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It is a matter of serious concern that a multilateral lending agency, involved in substantial infrastructure development, especially roads and highways, appears to be advocating a certain position regarding the Asian Highway Network, which would not suit the national interests of Bangladesh. According to a report published in New Age on Saturday, a paper of the Asian Development Bank, titled, ‘Restoring the Asian Silk Route: Toward an Integrated Asia’, points out that Bangladesh stands to gain substantially by reopening the ancient and fabled trade route that accounted for a considerable trade volume in the 13th century.
   Although the study, practically conducted by a couple of Indians, fails to project the potential volume of trade that might be generated by restoring this old route, it posits that restoring the route would eventually benefit Bangladesh. A critical look at the study shows that restoration of the Silk Route—which existed over 700 years ago and the dynamics of the region where it existed have changed significantly since— promotes and strengthens the Indian position of linking Bangladesh to the Asian Highway Network through India both on the east and the west. While we have no problem with India to gain certain advantages, we are concerned about the disadvantages that Bangladesh would be exposed to in case of restoration of the Silk route.
   Substantial economic gains are among the most compelling reasons for increased connectivity. Increased connectivity expedites and facilitates the potentials for increased trade and thereby increased interaction among the peoples of different regions. We have stated a number of times before in these leaders that increased connectivity among the countries of the subcontinent is imperative for an integrated South Asia. But such integration should come on the back of enhanced trade, increased interaction among the peoples and comprehensive mutual benefits from such interaction and cooperation.
   The Asian Highway Network provides such an opportunity for not just South Asia but also the emerging countries of South East Asia with their lucrative markets. Bangladesh should by all means join this highway network and there should not be an iota of doubt that it would be beneficial for Bangladesh. But Bangladesh needs to choose the best option for itself to get connected with the network when three alternative routes are there. Two of the three routes are through India on the east, the Silk Route being one and the third is through Myanmar—which has so far been favoured by Bangladesh, and quite rightly so—in the east connecting both Bhutan and Nepal in Bangladesh’s north-west through India. This route has a far greater potential to increase trade volume since these countries are virtually untapped markets for Bangladesh. We believe the only benchmark to decide on a certain route must be on the basis of comparative economic gains, as well as strategic advantages for Bangladesh. The choice of route must be such that it offers Bangladesh substantially better terms of trade through economic advantages and at the same time help preserve its strategic interest. Of the available routes, the one linking the Asian highway through Myanmar on the east ensures both, and therefore Bangladesh should go for that, in case it cannot wrestle out something better.

Dhaka’s chaotic road scene

Road traffic in Dhaka city is not only crowded but also chaotic causing interminable snarl-up which disrupts daily business at all levels. As this is an everyday problem in the capital it also becomes a factor of development and governance. Partly the problem arises from growth of population, and also from the process of development itself — more cars and buses and trucks. But to a greater extent the road jam is due to poor management and lawlessness on the roads. As a New Age report published Saturday notes, lack of proper enforcement of traffic laws and the road users’ reluctance to go by the rules lead to the traffic mess that makes life miserable. Quoting officials of the Bangladesh Road Transport Authority the report says that they are helpless as they lack the necessary manpower to handle the more than one million motorised and non-motorised vehicles that ply the city’s roads, lanes and by-lanes.
   Indiscipline on the road is a chronic woe of this city. Public buses load and unload passengers at any point of the road in defiance of the rules. Vehicles are run on ‘contract’ basis which makes it rewarding for the vehicle operators to carry maximum passengers within the shortest possible time which tempts them to break all the rules. Use of hydraulic horn in buses and trucks has been banned years ago but this eardrum-bursting horn is still freely used adding to the disorder and panic of the traffic scene. In this case the solution is very simple, since the offender cannot blow the hydraulic horn surreptitiously. Just catch the offender and prosecute. But this could not be done in two decades. The authorities were quick to ban rickshaws but did not exhibit the same alacrity in dealing with owners of buses, trucks and cars. This perhaps encouraged the latter group that they can get away with everything.
   Another woe is untimely road digging. The different utility services have to dig the roads but this is not done in a discreet manner. The pit is kept open longer than necessary with mounds of earth surrounding it, intensifying suffering of road users. And the wet days are chosen for the digging though it could be done at a better time. And after the digging that spot of the road is not re-carpeted for weeks. Lack of coordination between the different agencies like the DCC, WASA, Titas help to prolong this avoidable disruption.
   Improvement of communication infrastructure was a point in the election manifesto of the ruling party which said that underground railway, mono or circular rail and navigable river route around Dhaka will be constructed to solve the public transportation problem and traffic jam in the capital. Although some are long-term projects, there are some others which should be implemented immediately for easing traffic woes such as construction of proposed flyovers and a higher number of east-west roads in the capital.

WHEN Bangladesh was liberated, the people who had struggled hard to give birth to it sought to have their civil, political as well as socioeconomic and cultural rights guaranteed in a new constitution. Unfortunately, the constitution was not drafted by a constituent assembly elected by the people of independent Bangladesh, where participation of all sectors of society would have been ensured. Since the journey of Bangladesh was not initiated under a national government, and as the national agenda had not been prioritised with a consensus, political conflict erupted and the socioeconomic agenda took a backseat from the very beginning.
   The right to health is an important socioeconomic right that, unfortunately, the Bangladesh constitution does not address directly and adequately; governments also failed to make people’s health as one of their central concern of governance. Article 18(1) of the constitution states that ‘The State shall regard the raising of the level of the nutrition and the improvement of public health as among its primary duties, and in particular shall adopt effective measures to prevent the consumption, except for medical purposes or for such other purposes as may be prescribed by law, of alcoholic and other intoxicating drinks and of drugs which are injurious to health’ while article 32 states that ‘No person shall be deprived of life or personal liberty save in accordance with law.’ Regardless of these guarantees, hundred and fifty million people, after 38 years of independence, are at the mercy of almost casual medical access. State—run hospitals vie with private clinics for patients and money decides the course of treatment – not the patient. Furthermore, there are no guarantees that the produce and other food products that we are buying – be they local or imported – are free from adulteration or harmful chemicals.
   Article 15 promises ‘a steady improvement in the material and cultural standard of living of the people, with a view to (a) the provision of the basic necessities of life, including food, clothing, shelter, education and medical care...’ However, such goals are not envisaged as direct objective of the state but through ‘planned economic growth’. The articles 15 and 18 belong to part II of constitution which ‘shall not be judicially enforceable’. They guide state principles but are not obligatory for the state.
   
   The state of our health, in brief
   The term ‘health’ does not just mean absence of illness or disease. It also includes physical and mental well—being. However, given the state of our health service delivery system, even physical and mental well—being are adversely affected – if not the patients’, then their family member’s.
   
   Hospitals, doctors and health care
   According to statistics, there is one hospital bed available per 2,732 persons and one doctor per 3,125 persons according to the Bangladesh Bureau of Statistics. The quality of medicine has gone down and adulterated food, drink and medication has created a negative impact all over the country. For example, in 2008, the disease Kala zar struck 45 districts and it was reported that 7 persons had died after taking the medicine Miltefosin. The medicine was tested in a WHO approved laboratory—and found to be inadequate. Again, in the early 1990’s infants in Bangladesh were falling grievously ill due to adulterated Paracetamol-based medication and on June 5, UNB reported from Faridpur that ‘some 150 children aged between six months and five years reportedly fell sick day before after taking Vitamin A capsules and deworming tablets at Charshalipur village in Charbhadrashan upazila’. On June 9 The New Age reported, ‘Another child reportedly died of complications from Vitamin A plus capsule and antihelminthic or deworming tablet in Munshiganj on Sunday night raising the number of such deaths to two and several thousand children across the country fell sick in the last three days after taking the medicine.’
   Though there are hundreds of upazila health complexes all over the country, it is hard to find service. Denationalisation and privatisation campaigns of successive regimes have made the situation worse. Conditions imposed by international financial institutions and multilateral donors have made things more complex. Medical service has become a money minting machine instead of a national service. Poor taxpayers rarely get even standard treatment and their health situation has been compromised with the trends of consumerism and commodification.
   Health services are delivered by specialised personnel. When one thinks of health and well being, one of the first images that come to mind is that of a doctor. However, given the poor state of our health services, it is safe to say that some doctors are involved in contributing to the terrible state of things. The health ministry established a Monitoring and Supervisory Committee on August 31, 2008, in response to the reports of appalling health care conditions published in newspapers. In September that year, it was reported that 104 personnel in several government hospitals were found to be responsible for mismanagement and corruption, and were penalized. (Daily Prothom Alo, September 22, 2008) Between January and October 2007 alone, there were over 76 death cases reported to be caused by medical negligence, according to an investigation of a Dhaka-based NGO, Ain-o-Shalish Kendra.
    Again, between January and September 2008, press reports indicate that some 52 persons had allegedly died due to medical negligence.
   Malpractice cases are numerous, and even affect some of the country’s senior-most and reputed doctors because they treat scores of patients daily, giving each little time or thought, points out Dr Quazi Quamruzzaman of Dhaka Community Hospital. ‘It’s just that the whole system that needs to be fixed.’ (New Age, February 29, 2008)
   According to Dr Mohammad Saiful Islam, paediatric surgeon and dean of surgery, BSMMU, one of the biggest flaws in Bangladesh’s medical system is that there is no monitoring mechanism which checks whether doctors are administering wrong treatment resulting deaths. ‘The organisation that is to oversee such cases of negligence, the Bangladesh Medical and Dental Council, is now dead.’ (New Age, February 29, 2008) 1 While an alarming number of cases goes unreported, the issue of accountability is hardly on the agenda of health care sector in Bangladesh.
   Again, our country’s numerous private clinics need close monitoring. Many of such clinics are nothing but money—making ventures, paying little regard to human life. In the last two years many such clinics, especially those outside Dhaka City, have been fined or shut down due to malpractice and fraud. In Dhaka, LabAid and United seem to have gained some notoriety, especially in recent times. (New Age, February 29, 2008)
   
   Melamine in milk
   At the end of 2008, the world-wide scare of Chinese infants critically ill in hospitals due to melamine poisoning hit Bangladesh and caused major public concern. The government was forced to carry out tests on 8 popular brands of milk, resulting in the ban of three brands on November 3, 2008. What about other food products? Fruits and vegetables are being sprayed/ injected with harmful chemicals to ripen them faster, crops are being sprayed with chemical pesticides and fed chemical fertilisers which may have serious effects on our bodies. Genetically modified seeds are being sown, slowly wiping out the ‘healthier’ indigenous crops and making environment and ecology vulnerable. All these, too, affect our right to health.
   
   What can be done?
   Human right to health is now widely recognised in numerous international instruments. Article 25.1 of the Universal Declaration of Human Rights affirms: ‘Everyone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, housing and medical care and necessary social services.’ The International Covenant on Economic, Social and Cultural Rights provides the most comprehensive article on the right to health in international human rights law. In accordance with article 12.1 of the covenant, signatories recognise ‘the right of everyone to the enjoyment of the highest attainable standard of physical and mental health’, while article 12.2 enumerates, by way of illustration, a number of ‘steps to be taken by the states parties ... to achieve the full realisation of this right’. Additionally, the right to health is recognised, among others, in article 5 (e) (iv) of the International Convention on the Elimination of All Forms of Racial Discrimination of 1965, in articles 11.1 (f) and 12 of the Convention on the Elimination of All Forms of Discrimination against Women of 1979 and in article 24 of the Convention on the Rights of the Child of 1989. Several regional human rights instruments also recognise the right to health, such as the European Social Charter of 1961 as revised (art. 11), the African Charter on Human and Peoples’ Rights of 1981 (article 16) and the Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights of 1988 (article 10). Similarly, the right to health has been proclaimed by the Commission on Human Rights, as well as in the Vienna Declaration and Programme of Action of 1993 and other international instruments.
   Apart from the constitutional guarantees of right to health and well being enshrined in Articles 15, 18 and 32, the penal code does have some provisions penalising medical practitioners for fraud, wilful harm and hurt and negligence. Nevertheless, given the wide acknowledgement of the right to health in Bangladesh constitution, legal regime and health policy fall far short to meet the obligations. This should be a priority of the rights activists in Bangladesh.
   Another critical area for health activists is the issue of medical negligence. In the eyes of the law, medical negligence typically comes under the ambit of tort laws, since it is a civil offence as opposed to a criminal offence. The concept of tort applies to an act which is ‘wrong’ or constitutes ‘breach of duty’ as distinguished from a crime. The idea is that the doctor has a duty towards a patient who entrusts his health to the doctor’s care with the reasonable expectation that he will get a certain standard of treatment, even though there is no specific contract between them.
   The penal code in Bangladesh allows a victim of negligence to file a case if the doctor involved did not possess the educational or professional degrees he claimed he had, or if he failed to take the patient’s consent before operating on him. However, a surgeon is protected by Section 88 of the penal code which exonerates him from wrongdoing if his act was done in good faith with the patient’s benefit in mind. Moreover, the concept of a civil offence is intricately related to the idea of whether the law sees the act of administering treatment as a service which a patient is purchasing, and if so, whether there are minimum standards of the quality of this treatment that a doctor has to meet, say legal professionals.
   As has been mentioned previously, the extent of corruption within the health sector itself ensures that it is extremely difficult to prosecute medical malpractice or negligence. People should be made aware of the fact that it can, however, be done.
   There is also a large chapter in the penal code related to ‘Offences affecting the Public Health, Safety, Convenience, Decency and Morals’, which includes sections dealing with adulteration of food and drink, sale of noxious food or drink, sale of adulterated drugs and the sale of a drug as a different drug or preparation. Again, the Drugs Act of 1940 regulates the import, export, manufacture and sale of drugs. This act provides penalties for ‘misbranding’ drugs, importing and selling banned drugs and manufacturing prohibited drugs. The Act of 1940 is supplemented by the Drugs (Control) Ordinance of 1980 which, among other things, makes the registration of medicines compulsory, provides for good practices in the manufacture and quality control of drugs; provides penalties for the manufacture and stocking of sub-standard drugs; and provides for the setting up of a Drug Control Committee and a National Drug Advisory Council.
   The government has passed health and drug Policies. While the drug policy of 1982 was widely acclaimed the subsequent amendments have been widely criticised by health workers and others and we are still to have a realistic, practical, and accessible to all, National Health Policy that is people oriented. This is a big challenge, of course. Like justice, in Bangladesh health seems to be the property of the rich and powerful, and not something that is also the right of the marginalised and the poor. What can we do to overcome this?
   We conclude with a few recommendations: a) Address constitutional and legal absence of ensuring rights to health for the citizens b) Put in place a peoples’ oriented National Health Policy c) Put in place an effective and practical consumer law d) Establish a system whereby medical practitioners are periodically reviewed and lastly e) Establish a separate Food, Health, Cosmetics and Consumer Tribunal.
   Adilur Rahman Khan is an advocate of the Supreme Court of Bangladesh and secretary of the human rights organisation Odhikar. This paper was written with the assistance of Saira Rahman Khan, assistant professor, BRAC University and Farhad Mazhar, UBINIG.