A Gifted Son of the Soil

Dr M Mujibur Rahaman

International Centre for Diarrhoeal Disease Research (icddr,b) has established an annual lecture series in the name of health scientist Dr M Mujibur Rahaman to honour his contribution to research and his leadership in transforming research into action and in institution building. It is the first of its kind at the icddr,b and possibly in Bangladesh, an indication of the degree of appreciation of the world-class organisation for this internationally-reputed scientist.

During the Seventies, his research focused on curative care to reduce diarrhoeal deaths, reaching the care to the community for its optimal impact, and preventive solution to reduce diarrhoeal incidence, the major cause of death.  

The remarkable health development of Bangladesh has been termed a 'miracle' in the international health arena. In a special series on Bangladesh, the prestigious medical journal Lancet examined the reasons behind the development, and the authors found it to be a 'paradox' meaning that the extraordinary success cannot be explained by the conventional belief that health development is simply a function of socioeconomic improvement. Sir Fazle Hassan Abed has termed the Bangladesh health development the 'Bangladesh health revolution'. The Lancet articles recognised a basic ingredient of the health success as the researches that have been carried out by icddr,b and other organisations to find appropriate, effective, and affordable health solutions beginning in the 1970s.

To describe the health revolution, notable changes of a few key indicators must be mentioned. In the 1970s, life expectancy was around 50 years, and under-five mortality was about 200 deaths per 1,000; diarrhoea caused 33 percent of child deaths; and only 25 percent of diarrhoea was treated with oral re-hydration salt saline (ORS). Less than 10 percent of households had latrines and less than 30 percent used tube well water for drinking. In contrast, in the 2000s, life expectancy rose to about 70 years, under-five mortality reduced to less than 50 per 1,000. Now, diarrhoea causes only 5 percent of child death, and over 80 percent diarrhoeas are treated with ORS. And, 95 percent households have latrines, and 98 percent households have access to safe drinking-water.
On the curative side in the 1970s, more effective intravenous solution was needed to treat hundreds and thousands of acute and severe diarrhoea patients. Moreover, the effective management of diarrhoea was only available from fixed-site facilities access to which was limited at the community level. On the preventive side, the practice of preventive measures was very poor, as seen above, due to the lack of access to safe water and sanitation.

Dr M Mujibur Rahaman

Dr M Mujibur Rahaman and his team developed an intravenous solution (named it 'Dacca Solution') which was more effective in the management of diarrhoea than the then WHO-recommended solution. The use of Dacca Solution was then scaled-up in Government health facilities to more effectively treat acute and severe diarrhoea, including cholera. The highly effective ORS already developed at the then Cholera Research Laboratory (CRL), was available but had limited access.   

Rahaman's research in the 1970s showed that diarrhoea care-seeking rate decreases with the distance between patients' residence and health facilities, especially for women and children, leading to higher mortality in the distant villages than the nearby ones. The implication of this research was that healthcare should be accessed at the community level for an optimal impact. Now, in the national health-service delivery system, healthcare is delivered through an approach called satellite clinic to reach women and children at the community level. The Directorate General of Family Planning itself conducts over 35,000 such satellite clinics every month across the country, and donor-funded NGOs also conduct thousands of such clinics.  Child immunisation is provided through EPI centres, a similar approach of satellite clinic. The concept of this approach of providing health services at the community level came from the Rahaman's study.

To reduce diarrhoeal mortality, Rahaman did an intervention of community-managed ORS delivery in Shamlapur, a remote village in Teknaf Upazilla. ORS packets were made available in selected households as depots from where villagers could receive ORS packets. After one year of intervention, ORS-use doubled in Shamlapur, compared to a neighbouring village Bordil that had a similar level of diarrhoea incidence. Diarrhoeal mortality rate was one-fifth in Shamlapur compared to Bordil. Rahaman then approached the Government and BRAC to develop programme on community-distribution of ORS throughout the country. Since then the use of ORS began to increase due to community-level activities of the government and NGOs.

In the preventive side, Rahaman conducted highly innovative interventions on water and sanitation in Teknaf and Mirzapur. Basically, latrine use was not in the rural culture, people used open space for defecation. Dreze and Sen in their book An Uncertain Glory highlighted that this defecation behaviour is still common in India but it has completely changed in Bangladesh. Similarly, use of tube well water for drinking was not common. The ingenious work of his team in installing latrines and tube wells, educating community women for maintenance and keeping them clean, and educating household members for drinking tube well water and continued use of latrine was fundamental for changing people's hygienic behaviour in Bangladesh.

Research from his team provided the evidence that the use of tube well water, keeping faeces way from yard, and handwashing reduce diarrhoeal incidence. Furthermore, they showed that the use of tube well water or use of latrine or small family size helps reduce infant mortality. These were the hard evidences that were used in justifying large investments in water and sanitation by the policy planners, development partners, and donor agencies during the early stage of health development in Bangladesh. Now we see the fruits of these researches and subsequent investments in the health improvement.   

In addition to his effective leadership in research and translating research into action, as mentioned above, Dr M Mujibur Rahaman helped institution building. He directed the Clinical Sciences Division of the then CRL; founded and directed the Nutrition Division at icddr,b; established several field research centres for icddr,b; and more importantly played a key role in founding icddr,b through a transformation from CRL. Even before and during the critical period of 1971 when CRL lost its funding source, he took the stewardship role of keeping the organisation alive, securing funds, and re-establishing its stable funding sources.  

Dr Rahaman has been able to see that the health solutions he developed have played a key role in the Bangladesh health revolution as well as in health improvement in similar countries. A gifted and talented son of the soil, the octogenarian otherwise healthy Mujibur Rahaman, is currently fighting against a terminal illness. His contributions will be remembered forever in Bangladesh and elsewhere.

The writer is an icddr,b alumnus.