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It was perhaps for the umpteenth time that Sheikh Hasina, the prime minister, as well as president of the ruling Bangladesh Awami League, spoke tough against tender manipulation, extortion and consequently plain violence by her party cadres. Ever since the Awami League assumed office in January this year, different wings of the party, particularly the Juba League and the Chhatra League, which are the youth and student fronts of the Awami League, have been embroiled firstly with other parties, and once they were practically removed from the field, amongst themselves.
   There were the violent clashes among factions of the ruling party’s student wing on different university campuses to begin with. The violence was followed by warnings of dire action where key cabinet ministers including the prime minister directed the authorities to take stern action against unruly quarters and those causing violence. There were similar warnings when factions of the ruling party’s different wings locked in clashes over territorial control or tender manipulation. It is typically the case that the ruling party’s coterie considers it their rightful privilege to secure government contracts by manipulating tender bids, or securing territorial control over certain areas for extortion or some other form of rent seeking. But a bad precedent cannot be taken up as an example to be imitated and furthered in a worse manner.
   Whether within themselves among their factions, whether within the coalition or up against the opposition, which is almost negligible both in the parliament and in the streets, except their voter base, there are almost daily reports of the ruling party men clashing and inciting violence at some corner of the country. When the clashes become too frequent, or when media coverage of a certain incident becomes a little too embarrassing even for the party’s apparently brazen central leadership, one or the other comes out with a strong statement. So did Hasina, as reported in New Age on Thursday, at Juba League’s 37th founding anniversary.
   This time Hasina cautioned her youth front’s members about the rising allegations of tender manipulations and extortion and other such misdeeds. As mentioned before this was not the first time since the first month of the government’s tenure. As head of the government, Sheikh Hasina, has the responsibility to direct the state machinery to initiate legal action against the wrongdoers effectively and bring them to book; and as the president of the ruling party she has the responsibility to take disciplinary measures against the unruly activists. While police has not yet been seen taking any effective steps against the excess of the ruling party activists, nor has the party been seen taking any disciplinary actions against the unruly elements at the organisational level so far. The message is simple, either the prime minister does not have the required control over her government and the party, or she does not seriously mean any action against the wrongdoers of her party. In either case, the premiere is not up to her electoral pledges. It is time she takes some decisive actions against her unruly activists, rather than giving lip services about tackling internecine conflicts, extortions and tender manipulations.

Better pay to secure
better teachers

The government must be commended for having revised the pay scale of its employees upward. Given the price spiral of essential commodities, the generous increase that has been initiated is also necessary for the government employees to lead even remotely decent lives. As such, the increase of salary and wages between 55 and 74 per cent is also quite commendable. Furthermore, that the lowest three grades have witnessed increases over 70 per cent should be a further credit to the government for rewarding those who needed the money most. That is not to say that the new pay scale is flawless and well justified. Surely there would be a number of government employees who would feel deprived and not duly rewarded compared to those in the other grades.
   But that is not where we wish to comment regarding the new pay scale. A report in New Age, published on Thursday, points out that the teachers of government primary schools will continue to get the same salary as that of drivers of the government offices. The report cites certain leaders of the teachers’ association saying that it has been one of their consistent demands that entry level teachers of government primary schools be paid at least more than that of the drivers. They also lamented the fact that there had been no change in their fate even after the current government took power although there had been lofty promises.
   Quite naturally, the teachers had hoped that they would be given a better grade and better pay with the introduction of the news pay scale for government employees. Unfortunately it is not so and they are still in the same grade as drivers. That teachers, no matter where or which level, are put in the same grade as drivers indicates a perverse mindset of those who designed this pay scale in the first place. Furthermore, it indicates the kind of respect that the government wishes to give its teachers who are effectively shaping the country’s future. It was one of the Awami League’s election pledges to ensure universal primary education within its tenure. As such, there is an added obligation for this government to invest in the education sector and work towards improving the quality of teachers so that the standard of education genuinely improves.
   Towards that end, the government is not only obligated to ensure that school teachers, especially those in government primary schools, should enjoy a certain status in their lives and be able to lead reasonably decent lives but also allow them to dedicate themselves towards their students. Thus the government should immediately look into this matter and announce a respectable package for the 2,00,000 primary school teachers in order to attract more qualified and educated graduates to shape the country’s future.

Over the last few decades and especially since the 1990s there is a resurgence of interest and some new initiatives in traditional medicine both in developing and developed countries. A number of factors contributed to this resurgence of interest. Perhaps, the most important factor is the nationalist spirit that engulfed the developing countries on their independence from the colonial rule. With political independence during 1950s and 1960s, most of these countries experienced a sense of cultural revival. Reviving one’s own culture and taking pride in it became a nationalist goal. Nationalist political leaders of this post-colonial era, like India’s Nehru, Ghana’s Nkrumah, Algeria’s Ben Bella, Indonesia’s Sukarno, Tanzania’s Nyrere, Egypt’s Nasser and Zambia’s Kaunda, championed such cultural revival. Traditional medicine, along with other cultural heritage, undoubtedly benefited from this nationalist revivalism. For the Indigenous people of the Americas, the growing demand for self-determination, land rights and self-government have produced a similar result. This cultural revival renewed interest in traditional health practices and products among the Indigenous people. At a Pan American Health Organisation conference held in mid-1990s on indigenous people and health, many country representatives from South America and Canadian and American Indian bands, stressed the need to ‘rediscover and restore’ the traditional healing systems practiced by indigenous people of these centuries. Latin American representatives reported on the growth of activity and interest in traditional medicine in their countries. Several countries established a separate department or division of traditional medicine within their health ministry. Fifty-two different associations representing traditional health systems were represented at a recent meeting on traditional medicine in Mexico City.
   More recently, hard economic realities also contributed to this renewed interest in traditional medicine. For many developing countries, the Western health care system became economically too burdensome. This system, in most cases, is based on institutions (hospitals) with a curative focus. In many developing countries, hospitals are primarily located in large urban centres while the bulk of the population lives in rural villages. These hospitals, with all their modern technology, often consume a greater share of the health budget, leaving little resources for other essential community-based health initiatives. In some countries, one single urban-based large hospital often account for more than 30 percent of the total health budget. Drugs, produced by multinationals, and often imported from outside, are also a cost burden that few developing countries can afford. Faced with such economic pressures, many developing country governments have recently increased their support for the long-standing traditional medical practices.
   In part this resurgence is also simply an acceptance of reality. In many developing countries, more than 8O percent of the population, mostly living in rural areas, depend almost exclusively on traditional medical practitioners for their primary health care needs. Governments could hardly continue to ignore this reality. On the other hand, the priority for these governments was to create a legal framework for standardising and regulating diverse traditional medical practices within their borders.
   International concern and pressure to conserve bio-diversity is the latest source of influence on the promotion of traditional medicine. Two other interrelated factors must also be noted: clinical tests on the efficacy of some traditional medical practices (with positive outcome) arid, consequently, a rush by some multinationals to patent and market those products. These developments, one the one hand, saw a resurgence of interest in traditional medicine and, on the other, brought forth a plethora of problems and issues.
   The use of natural products for medicinal purposes, according to proponents of traditional medicine, has many benefits. For example, a crude herb contains numerous chemical elements along with the ‘active ingredient’. Since the herb is used as a whole, often in combination with a number of others, a natural mechanism is there, according to this argument, to protect the user of the drug from its potential side effects. This argument underscores two fundamental principles: that the synergistic effects of all the chemical constituents present in a particular herbal drug make traditional medicine less susceptible to side-effects and that in so far as traditional medicine is concerned, it is counter-productive to look for the ‘active ingredient’. The very desirability and practicality of applying Western scientific approach is thus questioned. Needless to say, such a line of reasoning is anathema to the Western medical tradition.
   Not surprisingly, such conclusions about the efficacy of traditional health products are often questioned. Sceptics are willing to accept them only after careful scientific research. The identification and separation of the active ingredient and its clinical trial are two fundamental elements of such scientific investigation. In these days of scientific development and rigorous experimental methodology, concern for consumer safety and security, and, not least of all, fear of litigation, such insistence on scientific validity is neither unexpected nor unjustified. It is argued that traditional medical practices and products, to be considered safe and effective, must have the same scientific basis like Western medicine. In some cases, multidisciplinary studies on pharmacologically active chemicals isolated from medicinal plants have clearly validated their traditional claims. Studies and tests are being carried out around the world - from China, Vietnam and India to Mexico, Nicaragua and Peru. Studies of Neem, for example, have validated numerous pharmacological qualities of this tree-leaf used in different Asian and African countries for a variety of ailments. In India both the government and the private sector are providing funds for research on herbal and mineral medicines. Some of these studies – testing of the Ayurvedic formulation for Parkinson’s disease and HIV/AIDS, bronchial asthma, viral hepatitis and diabetes mellitus, disease that are not amenable to satisfactory treatment by Allopathic medicine – have shown encouraging results. Such studies and, often, resultant scientific validations, have generated an intense interest on traditional medicinal plants among pharmaceutical multinationals in particular, and the Western medical practitioners and researchers in general.
   Some studies suggest that in most developing countries the use of traditional medicine has considerably increased in recent years. Its availability and accessibility – financially, geographically and culturally – are also contributory factors in this regard. Most of the traditional medical practitioners are ordinary folks, coming from similar socio-economic background as their clients. Referring to traditional medical practitioners in Thailand, for example, one researcher points out, ‘Indeed, traditional health services tended to be generally less expensive and more easily accessible.... More importantly, however, they were tied in with religion and the occult. In other words, traditional healers and therapies were, and are, quite integrated with the indigenous culture and ways of life. Even today, the social roles of traditional healers are well accepted and relatively close to those of the ordinary people. For instance, the role of the traditional midwife is similar to that of a grandmother in a village and the names of traditional healers are associated with the status of an uncle, aunt, or a grandfather. In consultations with traditional healers, patients feel free to ask questions on the ways to solve a problem or how to obtain more herbs or more remedies. Traditional healers are respected and held in high esteem in their village. Most healers are old, and they are respected for the experience that comes with age. Also, their fees are low and the therapies they prescribe are associated with ritual and religion. The system of explaining illness is familiar and comprehensible.’ In short, there is an affinity or social bond between the traditional medical practitioners and their clients. The ultimate benefits of traditional medicine may, at least partly, be attributed to this cultural/social congruity between its practitioners and consumers.
   At the same time, there is a persistent belief, yet to be fully explained, that traditional medicine has effective cure for certain complex diseases such as cancer, arthritis, asthma, diabetes, severe dermatological disorders, sexual malfunction etc. In making treatment decision people tend to be guided by some perceived relative efficacy of the modern and traditional health systems. Some recent studies conducted in China, India, Bangladesh and elsewhere, tend to support this view. For example, in treating eczema and certain chronic skin conditions, Chinese traditional herbal therapy has produced quite encouraging results. In India and Bangladesh, Ayurveds and Hakims often claim specific advantage in treating such chronic diseases as asthma, liver cirrhosis, atopic dermatitis, etc.
   The fact that traditional medicine does not include such ‘invasive’ practices as blood transfusion, surgery, injections, etc. may have also contributed to their appeal. On the one hand, this reduces the risk of infections and, on the other, dependence on technology that is increasingly costly. It should be pointed out that these characteristics of the traditional health system (avoidance of ‘invasive’ practices and non-use of ‘modern’ technology), may also explain, at least partially, its historical lack of appeal to the Western educated, primarily urban-based, population in developing countries. Vaccines, surgery, x-rays, ultrasound, etc. have their own aura of scientific authenticity which traditional medicine clearly lacks.
   It would be misleading to say that the appeal or prospect of traditional medicine is limited to developing countries. Obviously, China, India, Pakistan, Bangladesh, Sri Lanka, Vietnam, Indonesia, Malaysia, Sudan, Egypt, Ghana, Nigeria, the Philippines, Mexico and other countries have made great advances in traditional medicine. In China traditional medicine is fully integrated with the modern medical system. In India, as Srinivasan has pointed out back in mid-1990s, there are ‘more than 100 Ayurvedic colleges, 26 Unani colleges and two Siddha colleges’, and they ‘turn out nearly 9,000 graduates every year - pretty close to the 10,000 churned out by the allopathic mill’. At the turn of the twenty-first century, Bangladesh had 10 Unani and 5 Ayurvedic Diploma colleges. There is also a graduate Unani college in the capital of Dhaka with five-year study curriculum accredited by the University of Dhaka.
   It is interesting to note that herbalism has slowly emerged as an alternative form of medicine in much of the developed world too. In the United States alternative medicine, as one article noted, is ‘finally coming out of the medical closet and into the mainstream.’ The prestigious National Institute of Health established an Office of Alternative Medicine in 1992 and allocate considerable amount of money for research in this area. A survey published in the New England Journal of Medicine in early 1990s showed that 34 percent of Americans used some type of alternative therapy in 1990, with an estimated cost of $13.7 billion. The current estimate puts the figure at more than $30 billion, 75 percent of which was paid by the users themselves. The establishment of the Traditional Medicine Programme at the World Health Organisation in 1978 should be regarded as an important milestone in this resurgence of interest in traditional medicine. Needless to say, the term ‘traditional’ or ‘alternative’ medicine is not a foreign term any more with international agencies like the World Health Organisation or the World Bank or with multinational drug companies.
   Despite all this renewed interest and real progress, the scientific validity and efficacy of traditional medicine remain questionable. Consequently, traditional medicine is yet to be accorded its proper role within the overall health system in developing countries. Three issues seem to dominate any discussion on traditional medicine: (a) lack of rigorous scientific ‘proof’ of its efficacy; (b) lack of standardisation across different drugs or remedies; and (c) the nature and quality of education, licensing and safety regulations. Needless to say without further research it is impossible to adequately address any of these questions. In Bangladesh, for example, except Hamdard (Unani) and Sadhana Aushadhalaya (Ayurvedic), none of the other traditional medical enterprises has standardised their products. At the same time, despite government regulations, information on the quality of education imparted by the Ayurvedic and Unani colleges in Bangladesh is scant. Little is known about the comprehensiveness of the curricula and/or its continuing modernisation/upgrading. On the other hand, although the Board of Unani and Ayurvedic Medicines was created decades ago to bring the Hakims and Kaviraj within the fold of the ‘formal’ healthcare system, the gap persists in truly implementing the plan. The traditional medical systems receive little attention while developing health sector plans or its strategic directions. Effective collaboration of the ‘modern’ and the ‘traditional’ still seems to be an elusive goal. The draft National Health Policy of 2009, for example, hardly mentions anything concrete about the traditional medicines and/or their role in the mainstream health system.
   Given the fact that medical pluralism is here to stay, it is time that Bangladesh develops and rapidly implements a policy of integration of the modern and the traditional and their active collaboration for the common good. Mutual recognition and active collaboration of a plurality of medical systems must be predicated on the establishment of an inclusive health system that takes each of them into account while developing polices and/or setting strategic directions. In other words, medical pluralism must be fully recognised at all levels. This will undoubtedly require a paradigm shift that must be led by the government. At the same time, social scientists in general and, anthropologist and sociologists in particular along with public health specialists could play a critical role in promoting greater understanding and acceptance of medical pluralism in Bangladesh. Our experience could serve as an example for other developing countries.
   The writer is an associate dean and director, James P Grant School of Public Health, BRAC University, Dhaka