're one mile away from the Docklands here, one mile away from the City. We're one mile away from the richest part of the country. Yet we're in the poorest part of the country with some of the worst health that you'll find in this country - not only that, but with illnesses you'd normally expect to find in the Third World.

COMM: Every night, Sam deals with the routine caseload of Britain's National Health Service.

SAM: Hi, how are you?

WOMAN: All right, thanks.

SAM: Celia's upstairs, is she? OK

COMM.: From minor 'flu cases to bedridden stroke patients.

SAM: How are you doing, now?

CELIA: Not too bad.

SAM: Did you um, did you try the - the diazepam?

CELIA: No. But the other painkiller's better. With these stronger tablets I feel more mobile.

COMM: Many of the cases that he sees could not have been prevented.

SAM: A hundred and eighty over eight-six. That's not bad, actually.

COMM: But that's not always the case.

SAM: So how many people sleep in this room?

MR SULIMAN: Five.

SAM: Five.

MR SULIMAN: Five of us sleeping in this room in here.

SAM: And there's three in one of the beds, um-

MR SULIMAN: Three. Three of us. Three of us with- with this one mattress here.

SAM: Right.

MR SULIMAN: This is dampness this place on side of the wall - that side of the wall is very bad, you know.

COMM: Sam also has to cope with the illness caused by poor housing and by poverty.

SAM: And how many people live here now?

MR SULIMAN: Well, er we got ten people.

SAM: Ten. And how many of your children have asthma and eczema?

MR SULIMAN: I got three of the children got asthma and two of the children got eczema.

SAM: And how are they doing in terms of their weight and height?

MR SULIMAN: Well he is getting very thin and things, you know and she's not growing up - in my opinion. My wife got diabetic, she got rickets. And she got - her depression is worse. . .

SAM: Well, it's er very bad health problems in this area. We have increasing numbers of people with T. B., er a lot of the children are malnourished, er many of them suffer er from anaemia. Er, it's the sort of health problems you would expect, normally, to find in the Third World. When I was at medical school, we never thought we'd see T. B., er now it's a normal part of er our health care.

COMM: Sam's clinic in London's East End reflects his view that tackling health must mean tackling poverty and helping people with their everyday lives. Medicine, he believes, isn't just about the prescription pad - it can also mean helping people back to into work. The clinic even includes a gallery for local artists. Sam's not just a doctor he's a man who's helping to give confidence back to a depressed community.

With children of his own Sam has little time to spare. Yet he's also one of the top advisers to Britain's National Health Service - and a leading authority on health and the community. So, who better than Doctor Everington to report for 'Life' on a country where poverty is the most lethal killer of all.

We invited Sam to travel to Dhaka City, the capital of Bangladesh. Four out of ten of his patients are of Bangladeshi parentage. Yet this was his first visit.

SAM: Amazing. It's incredible - so many people on the street! It's very colourful - it's very colourful, though.

COMM: But Sam has come to a country whose Gross Domestic Product is just one seventieth of Britain's. A country which the United Nations ranks as one of the two dozen least developed in the world.

SAM: I just hadn't realised it was this poor.

COMM: A very few Bangladeshis do have a token stake in the Global Economy. But this is still a land of more beggars than businessmen. There has been progress.

In just twenty-five years, life expectancy for children has risen from forty-four to fifty-eight years. But despite their resilience, people in Bangladesh are almost four times as likely to die before they're sixty as in Great Britain.

PROFESSOR AMARTYA SEN (1998 Nobel Laureate Trinity College, Cambridge): The two countries where I spent my childhood, mainly Bangladesh and India and both of these, it, it's true in many ways um people do live much er longer and the disease is much less common. The average Indian lives today fifteen years longer that then average British did in 1900 - though the income level is still lower than, than Britain in 1900, er so I think there are differences. And yet it is scandalous that, that curable diseases could batter the lives of so many people in Bangladesh and India.

COMM: The Burriganga river runs through the heart of Dhaka. Half the population have no access to proper sanitation. So Bangladesh's ubiquitous waterways can be lethal carriers of disease.

SAM: It's incredible just to see children washing in the river like this. No doubt most of the sewage goes into this river and just down the river two people - other people - are washing too with buckets which they're putting into the water. To see a young kid like this just er jumping into the water and washing is really frightening.

COMM: And the frightening consequences, Sam found in the Dhaka Shishu Children's Hospital, funded mainly by the government, and in a country which spends scarcely over one per cent of its GDP on health, always short of funds.

MALE DOCTOR: But Sam, this is the observation unit. Some patients we cannot put straight away into the ward because we have a limitation of . . .

COMM: This is where children come if they're lucky. Children with infections caused by poor sanitation, by poverty. Bashir is unconscious from Meningitis. His mother Ayesha brought his here from a local hospital a hundred and twenty kilometres away. Tasleena's child is severely malnourished.

TASLEENA (ENGLISH TRANSLATION): Ever since she was born, my daughter's arms and legs have been very flappy and soft. She can't sit, so we've given her many medications. But it didn't work, so we brought her to the children's hospital, all the way from Rangpur.

COMM: That's a journey of some four hundred kilometres. Tasleena's daughter should survive. But about one in twelve children in Bangladesh die soon after birth. Half as many as thirty years ago but still over ten times as many as in Britain.

DR. NAILA KHAN (Paediatrician, Dhaka Shishu Hospital): The main causes of death in the first few months of life are actually infections related to the child being er born with low birth weight that is less than two point five kilograms. And being growth retarded in the mother's womb and so is vulnerable to all sorts of infections after delivery. So easily the largest cause is neonatal and infant infections.

COMM: As Sam found, it's not only babies who are at risk form poverty. One in two pregnant women have anaemia. And eight out of a thousand die in childbirth.

DR. NAILA KHAN: The main causes of maternal morality in Bangladesh are, I would say, a) er the mothers being married off very young - so that, you know, fifty percent of mothers are married off by seventeen point five years of age. So they're having children when their pelvis is small, they're not developed themselves - they're malnourished themselves. So they are having a lot of problems during pregnancy; b) I should think is a lack of obstetric care when they need it, for example a lot of mothers are haemorrhaging to death. And c) I would say is er violence against women and there's a lot of er instances of violence towards the pregnant mother - the girl - and er I would say that would be probably one of the largest causes of mortality.

COMM.: Outside the children's hospital are expensive private clinics. But there's increasing debate as to whether this kind of Western hi-tech medicine is really what countries like Bangladesh need.

CLARE SHORT Secretary of State, Dept. for International Development, UK): If you look at spending on health across the developing world there'd be varying amounts. And people often say, "Ah, this country needs to spend more on health!" But you have to say, "Who's getting what out of the existing health spend?" And you very frequently find that the overwhelming bulk of the money is going on very flash, quality modern hospitals in the capital. And of course the elite use those hospitals and there's state of the art medicine - as good as hospitals in any part of the world. And there is no health care of any kind whatsoever for the rural poor. Now, of course, we all want everyone to have everything, but surely the first priority is the basics of health care for everyone in the country. And in most developing countries that's not the case.

FRED SAI (Professor of Community Health University of Ghana): We have got a situation where practically all of the health training of the health leadership in many of the developing countries has come from direct - either directly from Western institutions, or indirectly from the same western institutions and they, they have moved away from the kind of medicine that is needed for the majority of the problems of the developing countries to the kind of medicine that is needed for the developed countries.

COMM: The Agargoa slum in Dhaka - conditions that breed diseases that could be cured if the right medicine was available. Before Sam leaves for the countryside, it's time to reflect on health in the city.

SAM: I'm right in the middle of Dhaka, now. Er, I've been really shocked by the - the enormous amount of illness, particularly in young children. Er, we've just spent a day in two hospitals and seen children with infections here er that are deadly, but back in the West would be treated very easily by a simple antibiotic.

PART TWO

COMM: Half an hour from Dhaka, the village of Charigram Tharma. The countryside of Bangladesh may look picturesque, but there's poverty here too. This morning: a rare visit by a doctor from the city - Dr Everington is visiting from London. He's come to see Sabeda Begum who's just had twins. In Britain she'd have had specialist care in hospital. Luckily, with help from the local nurse her children are fine, so far.

SAM: What sort of immunisation does the children have?

COMM: Sam's told that Sabeda's children will be immunised. With help from foreign doctors, Bangladesh is now able to immunise six out of ten children with the latest vaccines. But that leaves hundreds of thousands unprotected from common diseases.

PROFESSOR JEFFREY D. SACHS (Centre for International Development Harvard University): These are diseases vaccine-preventable that take hundreds of thousands or perhaps millions of lives in the developing countries. But those countries have been too poor even to take up these new vaccines and so you have people dying absolutely clearly because of their utter impoverishment.

COMM: Next stop, the Gonoshasthaya Kendra People's Health Centre. Dr. Zafrullah Chowdhury's patients are local villagers who haven't been able to safeguard themselves from disease or who couldn't afford the most basic drugs.

DR. CHOWDHURY: Most of the diseases prevalent here are easily treatable and can be cured it would depend on two things: education and some basic medicines. Basic painkillers would help - simple painkillers like paracetamol.

COMM: But some diseases require more than paracetamol.

SAM: T. B. This X-ray shows T. B. Here.

DR. CHOWDHURY: T. B. is really, really - it is on the increase. And still T. B. treatment is minimum six months. T. B. medicine is so costly. It costs - really for one week's treatment it costs two days wage.

COMM: Still - over sixty thousand Bangladeshis die of the disease unnecessarily every year.

DR. JIM YONG KIM (Partners in Health', Harvard University): Tuberculosis can be used in many ways as an indicator of the performance of a public health care system. The sufferers - tuberculosis sufferers - are generally the poorest people in society. And are unable to pay for, for therapy in many, many instances. In addition, you need to provide tuberculosis therapy for a minimum of six months. And the doses must be directly observed by a health worker or by a physician or a nurse. And er in order to get a system like that together one needs to have a strong commitment to public health for the entire population, including poor people. So what's happened is as countries er like Bangladesh - and er certainly in Latin America - have attempted to pay back external debt, one of the things that has - have had to be sacrificed is a kind of public health care infrastructure that would lead to high quality treatment for diseases like tuberculosis.

DR. CHOWDHURY: To buy health care people here have sold their house, tin roof, and become poorer. Almost they started selling their blood.

SAM : You're saying people who are will sell their blood in order to pay for their health care?

DR. CHOWDHURY: Exactly that's what I'm saying.

SAM: And how much to they get for their blood, then?

DR. CHOWDHURY: About a pound - about one sterling pound for once you've been bled. And it is almost two days wage.

SAM : Two days wage? And how much health care do they get for that money, then?

DR. CHOWDHURY: I would say really completely the worst - most of the time it's the worst - it's the wrong healthcare. That is the most sad part of the story. You have sold everything, including your blood and then you're not getting the right health care.

FRED SAI: Poor people are generally not very healthy and if you are not healthy you cannot work well and you also spend money trying to get healthy. So the little money you have you want to spend in trying to get healthy. You go trying to get healthy and you are not on your farm, you are not going fishing and you are not producing anything. And this can be looked at a national level too: a healthy population is a much more useful tool for development activities than an unhealthy one.

COMM: With patients even selling their own blood, Dr. Chowdhury wants to show Sam how he's helping.

DR. CHOWDHURY: We are trying to create jobs for the rural women we train women in a variety of ways.

COMM: If the problem is poverty, the remedy may be jobs - jobs the global economy does not provide.

DR. CHOWDHURY: We are not that excited about the global market. We think our people are too poor to take the benefit.

COMM: So, Doctor Chowdhury's doing just what Sam's doing in London - he's turned part of his clinic into a workshop. These women aren't nurses but local villagers. Their masks protecting them from glass fibre they use to manufacture chairs - these for a local football stadium.

DR. CHOWDHURY O/S: The whole question is are you going to allow the poor people to have entry into opportunity? That is the main thing, so that is what we do here.

WOMAN IN WORKSHOP (TRANSLATION): From my salary I look after my mother and two children: my husband is not a good man - he doesn't pay anything for us. The money I am earning I'm spending on my children's school fees, books, clothes and so on.

SAM: Why as a doctor are you creating all these job opportunities?

DR. CHOWDHURY: Simply dolling out medicine doesn't create health. Employment has got a tremendous impact on the health care. So employment, it leads to good housing, good sanitation and good health that's why we're creating more jobs at the rural level. And better family life.

COMM: Back down river, Sam returns to the capital. Here in Dhaka - just as in the countryside - poor people desperately need work so they can afford modern medicine.

But - as Sam's about to be reminded - being healthy in the Third World, isn't just a matter of combating disease. At the centre of Diarrhoeal Disease Research Centre, American doctor George Fuchs works on the cutting edge of cholera research but spends much of his time looking after children who are not diseased but simply malnourished.

DR. FUCHS (Director, Clinic Services Division, ICDDR, B): So this is our Nutritional Rehabilitation Unit. As I was telling you earlier, about two thirds of our patients that come here each year are children and eighty percent of them have malnutrition. I think you can see how skinny this one - how wasted - see this, the thin little arms. How old is this little. . .?

NURSE : Eighteen months.

DR. FUCHS: Eighteen months. So how - I mean that's the size of what? About a six month infant?

SAM: If that.

DR. FUCHS : Eight months? Who's eighteen month old. This child's earlier in rehabilitation phase, now I want you to compare this child that we just saw that's eighteen months. Now, no doubt it's still malnourished. But if you see how this one's brighter eyed, more interactive with the environment, and you know as a mother, which one are you going to respond to? You're going to respond to the one that's interactive in terms of providing more input and care.

SAM: Absolutely.

COMM: This clinic is also a canteen. Teaching mothers to prepare the right food a crucial part of the treatment Dr Fuchs prescribes.

DR. FUCHS : Most nutritional rehabilitation units are using formulas, commercial formulas, that are very expensive. This is very inexpensive. This is Khitri, a diet that was developed here that's fairly nutritional- nutritionally balanced and it's inexpensive and it's using locally available foods so we teach the mothers how to prepare this and we have a demonstration kitchen out in the back and they learn how to prepare this so that when they go home they can feed the children themselves - prepare this. Almost half of all infants in Bangladesh are born low birth weight - that is twenty five hundred grams or less. Those infants, right off from birth start disadvantaged. Those low birth weight infants have more poor development cognitively, so they don't do as well in school. Having half the population starting off disadvantaged like that has enormous consequences for the country's economic development.

SAM : What you're saying is that, that health is critical to development?

DR. FUCHS: Yes. Yes. There's a direct link: er nutrition and health, yes. You can't develop a society economically and er financially if you don't have good health.

DR. GRO HARLEM BRUNDTLAND (Director General, World Health Organization): One point two, one point three billion people live on less that one dollar a day. And the diseases linked to poverty is a devastating er blow to the opportunities of these families and people to move out of their poverty, Because the health of these people are linked to their ability to learn; their ability to believe that their children will be growing up as healthy individuals, er and they are in a vicious cycle of ill- health and poverty.

NEWS PRESENTER: Welcome to 'News at Ten'. Hearty and red carpet warm welcome awaits the US President William J Clinton. It is the first. . .

COMM: As Sam prepared to leave, Bangladesh prepared to welcome another guest. It was to be a warm welcome for Bill Clinton - even though the US like many other Western countries has cut its foreign aid budget to developing nations.

PROFESSOR JEFFREY SACHS : This is a country - in the United States for example, where since the beginning of 1996 the gains on the sock market are eight trillion dollars- would it be so much to take one percent of that - maybe eight billion dollars - to put to use for poor people all over the world.

You could get everybody vaccinated with all of these new vaccines - no problem! You could use that money to develop the new vaccines of malaria, for tuberculosis. I'm talking about one per cent of the capital gains of the last four years in the United States. But it hasn't even reached the political radar screen.

COMM: At the last count, thirty million people in Bangladesh - one in four - have no access to health care.

SAM: When I came back to my clinic, the first thought was how lucky we are to have the National Health Service. I work in the most deprived area of Great Britain with enormous poverty and deprivation, but it's nothing compared to what I've seen in Bangladesh.

INTERVIEWER: How do you feel about that?

SAM: I feel quite uncomfortable actually, in a funny way, I feel quite uncomfortable, because we just don't know what true poverty is.

END