Bangladesh Rises

By Philip J. Hilts

At its base, any proposal to greatly increase aid to poor countries will depend upon a belief that the projects will have good results. Unfortunately, for many years, foreign aid efforts have been subjected to caustic criticism, and too many projects have deserved it. But it is wrong to say that we have learned nothing in the past fifty years of administering aid to the developing world, or that we cannot run successful projects now if we have good leaders for the work. That is no longer a responsible argument. There are simply too many first-rate aid projects on the record over the past two decades for those objections to hold up. Models have emerged to guide the way about how money can be best directed, and perhaps no such model is more impressive than that developed by the Bangladeshi businessman who returned home to help save his country.

Fazle Hasan Abed, when he was growing up in Bangladesh, dreamed of building ships. After training for that, he eventually realized that not too many ships were going to be built in Bangladesh, and settled on the more likely career of accountancy. After a British education he joined Shell Oil, and rose rapidly to become a top accounting executive by his early thirties.

Then, politics and history pulled his career out from under him. On the night of November 12, 1970, the Indian Ocean conspired to end his career as an international executive.

There was a full moon over the Bay of Bengal on that night. That meant the tide was already high when a storm roared up the bay, driving it even higher. It was a cyclone, massively broad and throwing winds more than 150 miles per hour and tidal surges up to twenty feet high. But it was not the breadth of the storm or its wind speed that eventually put it above all other storms; it was what followed. U.S. forecasters saw it coming, and government forecasters in what was then East Pakistan saw it. Notice never reached the people where it would strike the next day, November 13. The counting is still vague, though it is believed that five hundred thousand people, maybe more, died in that storm—the worst in recorded human history.

Bangladesh was already in turmoil—both political and social—when the great storm arrived. Leaders were pushing for independence from Pakistan. When the storm arrived President Yahya Khan, who lived a thousand miles away in wealthier western Pakistan, ignored it. Instead, he flew on a junket to China. It was a turning point in history; the revolt against him soon began, and within months all-out war between East and West in Pakistan had started. After a startling rampage of rape and slaughter by the western troops, India intervened and helped push the West Pakistani troops out.

Out of this double catastrophe Bangladesh was born, an independent and utterly devastated state. And with the independence also was born a small group of well-educated Bangladeshis who went to the villages and borders to give aid to the victims of the storm and the war. Ten million refugees who had fled to India and Burma were now streaming home to villages that no longer existed.

For Fazle Abed, it was the end of one life, the start of another. He had been living both in Europe and in Bangladesh comfortably; now he could see his country ruined, yet struggling to be born. He happened to be in Europe and quickly went home to help. ‘Two years,’ he thought, ‘or maybe a few more.’ Abed once described the moment to a reporter: ‘I was suddenly confronted with the massive death and destruction after the cyclone. It was a life-changing experience, immediately followed by the political turmoil.’ Then, as he began the work of building Bangladesh back up, he said, ‘It was a continuous process of questioning your own existence, and the kind of life you lead.’

That was a third of a century ago now. Fazle Abed never went back to his job in international business. He began with refugee work, carting bamboo for houses, supplying tools for workers, and organizing medical aid. But as he worked, month by month, and then year by year, he was drawn further in. He could see that Bangladesh, while it was dirt poor, was nevertheless united by language and culture and religion; a completely new start was just possible, building on the glories of ancient Bengali culture, known for it high-mindedness, its poetry, its music and art.

Mr. Abed often wears dark suits, his face is mahogany brown, and above it all floats a shock of all-white hair. He wears rimless spectacles. His face is round, gentle, and almost cherubic. Journalists coming through have said his gentle demeanor makes him seem like a holy man without the robes, or maybe a Mother Teresa who can count and manage.

His office is in a building that is among the tallest in the country—it’s nineteen floors—and he points through the window to the sprawling city of Dhaka below. There are 13 million people in the city, pressed cheek by jowl in one of the greatest encampments of the poor in the world. Next to his office is a narrow lake. On one shore are modern roads, apartments, and shops, and from his window you can see the corrugated tin shacks jammed in rows along the other shore, so close to one another it is hard to walk between them. ‘Look there,’ he says, ‘We have shastho shebika [health workers] in that neighborhood. We started with the rural areas, but now we are in the city. Two for every one in the rural areas are needed in the city.’

Accountant Abed is now nearing seventy years old and he is the head of an organization that has become well known among those who work in the teeming field now called ‘development.’ It is the field you go into when you want to build society from the bottom. Among organizations that do this work, the one led by Mr. Abed is actually more than just famous; it is in danger of becoming a legend. It has even been referred to as ‘the world’s greatest NGO.’

Here is the accountant’s-eye view, just the basic numbers, on its work since those days after the storm and the war of independence.

It is the largest nongovernmental organization in any developing country. It started with six people (Abed and five friends) who borrowed $300,000 dollars from family and others who sympathized with refugee care. The group had no intention of staying with the work, or of growing larger. But as the government of the new nation was unable to muster all the effort needed, the duties and opportunities kept coming to the little group that gave itself the name (remember, he’s an accountant) Bangladesh Rural Advancement Committee.

Now, from six people, BRAC has 146,000 workers. Over the years, it is said, BRAC has become so large and powerful that it is in fact a parallel government within Bangladesh, though it has actively avoided trying to become that. It has taken on three basic missions for the rural poor: first, a few key health services; second, primary schooling for dropouts; and third, microfinancial services for poor villagers. It has intentionally limited its work to the poor only. (BRAC discovered that providing services for all made it certain that the better off would swamp demand and push out the poor.) Its work was limited largely to women, who also ran the programs in villages. (BRAC learned that offering services to women gave their efforts great leverage—women and children were the worst served but the most likely to benefit from health, schooling, and small loans.)

Still, BRAC is a large and potent organization, touching in some way the lives of about half the country’s people every day. The original intent was to try to help build the nation from the bottom up. Now, after three decades, it is difficult to say what proportion of progress in Bangladesh is due only to BRAC. Many other groups have been begun as well, and the government shoulders a substantial part of the burden, as do charities and commercial companies.

            However the parts are added up, Bangladesh has far outstripped all predictions for its future. In the 1970s, when referring to the dregs, the worst in the world, it was usual to mention Bangladesh. American secretary of state Henry Kissinger publicly called it, ‘a basket case.’

About that time, deaths of children under five stood at 248 dead for every 1,000. Because each woman was having, on average, about seven children, this meant every mother probably lost at least one. But by 2003 the death rate among young children had dropped by more than two-thirds, from 248 to 69 per 1,000. As the children were saved, and as family planning methods were made available, families then decided to limit their growth. Family size went from about seven children per family in 1970 to three per family now.

In 1970, a baby born in Bangladesh could expect, on average, to live about forty-four years. Today babies can expect sixty-three years of life. And that life will be in a different environment. Bangladesh was one of the few countries in history where women had lower life expectancies than men; that has reversed. In 1970, boys went to school and girls stayed home—now both are educated in the same numbers. Literacy has doubled, from 26 percent to more than 51 percent. Polio was eradicated in Bangladesh years before it was eliminated from India, Pakistan, and many other, wealthier countries. The rate of economic growth at the end of the 1960s and in the early 1970s fluttered not far above zero. It has now run above 5 percent per year for a decade. The country was importing food; now it can more than feed itself, and three-quarters of the economy has turned to other business.

Among the most interesting figures about BRAC is the one for donations. BRAC started with gifts totalling about $300,000 from local families. International donors later began to chip in. By 1994, BRAC had a budget of about $64 million; 72 percent of it came from international donors. But the idea was not to take handouts forever. BRAC weaned itself away, and by 2004 BRAC had a budget of $235 million, and only 20 percent of it came from donors. The rest was raised by BRAC programs themselves with its own workers’ enterprises and sales. It might be tempting to think that an antipoverty program might even turn a profit, but BRAC is satisfied to produce 80 percent of its needed resources.

The first BRAC programs—and the most famous—are the health programs. That is probably because their outcomes are measured in lives rather than dollars or years in school. It is also because the BRAC village workers carried out the single greatest ‘technology transfer’ in history, though it is little noted in the West. Researchers, first in other parts of the world, then crucially in laboratories in Dhaka and Calcutta, had discovered the key to the deadly diarrheas that come with the age-old plagues of cholera, rotavirus, shigella, and E. coli. With an accountant’s care and a revolutionary zeal, the BRAC workers proved that a medicine used for decades in intravenous solution in hospitals to save babies could be made at home—and used there successfully by women who were illiterate. Against the advice of doctors, and under the cloud of regular attacks, their scientifically rigorous tests proved the method. Then they began a ten-year-long project to teach the mothers of Bangladesh how to make and use the lifesaving solution. Using it, the death rate for babies with severe diarrhea dropped from 50 percent to less than 1 percent.

House by house, in its first years the volunteers trained thirteen million women in the techniques, beginning in 1979. Now, after more than two decades of working the villages the method has simply been absorbed as part of Bengali culture. The method, called Oral Rehydration Therapy (ORT), eventually caught on elsewhere and is now being spread worldwide under the official aegis of the World Health Organization. It is credited with saving more than a million babies every year around the world. And world figures reflect the change: In 1970, more than five million babies died each year of diarrheal disease worldwide; by 2003, two million were dying of it.

BRAC health workers, at the request of the government, also worked on delivering basic immunization. There are cheap vaccines for six diseases that children get, and in Bangladesh in the 1980s only about 2 percent of the population got them. After the BRAC and government work, the figure rose rapidly to over 65 percent, and now about 80 percent of Bangladeshi children get immunized.

Progress against disease and poverty comes not only from smart work and organization on the ground. It also comes from science and technology. Poverty workers sometimes complain that basic science gets too much glory and money, while the people on the ground are actually making the progress one spadeful at a time.

But both are necessary, and in Bangladesh, like everything else jammed together, they work side by side in the same buildings, the same rooms, and sometimes in the same person. As one former diarrhea researcher there put it, the job was to ‘take the science to where the diarrhea is.’

At the time of the first worldwide cholera epidemics, scientists, statisticians, and politicians were just beginning to use figures and graphs to see the big picture in human health and wealth. It soon was clear that in times of great trouble human anguish becomes centered in the bowels. During disasters like hurricanes and wars and in the most neglected places on the planet the condition that seizes the moment is diarrhea.

To Western ears it sounds like something from the past. Deadly diarrhea is caused by a variety of organisms, and to us they have an antique sound—cholera, rotavirus, shigella. But they are deeply embedded in our language. The guts are the seat of courage and of our fundamental moods; melancholia, the evocative term for depression, comes from the ‘black bile’ of the gut that was thought to cause it. In the Bible the psalmist says his bowels instruct him what to do, saying his inward conviction issues from them, and when Joseph ran to his brother, the text says that he made haste because his bowels did ‘yearn upon his brother.’ Elizabeth I in asserting her authority said, ‘I know I have the body of a weak, feeble woman, but I have the heart and stomach of a king, a king of England, too.’ When Shakespeare was speaking of political trouble he called up images of the innards: ‘Civil dissension is a viperous worm that gnaws the bowels of the commonwealth.’

All this because the gut is one of the more vulnerable parts of the anatomy. The digestive tract is a remarkable organ system, in the shape of a skin hose that can deftly separate water, chemicals, and nutrients, absorbing the required while flushing out the unneeded.

That is where the heroism in development begins. Researchers for years puzzled through the strange central event of diarrhea—that the intestine which usually absorbs water and nutrients suddenly changes in disease, at the level of individual bowel cells, and reverses their flow. They not only reject new fluids coming by, but dump out their own inside fluids, ultimately causing a total collapse of tissue walls and bloodstreams. The body is mostly water; during these events a massive internal drought breaks down the structures in the body and forces the heart and other organs to stop. Research eventually focused on the receptor molecules that dot the outsides of cells, and on how they were controlling the entry and exit of salts called electrolytes.

Some of the key work was done in Calcutta and in the Cholera Research Laboratory in Dhaka. (It is still there, and is now called the International Centre for Diarrhoeal Disease Research, Bangladesh. In fact, after the slashing of international public health funds in the 1980s and 1990s, it is the only major international research lab left standing in the developing world, after years when labs dotted the continents. Now, with a large HIV laboratory in Botswana, it is hoped a new cycle of research in developing countries is starting up.)

In principle, by the 1970s, the physiology was clear. Cells of the intestine must keep a balance of water and salt inside and outside themselves to carry on working. Some disease organisms, in an effort to get themselves spread from one person to another, have evolved the ability to create a huge flushing action of water by attacking receptors on the outside of intestinal cells, breaking down the inside-outside balance and turning the cells into outward-only pumps. Until these crucial years of research, it was thought that during disease cells could only dump their water, not absorb more at the same time. But the research proved there were two pumps available on the cells, and if the cells were given fluids with sugar in them, the second set of pumps would start working to take in water while the other pumps were still flushing it out. This was the key—sugar to get cells to stop the one-way outflow, and salt to get the normal operational levels back.

In hospitals it is possible to pump enough fluid into a cholera patient using an intravenous tube. But trying to translate this hospital procedure to the field was difficult. In fact, the first real experiment with the idea was disastrous. Robert Phillips, working during a cholera epidemic in the Philippines, tried giving a simple sugar-saltwater solution to patients by mouth. All were very sick, but five of thirty quickly died. His solution had too much salt, and the experiment killed the patients before the disease got them. Phillips was mortified. He began to think such field-rough treatment for diarrhea would never be possible. A few years later, he found himself the director of the Cholera Research Laboratory in Dhaka just as new discoveries on the physiology of diarrhea were made, ones that hinted at what might have saved his earlier patients. But he could not bring himself to approve further life-threatening experiments. As it happened, though, a small satellite clinic of the Cholera Research Laboratory came under different funding and jurisdiction than Phillips’s main laboratory. It was in Matlab village, south of Dhaka. Scientists there wanted to go ahead; Phillips agreed to not try to stop them if they worked in Matlab.

The doctors there felt they had to try again. After all, during the years of crises in Bangladesh the tragedy was painfully clear—Children in the villages were dying in waves. A lucky few near hospitals got intensive Western-style intravenous drips. It involved getting a doctor’s diagnosis as to severity, and a nurse to get a bag of expensive intravenous fluid into the patient’s arm with a sterile syringe, then someone to monitor the flows and progress.

At bottom, though, it seemed that the difference between the living and the dead was just some sugar and saltwater. The multiplication of cholera bacteria or rotavirus in the gut would gradually stop on its own. But the loss of fluid caused in the first day of illness was what killed the children. Replacing fluids was the key.

The turning point came with a couple of experiments. In one at the Cholera Research Laboratory, patients were started on intravenous drips, and then switched to oral fluids. The experiment showed they could eliminate the need for 80 percent of the IV fluid and setups. Then, during 1971, in one refugee camp in West Bengal when a cholera epidemic was cutting down children, a doctor from Calcutta took the next step, out of necessity. As the patients around him were facing death, he couldn’t even start with IVs. He gave homemade solutions to patients entirely by mouth, a sip at a time and with the right salts, until the worst danger had passed. It worked.

So in Bangladesh and India, the answer was in the air. The labs where the scientific work was being done were in the same building where the children were dying by the hundreds, and that alone moved the work to the next possibility. Fazle Abed and his assistance workers knew the scientists as well, and had followed the work.

            It was then, in 1979, that the BRAC group met to talk about increasing the size of its health work from a few villages to the greater part of the entire nation. They did not want to try to deliver too much; they decided to pick one intervention, one treatment that would make the most difference.

This was the 1970s; modern Western technology and medicine were greatly desired, while local products and technologies were denigrated. Medical authorities in Dhaka, the capital of Bangladesh, as well as authorities from the World Health Organization, were actively opposed to treating deadly diarrhea with homemade solutions in the hands of local women. Though it had been proven in lab work and shown in emergencies, it was not credible that village people could take over and use this medical technology. In fact, they said, it would be irresponsible to depend on illiterate women for such medical care. And they were right in a way; there was a serious problem. A study in the United States had shown that fully trained nurses, when taught how to make the oral rehydration solution in a lecture class, often failed to get it right. If they couldn’t do it, how could village women?

If mothers were to treat severe diarrhea, they had to know when to act, how to make the lifesaving liquid, and how to administer it. The liquid, in medical terms, was a ‘balanced electrolyte solution for rehydration.’ It was mostly water, with some sugar and a small amount of salt. But the proportions had to be correct. If it was too salty, it would accelerate the fluid loss and kill the infants instead of saving them. If it contained too little sugar, it would be ineffective, as if no treatment at all was given. Some researchers at the Cholera Research Laboratory in Dhaka, and at the Indian Council for Medical Research in Calcutta, now believed they knew more about how to get it right—just the right mixture and just the right delivery.

While the argument among medical people was going on, the BRAC group was ready to build a health campaign in the villages.

Abed led the discussion at BRAC over what to attack, and how—the diseases killing the most were pneumonia, diarrhea, measles, tuberculosis, and tetanus. Which one could be attacked most successfully? Diarrhea looked like their best chance because of the possibility that they might be able, as John Rohde of ICD said at the time, to ‘take the science to where the diarrhea is.’

For the BRAC leaders, as they sat in the village of Sulla in rural Bangladesh discussing their strategy, it was clear that the high death rate from diarrhea would continue. They walked through the problems.

Bags of saline were sold by local doctors in Bangladesh, but the price was one hundred taka per bag, and five to ten bags would be needed to treat each patient. At the time, the average income in the villages was about fifteen hundred taka per family per year, and the average child had three bouts of serious diarrhea per year, so the bags could quickly bankrupt a family. Packets of soluble salts were also beginning to be manufactured—couldn’t they be mixed at home? They were cheaper than saline, and in theory could be sold in Bangladeshi villages, where the women would then buy them in emergencies, take them home, and mix them in water to give to their sick babies. But no distribution system was in place, and if the government were to buy the packets for distribution, it would take hundreds of millions of packets to cover the country. And in the end, would the marketed packets reach the ones who needed them most? The instructions on the packets might or might not be clear; but in any case, 80 percent of the women intended to use them were illiterate. And finally, even with relatively inexpensive packets, it would still have to be the mothers who would diagnose the problem, buy the salts, mix them in water at home, and give the solution to their babies.

It was clear the center of the problem were questions about the mothers, not the solution. Why not acknowledge it and deal with it?

‘From the beginning we had this sense that you must trust people,’ said Abed. ‘Trust the mothers. We had a great belief that illiterate people, any human being, trained to do certain things could be very good at it. Put in a position to help their own communities, they could do it.’ In the long run many of the most basic problems came down to whether they should ‘get local people to do something, or get professionals to come in and do it for you. We are too poor to hire professionals everywhere, all the time.’

After thinking it through, they decided the first issue was the mother’s ability to mix the solution.

Directions that called for using a teaspoon would be no help; the village people don’t have or use teaspoons routinely. Sugar was to be used, but which sugar? Refined white sugar was not commonly available and was expensive. What the villagers more often had was gur, a brown sugar made from local cane or date juice. Analysis soon showed that gur was actually better than refined sugar because it often contained small amounts of potassium and bicarbonate—which were ingredients in the official oral rehydration solution.

So Abed started from scratch, in his own kitchen, with ingredients from the street. He took local salt, lobon, gur, and a tin cup common in the villages, a seer. After Abed and his wife cooked up dozens of batches of differing measures, they were sent to the Cholera Research Laboratory. The homemade concoction that proved closest to the official WHO formula was the following: a pinch of salt (in Bangladesh, it’s a three-finger pinch using the index finger, middle finger, and thumb), two small scoops of gur, and half a seer of water. Later it was modified slightly in the field, because women use their hollowed palms to measure scoops. One ‘fist’ was about two scoops.

After much more work, the formula finally became a simple chant: ‘a pinch, a fist, and half a seer.’ The mixture was dubbed ‘lobon-gur solution’ and the first great trial of the fundamental question—could illiterate mothers be taught to make and use lobon-gur successfully?—began in Sulla, Bangladesh, in February 1979.

BRAC carefully selected teachers (the first two were young village women, Hemlata Sarkar and Shwapna Bowmick), wrote and tested a teaching method several times, and only gradually spread the experiment from Sulla to other villages. Routinely, they took samples from the solutions made by mothers and sent them to the Cholera Research Laboratory for analysis.

Doctors in Bangladesh felt their turf was the treatment of human illness and that BRAC’s experiments were now starting to invade that territory. One official from the World Health Organization rushed to Bangladesh to try to get the government to greatly expand its anti-diarrhea program to head off BRAC. But that program was poorly planned and did not take into account the scale and difficulties of the problem.

BRAC went ahead, and over the next year young women trainers in groups of six moved through 662 villages, a few weeks in each village, attempting to train 58,000 mothers in the new treatment method.

One thing distinctive about this project when compared to many ‘development’ projects over the years is that it was carried out entirely locally, by people who had become deadly serious about making it work. So the many mistakes and repeated trouble in this or that part of the program were confronted, not ignored. That doing and redoing turned out to be the most difficult part. After the first thirty thousand women were trained, and their competence had been checked and rechecked by visits from monitors, Abed said, they reached a first plateau. It was thrilling to have built the project up so far, especially as it was under fire even as it carried on.

‘This was our first opportunity to scale-up programs from small areas to the whole nation,’ he said. ‘When we got done teaching the first thirty thousand mothers, we went back to check how we had succeeded. But we found that of all the women who had been taught the method, only six percent were using it when their children became sick. I was very disappointed. Disheartened. Why should we be going from house to house teaching women to do this if then they are not going to use it?’

Abed and the other leaders of BRAC believed in it. It was technically sound and medically potent, truly lifesaving. ‘We decided there must be something wrong with our teaching. The commitment we had was not being transmitted, somehow.’

They heard of one case when a mother with a very sick baby was visited by a young BRAC worker. The worker quickly suggested running down to the medicine shop for some diarrhea medicine. saying, ‘It will be quicker.’

Abed, talking about it now, looks down at his desk. ‘So we found out that some of our workers didn’t believe in what they were teaching. They thought our homemade solution was crude, second-rate.’

Abed realized their earlier explanations had been too sketchy and had not caught the imaginations of their workers. So he rounded up all three hundred workers of the time and started from the beginning, explaining why this solution was lifesaving and that anything else, short of intensive hospital treatment, could be deadly. They explained the infections that cause diarrhea and the reaction of the bowel; they gave details of why sugar and salt were crucial. They talked about the number of deaths of children in the villages in which they were working.

‘Once workers became convinced this was the best therapy, their whole attitude changed, their behavior changed. They became committed,’ he said.

In all BRAC work, that is now a vital test of whether a project will succeed or fail. Do the workers understand it? Are they excited, committed?

When they went back a little while later to check again, ‘we found things had improved a little—now twenty-one percent of mothers were using the method. But again, we were not very happy.’

There was another element they hadn't considered enough. They decided to bring in some anthropologists to talk to the mothers and other villagers about BRAC and diarrhea and their lives in general.

‘We found that the women were not the only ones we had to convince. They were not the sole decision makers in the house or in the village,’ he said. There were the husbands and brothers, who would say, ‘Don’t use that cheap method, I don’t trust it.’ And there were the local traditional healers who advised against using the BRAC method. So they added to their effort visits to the men in the villages, talks in the marketplace, and later added even radio advertising.

This round of effort pushed the rate of usage up over 50 percent, Abed said. Still not enough.

On further probing they found some of the workers were doing their teaching in too rote a fashion when they were tired, and some even cheated, skipping the teaching and mixing up solution themselves and sending for tests as if the mothers had made it. So a further round of fixes went in. They set up monitoring and paid the rehydration teachers not on the basis of houses covered, or sessions with mothers, but on the basis of a sampling of the actual performance of the mothers. For each mother who could answer questions and make an effective lobon-gur solution, the worker would get paid a certain amount. For each mother who was taught but did not perform well, the BRAC workers earned less.

And on it went. ‘The commitment grew, and the teachers began to get more creative and involved,’ Abed said. Eventually they were able to get the quality of teaching up and routinely get mothers to make the solution right over 98 percent of the time. The rate of death from diarrhea began to drop across the nation.

‘I have seen a lot of bad development projects,’ Abed said. ‘It is not that the people doing them are not sincere. They are. But in many cases, whether they come from outside the country or from inside, they expect to work a project for three years, do the best they can, and then go on to something else.

‘But in BRAC we were there for the long haul. We were committed to building the country forever. We wanted to make sure things really change. We were totally results-oriented from the beginning. That made quite a lot of difference.’

The project took ten years, but by the time it was over it was firmly rooted in the national psyche. Entrepreneurs soon began to take advantage of it, and started importing and selling packets of rehydration salts throughout the nation and in all the village medicine shops. Mothers could now make their own or, if they could afford it, buy the salts and work from there. The treatments of deadly diarrhea were now in their hands. The whole BRAC project from 1979 to 1990 cost about $9.3 million.

By 1990, the word had spread, and oral rehydration was being used in dozens of countries around the world. In 1991, one of the worst epidemics of cholera since the nineteenth century struck South America and Mexico. But the usual rate of death—one-third to one-half—did not materialize. In this epidemic millions of packets of salts were flown in and put in the hands of local medical people and villagers. The death rate when the epidemic died down proved to be nearer 1 percent than 50 percent. The transmission of Bangladesh’s success was, in fact, another kind of globalization.

In the end the object is really to give the people in the villages some mental and physical skills so they can do the work on their own, in their own villages.

During the years of scaling up the diarrheal disease treatment, BRAC also began its project to start village schools. Many girls in the villages were never sent to school, or soon dropped out because the work seemed irrelevant (mostly to parents) to their daily chores at home. So BRAC decided to take the village dropouts, about 70 percent of them girls, and offer a few hours of instruction per day. This is Bangladesh, the country with the densest population, so teaching just dropouts became a large task. Now BRAC has thirty-four thousand schools, which is said to be the largest private school network in the world. Each school is a single room with jute mats, chalk slates, and a few books for thirty students. Across Bangladesh, there are now 1 million students in the schools, and over the last couple of decades the system has graduated 2.8 million children; 92 percent of them have gone on to secondary school. The cost of the whole system is about eighteen dollars per pupil per year. To keep up the mental opportunities for the village girls after the primary years, BRAC added on libraries—there are now 873 libraries, 168 mobile libraries, and 8,800 discussion clubs for the village girls after they graduate.

BRAC was also among the first to create a ‘Micro-finance’ plan for the poor. It works as a series of village cooperative ‘banks’. About twenty-five to thirty-five mothers in each village join the BRAC Village Organization, then with BRAC’s help begin to make microloans. At this level, they take on only poor women who have no collateral and want very small loans—essentially those people commercial banks have no interest in. By 2004, the number of women in these Village Organizations was 4.7 million.

All the members are poor, and virtually all are women, by design. They give out loans, along with doing some other community duties. The average loan the women give to their neighbors is $117. It is to be paid back over a year, in weekly installments. This is enough money to buy a few chickens, or a milk cow, or to get a big patch of vegetables going for food and for resale. One woman bought her husband a rickshaw, which now is the family transportation business. The loans are not always used for burgeoning businesses; the women may buy a few chickens but not build up to a large chicken farm. But about 15 percent succeed in building the tiny loans into bigger things—a success rate said to be about the same for small business loans (tens to hundreds of thousands of dollars) in wealthy countries.

Though the women are poor, the organization is tidy, and the accounting careful: The repayment rate is above 98 percent and has remained steady at that rate for more than two decades. The total amount loaned so far to the villagers is more than $2.5 billion, and their current savings accounts total about $122 million.

It was as the programs for women and girls began to take off that fundamentalists began to notice BRAC and take it seriously. Some of the schools teaching village girls were burned down; the facilities lending to women were attacked; some called for the arrest of Abed. Eventually BRAC headquarters was bombed. But Bangladeshis condemned the actions and kept working with BRAC. This is interesting evidence of just what kind of work can successfully counter terrorism at the grassroots level.

‘The reaction,’ said Abed, ‘confirmed our belief that we were on the right track.’

Bill Gates Sr. once visited a BRAC village school and asked the girls in one class, ‘What do you want to be when you grow up?’ Gates wrote later that one girl stood up and said, ‘I am going to be a doctor.’ Not, ‘I want to be a doctor,’ but, ‘I am going to be a doctor.’ ‘I will never forget that moment,’ Gates wrote. ‘A little girl, daughter of poor, illiterate parents, sitting on a grass mat, over a dirt floor, in a one-room hut with a tin roof, telling me with total confidence: ‘I am going  to be a doctor.’ I thought: this little one-room school house is changing the world,’

During the hardest times, when BRAC was beginning, Abed now says that he would sometimes recite to himself a poem of the Bengali writer Rabindranath Tagore. When you go out to begin your journey, the poem begins, ‘if you call out to your friend to join you...and your friend upon hearing your call does not come along with you, then start to walk this path alone.’

In recent years, visitors to BRAC have come away impressed to the point that they begin to say unlikely things. BRAC has been called ‘the greatest development group ever’. It has been said to be ‘the world model for creating health and wealth in poor places.’ But there is really no model for the world; that is one of the things BRAC has proved. Model is the wrong word, the wrong idea. But its work has established some attitudes, some guiding ideas.

Abed and BRAC started with disaster relief, but soon enough the underlying truth became clear: The disaster was not a hurricane or a war; it was in the desperate poverty that had already existed and had gone on without useful aid year after year.

But now we know a few things about this state of affairs. We know that citizen organizations can be effective, not only in small programs but in very large ones. We know that villagers can be trained to do effective, lifesaving work. We know that continuous monitoring and reworking to achieve results is vital. And through it all, the workers must believe in what they are doing.

Abed himself says that changes began at least in part with the spirit of independence that reminded people here of Gandhi and Nehru in their grand quest, and that led to enthusiastic Bangladeshis who became determined to change life at the ground level. Some of them worked for BRAC, some worked for other groups. The government of Bangladesh, while often unable to lead the effort, cooperated and encouraged and partnered at key moments. This is nation building from the inside, but not without help from the outside.

The creation of BRAC took years, and the successes did not just fall naturally from goodwill and effort. But something was learned in BRAC and similar projects over the past three decades. This learning is, I suspect, the equal of any of the great technology and science discoveries of the past half century. In numbers of lives saved alone, even though the development work is just beginning, these discoveries may already be greater.

Now they must be applied.

            In early 2005, in his Dhaka office, though Abed is nearly seventy he is talking about the future. A whole new ‘BRAC’ has begun in Afghanistan, he says, and he has already told the minister of health that the program will cut infant mortality in half within five years in the district where they are working.

‘When she heard that she said to me: ‘Good luck!’ He laughs, draws on his pipe, and says immunization has been scaled up in all the districts where they are working. Now, he says, the government has asked him to expand to more districts.

Isn’t that risky? Will you prove it out in the few districts first or will you go big so soon?

‘Go big!’ he says, and smiles. ‘We can’t wait around with the children dying; we’ve got to try.’ Now, he says, he is sending teams to some African countries to consider getting BRAC-like groups started there as well.

Abed ends by quoting an old BRAC saying. “ ‘Small is beautiful,’ ” he says, “ ‘but big is necessary.’ ”