Radical Journal of Health 1995 Vol. 1, No. 4, Oct. – Dec.
Item
- Title
- Radical Journal of Health 1995 Vol. 1, No. 4, Oct. – Dec.
- Date
- December 1995
- Description
-
Indian criminal law and industrial offences
Economic aspects of tuberculosis control
Family experience of epilepsy
Interpreting demographic data: SRS 1993
Leeds Declaration: Reorienting Public Health Research - extracted text
-
OCTOBER-DECEMBER
1995
A SOCIALIST HEALTH REVIEW TRUST PUBLICATION
New Series VOLUME I
INDIAN CRIMINAL LAW AND
INDUSTRIAL OFFENCES
ECONOMIC ASPECTS OF
TUBERCULOSIS CONTROL
4
FAMILY EXPERIENCE OF EPILEPSY
INTERPRETING DEMOGRAPHIC
DATA: SRS 1993
LEEDS DECLARATION: REORIENTING
PUBLIC HEALTH RESEARCH
Ks 25
Radicaljournal of Health is an interdisciplinary social sciences quarterly
on medicine, health and related areas published by the Socialist Health
Review Trust. It features research contributions in the fields of sociology.
anthropology, economics, history, philosophy.psychology, management.
technology and other emerging disciplines. Well-researched analysis
of current developments in health care and medicine, critical comments
on topical events, debates and policy issues will also be published
RJH began publication as Socialist Health Review in June 1984 and
continued to be brought out until 1988. This new series of RJH begins
with the first issue of 1995.
Editor. Padma Prakash
Editorial Group: Adili Iyer, Asha Vadair. Ravi Duggal, Roopashri
Sinha, Sandeep Khanvilkar, Sandhya Srinivasan, Sushma Jhaveri,
Sunil Nandraj, Usha Sethuraman.
Production Consultant: B H Pujar
Consulting Editors:
Amar Jesani, CEHAT, Bombay
Binayak Sen, Raipur, MP
DhruvMankad, VACHAN, Nasik
K Ekbal, Medical College,
Manisha Gupte, CEHAT, Pune
V R Muraleedharan, Indian
Institute ofTechnology, Madras
Padmini Swaminathan,
Madras Institute of
Development Studies, Madras
Francois Sironi, Paris
C Sathyamala, New Delhi
Imrana Quadeer, JNU,
Thelma Narayan, London
New Delhi
Leena Sevak, London School of School of Hygiene and
Hygiene and Tropical Medicine, Tropical Medicine, London
Veena Shatru^na, Hyderabad
London
Kottayani
Publisher: Sunil Nandraj for Socialist Health Review Trust.
All communications and subscriptions may be sent to :
Radical Journal of Health,
19,June Blossom Society,
60-A Pali Road, Bandra,
Bombay 400 050.
Typsetting and page layout at the Economic and Political Weekly.
Printed at Konam Printers, Tardeo, Bombay 400 034.
Volume I
NewScries
Number 4
October-December 1995
246
Letter to Editor
Editorials: Medicos’Strike: Relevant Issues Amar Jesani
Signs of Distress
247
Padma Prakash
Indian Criminal Law and Industrial Offences
Critique and Case Studies
Sapna Malik
253
Economic Aspects of Tuberculosis Control in India
Sujata Rao
264
Family Experience of Epilepsy
Premilla D 'Cruz
281
Document
Leeds Declaration: Reorienting Public Health
Research
Communications
Utilisation of Maternal Health Services
Report from Rajasthan
P R Sodani
296
Interpreting Demographic Data
SRS, 1995
5 Ramasundaram
302
Review Article
Sustainable Development: A Limited
Framework
KJ Joy
309
Index 1995
319
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Letter to Editor
UN Status of the Holy See
AS the United Nations celebrates its 50th anniversary and engages in process
of reviews and reform, we urge the UN Organisation, the secretary-general,
and member states to evaluate the appropriateness of allowing the Holy See,
a religious entity, to act on a par with states in the United Nations. We believe
that the Holy See, which operates in the United Nations as a non-member
state permanent observer, does not meet accepted criteria for statehood and
that it is in reality the governing arm of a religious, not a civil institution.
Furthermore, a study would document that the Holy Sec overreaches — with
increasing frequently — its observer status and obstructs action and the
development of consensus among member stales. Should this study conclude
that the Holy See does not meet reasonable, contemporary criteria for statehood,
we would further urge the United Nations to change the status of the Holy
See to appropriately reflect its nature-as a significant non-governmental
institution. Clearly, the Holy See operates at the United Nations to promulgate
religious viewpoints. Time and time again, we have seen demonstrated the
inappropriateness and the negative effects of allowing the Holy See to use
the UN system to advance the theological positions of the Catholic Church.
For example. Holy See delegates, invoking the Roman Catholic ban on
contraception, routinely attempt to hinder access to all family planning methods
except for the one approved by the Vatican — periodic abstinence. In UN
conferences from Rio de Janeiro (UNCED) to Beijing (FWCW), there has
been an incrreasing vehemence in Holy See diplomacy that sacrifices sub
stantial UN consensus on matters of women’s rights and reproduction to the
theological agenda of the church. As the United Nations increasingly focuses
on social issues in addition to political conflicts, the Holy Sec’s intractability
becomes even more problematic. In the spirit of the FWCW, we can no longer
ignore the problems presented by the UN status of the Holy See. The well
being of countless individuals is at stake. We, the undersigned, believe it is
highly inappropriate for the Roman Catholic Church to participate as a voting
member in UN conferences — something it can do only by virtue of its UN
status as a non-member stale permanent observer. The United Nations has
an ethical obligation to be neutral regarding religion. The privileges now
granted to the Roman Catholic Church under the auspices of the Holy See
violate such impartially and, in the interest of fairness, should be revoked.
Caribbean Association for Feminist Research and Action, Trinidad and Tobago,
Catholics for a Free Choice, Washington, DC USA, Center for Women’s Global
Leadership, New Brunswick, New Jersey, USA, DAWN (Development Alternatives
with Women for a New Era), St Michael. Barbados, International Women’s Health
Coalition, New York, USAm International Women’s Tribune Centre, New York,
USA, Latin American and Caribbean Women’s Health Network, Santiago, Chile,
National Coalition of American Nuns, Chicago, Illinois, USA, Sliching Ondcrzock
en Voorlichling Bevolkingspolitiek (SOVB) (Foundation for Information and Research
on Population Policy), Amsterdam, The Netherlands, Women in Development in
Europe (WIDE), Brussels, Belgium, Women’s Global Network for Reproductive
Rights, Amsterdam, The Netherlands, and others.
246
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Medicos’ Strike: Relevant Issues
By not incorporating a wider demand for expanding and revitalising
public health services with the wage and service conditions demand,
resident doctors may willy nilly aid the state's drive to destroy.
public health services.
THE withdrawal of the long strike by resident doctors in Maharashtra
days has brought relief to the poor patients but has hardly resolved the
issue raised in the strike. Several critical issues have remained hidden
and unarticulated. The main demand of the strike was for upgradation
of worming conditions get parity in wages and working condition with
those given to the resident doctors in Delhi. What they got at the time
of withdrawal of strike is an increase in pay far short of that given to
the resident doctors in Delhi and empty promises for improving working
and living conditions. More importantly, the association is left with a
divided leadership and rank.
The Maharashra Association of Resident Doctors (M ARD), which led
the strike and was born out of the resident doctors strike way back in 1971 72, has been responsible for an average of one longish strike every four
or five years. Most of them have been on the issues of wages, working and
living conditions. The only exception perhaps, was in 1985 when there
was a long strike to oppose the govenment decision to start private
medical colleges charging capitation fee. This exceptional strike took
place under exceptional leadership, and it was one of the very few
organised, though aborted, efforts to block increasing number of private
medical colleges by a section of doctors.
Doctors being part of a vital service section affecting lives of people
and patients, their strikes will naturally be viewed more closely and
commented upon by the wider society. Many would find it difficult to
view such strike as one more trade union struggle, and would seek
explanations on the role being played by doctors as a social strata in
general and as employees of public hospitals which are meant for service
to the poor, in particular; and the cause and consequences of the strike on
the health services. That is the reason why during the strike many felt that
their demands were justified but not the action. Such a reaction may sound
contradictory, but it is a situation created by the doctors, including
resident doctors, themselves and a part of the responsibility must be
owned by the MARD.
Indeed, there is not an iota of doubt on the justification of demands
raised. It is also true that the larger responsibility for pushing resident
doctors to strike rest on their employer, the government. The resident
doctors are so vital for the public hospitals that,in their absence it is not
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possible to carry out normal functions of the patient care. On this ground
alone, technically and legally, the argument that they are just training for
their post-grduation and so are not ordinary employees, is not convincing.
Besides, the resident doctors are full-fledged doctors, who are involved
in further studies while providing patient care full-time. It is also clear that
the payment given to them is really low and not commensurate to their
education, skill and the amount of work put in. The state has been
throwing crumbs to one section and depriving another, and waiting for
the aggrieved section to raise the stakes. Conspicuously missing in the
state policy are uniform standards for the payment to resident doctors
across the country. This is when post graduate education is controlled
and standardised at the national level. Behind the deliberate dis
criminatory payment system even is the state’s obvious intention to
divide, a well known dirty management policy devoid of ethical social
considerations.
Would the government be in a financial position to pay the extra few
crores to the resident doctors. The argument put forward was that, since
two-thirds of the budget of the public hospital is spent on salaries of
employees,acceptance of the demands of the resident doctors would
further reduce government expenditure on other vital supplies like drugs.
There is, of course, no substance in such arguments. The bigger share of
the expenditure is going to employees not because they have conducted
too many strikes and the government has been generous in paying them,
but because the government spending has not increased at the rate it
should. Besides, there are areas where the government is indulging in
unnecessary and conspicuous consumption, the resources of which could
be better used for the health care of people.
Apart from that, a more important issue is the situation prevailing in
the private medical care sector. The burgeoning medical market, the
vulnerability and lack of resistance on the part of patients (consumers)
and virtual absence of effective regulation of medical practice and the
price in the private sector, have ensured a three to five times more average
income for the doctors in private sector than their counterparts employed
in the public sector. Such a disparity in income will inevitably lead to
either exodus of doctors to private sector or to great unease among public
sector doctors, to the extent of pushing them to go on strikewfor better
wages. It is known that a larger number of experienced full-time doctors
are now leaving public hospitals to join private sector now. Many have
stayed put because of the government policy to allow private practice or
to turn a blind eye to the unauthorised private practice by them. Only a
small minority has continued with complete commitment to the service.
The point is, that unless the cost of medical care in private sector is
effectively controlled and the doctors’ average income there kept at a
reasonable level, there is no long term solution to the recurrent restless
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ness of public sector doctors on economic demands. Besides, such price
control is desirable in the situation where 80 per cent of medical care is
owned and controlled by the private providers and the cost of health care
is ruining people’s and nation’s economy and the health. Being trainees
for the post graduation, the resident doctors do not have an option of
opting out of the public hospitals, nor does their work load permit them
to spend time in unauthorised private practice. This explains why the
resident doctors and not the full-timers agitate more often on economic
demands. The very fact that the government is allowing budgets of public
hospitals to stagnate or is introducing cuts, and that it has shown no
intention to regulate private medical care nor costs prices, shows its
intention to let public health decay and private medical market flourish.
While resident doctors have argued ton justify their demands,they
have shown no responsibility towards seeking regulations over the
private sector in order to save public hospitals. Indeed, they do not have
much good opinion of the public hospitals, nor is their real destination is
to serve people by joining the public hospitals after geeting post graduate
degrees. No demand has been made for increasing number of public
hospitals in the under-served parts of the country to increase their chances
of employment after completion of their degrees.This demand has never
been made in any resident doctors’ strikes across the country in last
quarter century, with the notable exception of the West Bengal agitation
in 1970s when it was made an important issue. At least here,the interest
of resident doctors converge with the government, for they intend to
become a part of medical trading community after studies and like
government they would also like to preserve the private sector as a sacred
cow not to be touched by any regulation and price control.
Indeed, while the government (whose health minister is a medical
doctor) showed no signs of worry for the suffering of patients who
could not get medical care during the strike, the resident doctors
hardly put any effort in organising parallel out patient clinics to help
even a tiny proportion of sufferers, as the MARD had tried to in many
previous strikes. Both showed insensitivity to suffering masses,and
used that suffering to make their point in justifyint the stands taken.
Needless to add that no effort was made to inform and educate people
and gain their confidence and support for the extreme step they were
taking. In the demands highlighted there none was directed at improv
ing patient care. While, admittedly, resident doctors find it difficult or
impossible to have a decent middle class standard pf living the one
wonders whether they do not find it difficult to practice medical care
ethically with the medical resources and facilities they are provided in
the public hospitals. Isn’t equally essential for doctors to have ad
equate living standard as well as to have adequate patient care
facilities for ethical and reasonable quality medical practice? A
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doctor’s agitation, including strike with a demand for a reasonable and
minimum quantity and quality of health care for all people would
generate real support from the poor users as well as a large section of
present non-users of government hospitals across the country.
Strikes by service doctors are not so uncommon in our country and
the circumstance, they would continue to strike for their wages. The
basic conflict between employer and employees is a reality of present
social order. While lamenting people’s suffering, the task of reorient
ing doctors who are in the public sector to combine their trade union
demands with the demands for minimum standards of quality and
ethical medical care needs to be taken up. This is more urgent now than
ever, for the government is bent upon destroying public hospitals so
that its future actions for outright privatisation do not meet with much
resistance. Health care has been, politically and economically a ‘non
priority’ issue for the poor who are still struggling to just survive.
They would find it difficult to come out on the streets to defeat
privatiation moves. Health and other workers in the public hospitals
are better placed to provide initial resistance which might create an
atmosphere for the poor to extend stronger active support. Doctors arc
part of that lot. This strike only showed that while raising a justified
demand, the resident doctors have not moved closer to the people they
are serving. On the contrary they seem to have moved closer to their
counterparts in the private sector. Their upper class and caste back
ground, aspiration to join medical care trade, make this easier. In last
five years of new economic policy, the elite stratas - transporters,
stock-brokers, lawyers, private sector doctors (reactionary strike
against consumer protection act), etc - have shown increasing
assertiveness. Therefore, for the socially conscious and ethical doc
tors, the task to affecting change in the medical profession’s attitude
and consciousness has become even more difficult.
-Amar Jesani
[For a lively debate on this subject, see Sujit Das,’Doctors in health care: Their
role and class location’, SHR, September 1985:57-66; Anant Phadke ‘Organising
doctors: Towards what end?’, SHR, December 1985: 148-150; Thomas
George„’Contradictions where there are none’, RJH, June 1996: 40; Sujit
Das,’Organising doctors: A difference in approach’, RJH, September 1996:
73-4 and Anant Phadke,’Medical officers-the ‘new middle class’?, RJH,
December 1986:107-8.]
Have you renewed your subscription to RJH for 1996?
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Symptoms of Distress
Witch-hunts, being reported sofrequently, are a sign of the increasing
systemic distress. Not only is the public health system collapsing,
so are social support systems.
SOME months ago, newspapers reported the brutal mob attack on a
woman, a retired worker of the Bharat Coking coal in Dhanbad district,
for allegedly practising witchcraft and causing the death of some 10
people in the village. The woman had earlier been driven from the village
for having caused the death of five people in the area last year but had
returned her grandson’s wedding and thereafter had stayed back to attend
her daughter’s funeral. What is of significance is that almost all the
victims of the alleged witch had been suffercing from tuberculosis or
other severe illness, as was her neighbour’s daughter, the latest ‘victim’.
The ‘witch’ was not only lynched but her body was thrown in a nearby
ditch reportedly because there was no money for the funeral.
The lynching of women, usually alone with little economic or social
support, for allegedly using witchcraft to cause death or disease in the area
is not an unheard of phenomenon. And more often than not, these women
have been the community healers, particularly of women, and represent
the support system which systematised medicine cannot provide. In
history, at the time of the rise of professional medicine, witch-hunts were
conducted to weed out lay women practitioners. Often these women, the
repositories of generations of folk knowledge and practices, were better
able to diagnose and treat health problems than the male practitioners.
While this period of battle ended with the victory of the new statesponsored medicine, and the more or less banning of lay practice, the
latter never quite disappeared for a long time. Only with the very effective
modern medical practice was folk medicine forgotten in the west.
However,the story is a little different in countries like India where there
existed systematised traditional medicine parallely with lay practitioners.
While there is not much material available on what was the nature of the
relationship between lay practitioners, such as the dais, or the so-called
‘witches’ in the period before the entry of ‘modern’ medicine,there is
increasing evidence that communities depend on lay healers, other than
the formally recognised dais. The Dhanbad ‘witch’ for instance was
probably one such; while the numerous reports emanating from Bihar,
West Bengal and tribal regions of Madhya Pradesh and Maharasthra may
well be documenting a process which needs to be better understood.
In Dhanbad,it is clear that people had no access to health care
services and so resorted to symptomatic ‘treatment’ given by the
alleged witch. Having got no relief, and little understanding the nature
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of the disease it is not hard to comprehend, why the ‘healer’ was
transformed into a witch. In a tribal region of Dahanu (see SHR: Vol I,
no 2 for an analytical report) witch-hunting became more visible
because of a number of factors: the denudation of forests and vegeta
tion which provided the local medicine man with the necessary herbs
with the result that the women healers began to be seen as an alterntive
threatening the livelihood of the ‘medicine man’. In West Bengal,
while it is not clear whether these women were healers in the same way
as in Dahanu, it is obvious that they provided some form of support
which may have turned malignant under conditions of deprivation.
The fact is, that these incidents must be read in the larger context of
developments in health care as well as the social and economic change
that is occuring.
Witch hunts and the lynching of old and destitute women are
closely related to early deaths of breadwinners, of male children or
long and critical illnesses or, financial misfortune. In other words,
such attacks come only is a society which is being subjected to severe
stress, economic, social and political. Not surprisingly, the object of
attack is the weakest component of society, women and especially
destitute older women, who paradoxically are people who may have
been the community’s last resort in illness. This is why the large
number of reports of the lynching of witches must be viewed with
grave concern —they are the first signs of grave systemic distress
which will reverse all progressive gain.
Padma Prakash
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Indian Criminal Law and
Industrial Offences
Critique and Case Studies
Sapna Malik
Criminal law is there to protect us against the evil, dishonest
and reckless actions of wayward human beings. So serious are
the offences, that the state carries the burden of prosecution; for,
these are not simply civil disagreements between individuals, but
crimes against society as a whole. However the entire system crumbles
when the state itself is guilt}1 as a contributor to the offence, or
is in collusion with the offender to frustrate the proceedings.
TO DATE, the union of India’s record regarding its treatment of in
dustrial crimes against the person has been at best paltry and at worst
vindictive, and its reaction, or rather inaction, towards the Bhopal tragedy
proves that its loyalties lie with the perpetrators of these crimes rather
than the victims.
The legislation existing prior to the Bhopal tragedy dealing with
environmental pollution and worker’s health and safety, namely the
Water (Prevention and Control of Pollution) Act 1974, the Air (Preven
tion and Control of Pollution) Act 1981 and the Factories Act 1948, was
a motley bunch of measures of little real substance. The subsequent
amendments to these acts and the introduction of the Environment
Protection Act, 1986 enacteddn the wake of Bhopal, merely emphasise
the pro-industrialist, anti-citizen/worker stance of the legislature in this
potentially corporate-threatening area.
In essence, the legislation denies the citizens the right of direct access
to the courts (a right enshrined under general criminal law, vide si 90 of
the Code of Criminal Procedure) since it is only on complaint through a
government body that offences under the acts are recognised. With the
‘environmental acts’, complaint must be made by a State Pollution
Control Board (PCB) (s49 WA; s43 AA; s 19 EA), these bodies generally
being as much agents of industry as of government. Admittedly, some
minimal recourse is provided to the individual wishing to take private
action on condition that 60 days’s notice of intention to make a complaint
is given to the relevant Board, thus allowing the culprit adequate time to
temporarily appease the situation. Even then, the PCB may refuse to make
available to the individual the necessary information to put forward a case
— ironically under the guise that it would not be in the public interest to
do so.
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Under the Water and Air Acts, the severest punishments (for instance
for failing to restrain apprehended pollution) carry a minimum sentence
of 15 and maximum sentence of six years together with a fine of an
unspecified amount, these limits being raised to two and seven years,
respectively, if the contravention continues for more than on eyear past
the date of conviction. The Central Pollution Conrol Board claims that
since the introduction of the Water Act over 20 years ago, a total of 129
cases brought under it have resulted in imprisonment. However, when
pressed for further information as to actually how many people have been
put behind bars once their avenues for appeal have been exhausted, and
the length of prison terms served by these unfortunate offenders, the
central and state boards are mysteriously quiet. A corresponding figure of
97 imprisonments is given for the somewhat younger Air Act.
Under the Environment Protection Act there is no minimum sentence
but offenders may be punished with up to five years imprisonment and/
or Rs 1 lakh (about US $ 3,300), or up to seven years imprisonment if the
offence continues for more than one year past the date of conviction.
Offences under this latter Act include those relating to the manufacture,
storage and import of hazardous chemicals; the management and han
dling of hazardous wastes; and the manufacture, use and storage of
genetically engineered organisms.
The Factories Act 1948 was considerably revamped by the Factories
(Amendment) Act 1987 after the horrific and, more significantly, high
profile nature of the Bhopal disaster. Penalties were stiffened and a new
chapter added to deal specifically with hazardous processes. Even so,
under the present-day act there are still no minimum stipulations for terms
of imprisonment, and the minimum fines set for contravention of certain
duties leading to death or serious injury are Rs 25000 (about US $ 830)
and Rs 5000 (aboutUS S 170), respectively. The maximum penalties laid
down for offences involving hazardous processes are seven years impris
onment and/or Rs 2 lakh (about US S 6,670) and 10 years imprisonment
if the offence continues one year past the date of conviction.
As well as enhancing penalties, the Amendment Act of 1987 also
brought about the inclusion of workplace exposure limits for certain
toxins, now contained in the second schedule to the 1948 act. This
amendment, however, is not so encouraging when it is realised that the
values listed are taken from the American Conference of Government
Industrial Hygienists (ACGIH) of 1968; a conference where corporae
representatives — listed officially as ‘consultants’ — were given primary
responsibility for developing limits for their respective company’s prin
ciple chemicals. No doubt factory employees would be leSs thali reas
sured if they knew (hat the likes of Dow Chemicals and Dupont have been
instrumental in determining the exposure limits and carcinogenic risks of
the chemicals they encounter through their daily work.
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On top of the drawbacks outlined above, the Factories Act 1948 is also
extremely restrictive in its application. Offences under the act are
recognised only on complaint by, or with the previous sanction of, the
relevant Factory Inspector (vide si05). There is no route whereby
affected workers can by-pass this rigidity and directly approach the court
for restitution, a factor which played a significant role in both the case
studies cited below. In addition, complaints under the act are time barred
after a period of three months from the date on which the commission of
the offence came to the knowledge of the inspector, providing a conve
nient means of foiling, or fouling, an attempt to seek justice.
Because of the restrictions placed on litigation under these various
acts, and because of the tendency of the ‘environmental acts’ in particular
to regard environmental pollution as a ‘public nuisance’ rather than as an
assault on, and invasion of, the body, it would often be more apt to fight
a case via the Indian Penal Code 1860, and within the confines of the
Criminal Procedure Code 1973 (although, as shown by the case of Bhopal
and the TISCO fire disaster cited below, this is no guarantee of success).
Two Cases
In a case at Hindustan Lever, several workers contracted what was
eventually diagnosed as contact dermatitis through the use of gumboots
in 1993. Since adequate medical treatment was being denied to the
sufferers by the company’s medical officers they had no option but to seek
recourse at the government-run Sion Hospital, alo in Bombay. A report
issued by the hospital confirmed that the contact dermatitis is listed as a
‘notifiable disease’ under the third schedule of the Factories Act 1948
(FA). Section 89 of the act stipulates that where any worker in a factory
contracts a disease specified in the schedule, the manager shall send
notice to the appropriate authorities (s89( 1)); and if a medical practitioner
is attending on such a person s/he shall without delay send a report to
the chief inspector of factories, with details of the disease and patient
(s89(2)).
However, the penalty for non-compliance with s89(2) is so light as to
be ineffective, since any medical practitioner failing in his duty is liable
to a fine of up to Rs 1,000, or about US $ 33 (incidentally, this was
increased from a maximum penalty of Rs 50 —■ or US $ 1.70 — by the
Factories (Amendment) Act 1987). When viewed against some of the
other ‘notifiable diseases’ contained within the schedule, the true value
placed by the legislature on occupational health and safety is plain to see.
The list of 21 diseases includes such killers as mercury, arsenic and
benzene poisoning; asbestosis; silicosis; and occupational cancer.
Perhaps because of its minimal impact the factory inspector who
visited the plant to observe the workers in distress decided not to bring any
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action against the concerned medical officr or the other medical officers
for contraventions of their statutory duties. A complaint was, however,
filed him against A Lahiri, as occupier bf Hindustan Lever, for violation
of his duties under s7A of the act. This section stipulates that “every
occupier shall ensure, as far as it is reasonably practicable, the health,
safety and welfare of all workers while they are at work in the factory”
(s7A(l)). Contravention of the section is punishable with imprisonment
of up to two years and/or a fine of up to Rs 1 lakh, or about US $ 3300
(vide s92 FA). For two months Lahiri dragged his feet in responding to
the workers and did not inform the inspectorate of the situation.
The complaint was filed by the factory inspector on October 29,1993
at the Metropolitan Magistrates Court, Dadar, Bombay. However, less
than six months later, on April 14, 1994, the same inspector applied to the
court for withdrawal of the complaint. This came about for no apparent
bona fide reason; in fact during this period a medical report from Sion
Hospital was made available to the court which further corroborated the
medical evidence against Hindustan Lever. As detailed above, offences
under the Factories Act are only recognised if a complaint is made by, or
with the previous sanction in writing of, a factory inspector (si05).
Consequently, the right of withdrawal of a complaint is also confined to
the inspector, who is thus given a free rein to influence the prosecution of
an offender with no regard to the demands of the victims. What is a moot
point, however, is whether consent to the withdrawal by the presiding
judge or magistrate should be active or merely passive (this is not set
down in the relevant section of the Criminal Procedure Code, s321). In the
given case, consent was granted on September 21, 1994 on the grounds
that all the due formalities had been completed by the inspector. No
consideration was given to the evidence previously submitted which
proved a strong case of wilful neglect of statutory duties.
On the basis that such consent should be active, and citing a 1994
Supreme Court judgement holding that if prima facie material exists in
support of the prosecution, the judge may decline to grant consent, and on
the basis that s. 105 FA is bad in law — as being violative of employees’
rights under Articles 14 (the right to equality before the law) and 21 (the
right to protection of life and personal liberty) — and thus unconstitu
tional, a public interest litigation was filed in the high court at Bombay,
by some workers, through their union representative and an employee.
The petition was filed in October 1994 and will not come up for hearing
for at least another year. In the meantime, the affected workers have not
been granted any interim relief and two union activists have been
suspended..
The Hindustan Lever case unfortunately shows that even in a situation
where several factors would suggest a successful outcome, the competent
authorities will only go so far to rock the industrial boat. Here, the
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employees were active in voicing their complaints; their union willing to
help them fight; the factory inspector sympathetic to worker health issues;
and the government doctors quick to identify the notifiable disease, yet
still the company was given a mere prod that it should take more care of
the health of its workforce. What if next time it is the lungs of the workers
rather than the soles of their feet that are scarred, or what if it is found that
the yellow liquid in gumboots was indeed carcinogenic — will the same
degree of complacency be shown then?
The second case study involves the Tata Iron and Steel Company
(hereafter referred to as TISCO) factory at Jamshedpur, Bihar. The
factory is just one of a multitude of assets owned by Tata throughout
India and is situated in the heart of ‘Tataland’, the very name of the
city coming from the TISCO founder himself — the late Jamshedjee
Tata. Every year on the March 3 the employees of TISCO, their families
and other inhabitants of Jamshedpur come together to celebrate the
birthday of TISCO’s founder. This ‘Founder’s Day’ celebration is a
pompous affair with thousands of people congregating around a statue of
Jamshedjee, installed near the main gate of the TISCO factory, inside
the works.
On March 3, 1989 Founder’s Day was to be celebrated on an even
bigger scale than usual since it was Tata’s 150th birth anniversary.
Celebrations commenced at about 7 am, with onlookers squashed into
temporary pandals (seating enclosures) and galleries from where they
could view the procession of TISCO employees paying homage to their
former patron. However, at about 9.55 am the festivities were brought to
a tragic and horrific end when a devastating fire broke out in one of the
galleries, causing carnage and pandemonium as it spread.
Twenty people — mainly women and children — died on the spot, and
a further 29 succumbed to their injuries in hospital, many after going
through the harrowing experience of having limbs removed, one by one,
while over 100 victims were badly injured. Yet, as in the case of the
Bhopal tragedy, those guilty of causing the disaster are today walking
free, having paid no penalty, in spite of a damning report by the chief
inspector of factories, Bihar, which unequivocally accuses TISCO man
agement of causing the fire and failing to mitigate its devatating effects.
The report of the chief inspector of factories discloses the findings of
a committee set up to enquire into the disaster by the government of Bihar,
department of labour, employment and training, under s90 of the Facto
ries Act, 1948. The enquiry committee unravelled a whole litany of
statutory contraventions and acts of gross negligence on the part of the
management, the synergism of which’led to the catastrophe of March 3,
1989.
Firstly, a number of laws relating to fire precautionary measures had
been flouted. Since the fire occurred within the confines of the TISCO
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factory (a factory within the definition of s2(m) (i) FA 1948), the incident
is brought within the realms of the Factories Act 1948 (FA 1948). S38 of
the act slates that “in ever)' factory, all practicable measures shall be taken
to prevent the outbreak of fire and its spread” and that a safe means of
escape in the event of a fire and the necessary equipment and facilities for
extinguishing a fire must be provided and maintained. Read together with
Rule 62 (10) of the Bihar Factory Rules 1950, the minimum requirements
for fire prevention and control are clearly laid out, yet these were blatantly
ignored.
In addition, s6 of the Factories Act, read together with Rule 3 of the
Bihar Factory' Rules, was also overlooked. These sections refer to the
requirement of site and planning approvals by the chief inspector of
factories, yet no permission or licence was sought regarding the erection
of the galleries and pandals, or indeed the holding of the celebration itself.
An order under si44 of the Code of Criminal Procedure 1973 had even
been placed on the management previously, making it incumbent upon
them to obtain prior permission for holding the function, taking out
processions and using loud sound-producing crackers (although on
repeated violation of this order, no punitive action was ever taken by the
appropriate authorities).
On top of all this was the contravention of s41 B(4) of the Factories Act,
1948 (a section incorporated by the Factories (Amendment) Act, 1987 in
response to the Bhopal tragedy and specifically relating to hazardous
processes, of which the TISCO factory had been classified as one). This
section states that every occupier must “with the approval of the Chief
Inspector [of Factories], draw up an on-site emergency plan and detailed
disaster control measures for his factory and make known to the workers
employed therein and to the general public living in the vicinity of the
factory the safe measures required to be taken in the event of an accident
taking place”. No emergency plans had been drawn up and there was
evidently little communication between the management and the various
departments on what was to happen on the day.
As a result of all the statutory contraventions, the TISCO management
put on an ill-planned, showy event with no regard for human safety,
creating a veritable time bomb just waiting for a match to strike. Pandals
consisting of tarpaulin, cloth, bamboo, manila rope, ‘durrie’ (rug mate
rial) and wood were erected, without the fabrics first having been dipped
in fire retardant solution (as stipulated in Indian Standard Code 8758 of
1978) producing structures of a very high ‘fire load’ (ie, weight of
combustible material per unit area) and high ‘flame spread characteris
tic’. Thus when crackers were fired in the vicinity of the pandals during
the procession of TISCO’s security personnel, it was just a matter of
moments before one of the galleries was set ablaze, with the flames
rapidly engulfing its neighbour. Within three minutes the fire had totally
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destroyed the two galleries taking with it 20 lives and scarring forever
scores more. Fatally, when the fire broke out an announcement was made
for people to remain in their seats and the procession was allowed to
continue. Even for some who tried to escape, their efforts were thwarted
by the barricades placed in front of the pandals which blocked the escape
routes from the affected areas. It is particularly sickening to learn that one
of the unaffected galleries actually stood in the way of a fire tender kept
100 feet from the scene of carnage.
Yet even for those who made it to hospital, the horror was not to end.
Victims were taken to the Tata Main Hospital (an establishment owned
and run by TISCO) where, in spite of the TISCO factory being classified
as a ‘Major Accident Hazard Installation’ by the director general of the
Factory Advice Services and Labour Institute, ministry of labour (accord
ing to norms set by the International Labour Organisation), and declared
a ‘Lead Industry’ by the forest and environment department, government
of Bihar, there was no specialist burns unit and no appropriately trained
staff to deal with the burns victims. Even the required medicines had to
be flown in from the UK. On arriving, victims were dumped wherever
there was room and ineffectively treated by two general surgeons.
Repeated pleas to transfer patients to burns unit centres in other hospitals
were fobbed off (even though the company’s aircraft was ready and
available) sometimes with the excuse that this would adversely affect the
morale of the doctors! Conversely it was thought permissible to grant
leave to the director of medical services at the hospital.
Over the ensuing months a further 29 victims — many of them children
— were to die, often after the gruelling experience of having their limbs
hacked off. None of the amputees survived, not surprising when it is
learned that doctors were of the mentality that without skin or limbs the
survivors would not have lives worth living anyway. Presumably in an
attempt to compensate for the vastly inadequate services (or perhaps
merely as a public relations venture?) a burns specialist from the govern
ment-run Safdarjung Hospital, Delhi, was twice flown in as a consultant,
but his brief visits had little impact.
Yet in spite of such glaring evidence, and in disturbing similarity to the
Bhopal tragedy, neither have the victims of this ordeal been compensated
nor the perpetrators of their afflictions punished. TISCO has categorically
denied liability for the ‘accident’, first suggesting it was an ‘act of
sabotage’ and then an ‘act of god’. As such, management has consistently
refused to pay compensation to the sufferers, even though it is liable to do
so under si A of the Fatal Accidents Act 1855, with the further sideline
that it would merely add insult to injury to attempt to equate life with
money, and as none of those killed were wage-earners there was no direct
financial loss anyway. Conveniently, none of the women and children
killed or maimed were viewed as actual or potential money earners. Yet
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in a paradoxical and cold-hearted move, which made a mockery of its
claim to non-liability, TISCO saw fit to compensate a decoration centre
for the loss of its furniture from the fire.
As if to absolve itself from any further payments, TISCO has been at
pains to point out the money it has spent on the treatment of patients, yet
under the terms and conditions of employment with the company,
employees and their close relatives are entitled to free medical treatment
in both Bihar and in India as a whole. Also apparently in lieu of
compensation, some of the victims have been presented with second
hand air conditioners at nominal prices (in many cases a necessity since
there was insufficient air-conditioned space at the hospital) or upgraded
accommodation, but this was generally for those who ‘chose’ to keep
quiet. In contrast, one employee who has spoken out against the company
has faced considerable harassment in the form of denial of leave to visit
his dying daughter in hospital, replacement of his staff and an adverse
job transfer.
Thus as with the Union Carbide Corporation in the Bhopal case,
TISCO has so far avoided paying any meaningful compensation to its
victims while attempts to demand adequate recompenseare being thwarted
by the hoarding of medical records (where indeed these have been issued,
as was not the case for under 18 year olds) and post mortem details by the
TISCO authorities. The Supreme Court has not yet seen fit to demand
these are made available to the victims or their families, despite being
formally requested to do so.
Saddeningly, also akin to the Bhopal scenario, the criminal proceed
ings ensuing from the TISCO fire have fared no better than the civil ones.
The proceedings can be divided into two groups — those brought under
the Factories Act 1948 (FA) and those under the Indian Penal Code 1860
(IPC).
On May 7, 1990, 14 months after the tragedy occurred, a criminal
complaint petition was filed by R Prasad, inspector of factories, Jamshedpur
CirleNo 1 in the court of the chiefjudicial magistrate (CJM), Jamshedpur.
The complaint was brought under s96A of the FA for contravention of the
provisions of S.41B (i e, compulsory' disclosure of information by the
occupier). Such an offence is punishable with imprisonment fora term of
up to seven years and fine of up to Rs 2 lakh (about US S 6670) on
condition that complaint is made within three months of the date on which
the alleged commission of the offence came to the knowledge of the
factory inspector.
A preliminary investigation into the cause of the ‘accident’ was
conducted from March 4-6, 1989, and a report submitted to the Com
missioner of Labour, Bihar on March 8, 1989. However, Prasad, who
was in fact associated with the investigation, claimed that his first
knowledge of the offence was on April 24, 1990, when he received a
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copy of the enquiry committee’s report. This contention was not accepted
by the magistrate, and the complaint was thus barred for limitation.
Although the factory inspector filed a revision petition in the high court
at Patna contesting the ruling, the hearing was kept pending for two years
and has now been stayed. It is unlikely that the decision will be reversed,
thus closing one avenue of retribution. The decision of the CJM highlights
the inadequacy of confining cognizable offences under the act to those
brought to the attention of the court via the factory inspector. Could it
have been that Prasad delayed filing a complaint on purpose? What
recourse does an injured party have when its only audible vocalist is
struck dumb?
As for proceedings brought under the IPC, nothing much has been
achieved. In spite of a ‘first information report’ being registered at the
local police station at Bistapur on the day of the fire, and an investigation
by the CID branch of police supposedly being launched straight away,
charges were not filed until over two years later on May 9, 1991. The
charges made out were for violations of s 304A — causing death by
negligence, s 338 — causing grievous hurt by act endangering life or
personal safety of others and s 286 — negligent conduct with respect to
explosive substance, and were brought against 12 individuals belonging
to TISCO, including Dr J J Irani, former managing director. Charges
under ss 304A and 338 are punishable with up to two years imprisonment
and/or fine, and that under s 286 with up to six months imprisonment and/
or fine extending to Rs 1000 (about US $ 33). However, in spite, or more
likely because of, all the incriminating evidence, the high court at Patna
stayed the proceedings against Dr Irani with the ridiculous assertion that
the managing director of a company cannot be held responsible for its
day-to-day activities, while the Supreme Court stayed the proceedings
against the remaining accused at a later date.
In retaliation to the lethargic and biased legal proceedings, three
victims of the disaster came together and filed a public interest litigation
in the Supreme Court which came up for preliminary hearing on March
22, 1991. Among the prayers put forward by the petitioners are those for
writs of mandamus or other appropriate directions to force the Bihar
government to uphold the laws of the land; publish the findings of the
three enquires into the disaster (as well as that by the chief inspector of
factories, investigations were also conducted by the deputy commis
sioner, Singhbhum district, and the general manager (works) at TISCO)
none of which have been made public; punish any person, including Tata
Main Hospital (through its director) and its staff, for negligence in
organising the function and treating the patients; make the medical
records of the victims available to them or their next-of-kin; direct
appropriate compensation; and prohibit further Founder’s Day celebra
tions as a mark of respect to the dead, injured and bereaved.
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The petitioners also spoke of collusion between the government of
Bihar and the TISCO authorities in suppressing information and evidence
revealing criminal neglect, including a live video recording of the fire.
They accuse the state government, its officers and servants of liability
under s 119 of the IPC (the crime of a public servant concealing the design
to commit an offence which it is his duty to prevent).
Unfortunately, out of all the prayers put forward by the petitioners, the
Supreme Court has only latched on to the plea for compensation, possibly
this is the only form of ‘justice’ it understands. In fact the Supreme Court
is currently pushing for the victims to agree to an ex gratia payment from
TISCO, in a manner menacingly reminiscent of the infamous ‘Bhopal
Settlement’ of February 14, 1989, on condition that the sum is decided
through an independent arbitrator, is not seen in any way as an admission
of liability, does not set a precedent to be followed in future incidents,
revokes all criminal charges against the accused and bars any future
claims as to civil or criminal liability for the disaster. It is like a lurid piece
of history repealing itself.
As with Bhopal, the TISCO scenario shows the power of a corporation
to disable criminal proceedings against itself. Instead of a multinational
corporation, the main perpetrator here was a home product — an off
shoot of an immensely influential and much revered industrial group with
a deludingly caring and ‘family’ image. TISCO ran the city of Jamshedpur
as the feudal landlord of a modem day-fiefdom, having its own security
force and owning everything in the city from civic amenities such as water
and electricity, to transport, to accommodation — including that resided
in by government officials. It is no wonder then that this paternal figure
turned ‘Big Brother’ is so easily being allowed to obliterate the disaster
from its memory, going back to its self-gratifying leader-worship and
denying those marred by the tragedy the indulgence of even one day of
shared mourning.
The TISCO tragedy and the Hindustan Lever case arc once again
glaring examples of the failure of a legal system to deliver justice in cases
of corporate crimes against the person. Criminal law, we are made to
understand, is there to protect us against the evil, dishonest and reckless
actions of wayward human beings. So serious are the offences, that the
state carries the burden of prosecution — these are not simply civil
disagreements between individuals, but crimes against society as a
whole. However, as shown above, the entire system crumbles when the
state itself is guilty as a contributor to the offence, or is in collusion with
the offender to frustrate the proceedings. Adding to the problem is a fickle
judiciary which hands out arbitrary judgements, depending on the politi
cal and economic climate of the time, and the identity of the injured party.
If the apex court of the country can one minute hand out a judgement
declaring absolute, no fault liability for accidents resulting from inher
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ently dangerous activities, with punitive penalties where guilt or negli
gence was involved (as with the Shriram Food and Fertiliser case of 1987
where two people died due to an oleum gas leakage), and then clinch a deal
between a foreign multinational and the union of India, absolving the
former of its liabilities for killing thousands of people for a mere fistful
of dollars, the next (as with the Bhopal settlement of 1989), what hope is
there for the lower courts?
z
The right to life is enshrined in the Constitution of India, while duties
are imposed on the state and its citizens to protect and improve the
environment, and on the state to improve public health. Is this merely
fancy verbiage or are the stipulations intended to be adhered to? The
stringent enforcement of existing legislation specifically dealing wih
environmental pollution and worker health and safety would at least go
some way to achieving these aims, although as detailed above it has its
own limitations. Of more impact would be the successful conviction of
offenders for crimes such as culpable homicide and grievous hurt since
these carry heavier penalties and leave a deeper imprint on the public
psyche. Only through the fear of being penalised by the courts and
ostracised by the public will industry and government become more
accountable to workers and citizens.
Individual victims, support groups, trade unionists, occupational health
workers, lawyers and environmentalists are some of the people who can
and should make a cohesive effort to fight for change. Of course this need
not take place in the courtroom, and must now anticipate rather than
follow more industrial bloodshed. Direct action and public mobilisation
as ever have a crucial role to play, and the recent display of local hostility
to the siting of a Dupont factory in Goa — which succeeded in driving the
company out of the state — is a testimony to the strength of collective
action in the face of economic, political and judicial adversity.
Sapna Malik
23 Broadheath Drive
Chislehurst
Kent BR 7-6EV
England
Have you renewed your subscription to RJH1
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263
Economic Aspects of Tuberculosis
Control in India
Sujatha Rao
Almost half of the cases of tuberculosis reported all over the
world occur in India. TB is also the number one killer disease
in this country. Almost all of these deaths are preventable. For
overfour decades, there has been a Tuberculosis Control Programme
in operation in India and yet, not much is known about the economic
implications of tuberculosis and the control programme. This paper
is an attempt to look into some of these areas.
ACCORDING to the estimates of the National Tuberculosis Institute
(NTI), at any point of time four out of a population of 1,000 Indians
aged five years and above have the infectious tuberculosis. In addition,
16 out of 1.000 have the X-ray active, sputum negative disease. 16 out
of 1,000 uninfected persons become infected every year [NTI 1991].
Thus, 28-30 lakh people have the infectious form of TB, while more
than 112 lakhs are estimated to be sputum negative, but radiologically
active. Probably, about one-third of the above number is being added
every year, while an equal proportion is reduced through death or cure.
An untreated case of TB will live for two years and is estimated to
affect six to 12 persons in India’s dense population conditions as against
two to three persons who would be infected by a smear-positive case
before its detection in developed countries [NTI 1991]. Therefore, any
reduction in the sources of infection would inevitably improve the
epidemiological situation.
Estimates reveal that two-thirds of the TB cases occur among males.
And yet, the disease takes a proportionately much larger toll of young
females than young males, with more than 50 per cent of female cases
occurring before the age of 34. Among women, TB is estimated to claim
approximately the same number of lives as maternal mortality. When a
mother dies, her children tend to suffer high mortality. As such, an attack
of prolonged and debilitating disease in women of this age group affects
the whole family. Stud.ies reveal that children in households where a
parent suffers from a debilitating disease are more likely to suffer
malnutrition [Greenwood et al 1987; Pryer 1989].
Monetary losses suffered by households due to morbidity and mortal
ity would be higher than those indicated by nominal wage losses if costs
of treatment, transport, special diet, foregone earnings of other family
members and the imputed value of non-market activities such as child
care and food preparation are taken into account. Estimation of losses is
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a tricky problem especially in the developing countries with woefully
inadequate databases, and so studies attempting to quantify costs of
diseases arc rare. Anderson (1962) roughly estimated the indirect cost in
connection with disablement caused by pulmonary TB at Rs 27 crore
annually.
The majority of the TB cases in India occur below the age of 45, with
75 per cent of the diagnosed cases in the 15-44 age group. This is similar
to the age distribution of the disease observed in other countries like
Tanzania, Malawi, Mozambique and Benis [Murray et al 1990]. Mortal
ity due to TB is estimated at 84 per lakh per annum [NTI 1991].
Cumulative mortality due to TB from 1990 to 2000 is expected to be more
than 3.5 million, an enormous burden on the society [Comprehensive
Review Team 1992]. Of the estimated 3,50,000 annual deaths due to TB,
75,000 are in the 15-24 age group, 95,000 in the 25-34 group and 1,60,000
in the 35-44 group [NTI 1991]. Thus, there is a high morbidity and
mortality in the 15-44 age group. This age group is economically the most
active and therefore a higher mortality occurring in this age group has
adverse economic implications. Besides this, there are losses attributable
to increased absenteeism and lowered productivity due to a high concen
tration of morbidity in this age group.
Communicable diseases like TB are widely, if not solely, associated
with poverty, under-nourishment, over-crowding and unhygienic living
conditions. The National Survey (1955-57) found the prevalence to be
higher among those living in ‘kutcha’ houses as compared to those in
‘pucca’ houses indicating a possible association between economic and
hygienic conditions and the prevalence of the disease. Thus, to the extent
that they are directed towards the poor and vulnerable groups, expendi
tures on disease control programmes like NTP are justified not only by the
alleviation in human suffering that they bring about, but also from the
economic and social welfare points of view.
,
I
National Tuberculosis Programme
Launched as a state programme in 1951, the NTP was made a centrally
sponsored programme with 100 percent central assistance in the Fourth
Five Year Plan. During the Fourth Plan, it was converted into a matching
programme with 50 per cent central assistance, the other 50 per cent
coming from the slates. At present, the centre’s share is in the form of anti
TB drugs, X-ray films, X-ray machines, Odelca cameras, etc.
The long term objective of the NTP was to reduce TB in the community
sufficiently quickly to the level that it ceases to be a public health
problem. The operational objective was to detect maximum number of
TB patients among out patients at health institutions giving priority to
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265
sputum-positive TB patients. An important landmark in India’s TB
programme was the establishment of the NTI in 1960. Among its
objectives are the formulation and evolving of a practicable, economi
cally feasible and widely acceptable TB programme for the entire
country, and to train medical and paramedical workers to implement the
programme in rural and urban areas. Monitoring the NTP has been
included among the NTT’s functions since 1978 district tuberculosis
centre (DTC) which is the basic organisational unit of the NTP is situated
in the district headquarters and responsible for case-finding, treatment
and management of the programme, besides recording and reporting data.
The peripheral health units are responsible for implementing the NTP in
rural areas.
Three important aspects of the disease control programme relate to
prevention of new cases through immunisation and detection and treat
ment of existing ones. The reported efficacy of the BCG vaccine in
preventing TB is not uniform and ranges between 0-80 per cent across
countries; nor is there any conclusive evidence on its capacity to confer
immunity beyond the age of 15. The differences in the levels of protection
offered are attributed to a number of factors ranging from differences
in nutritional status of the recipients and in the strains of BCG to
infection with other mycobacteria. In the South Arcot district of Tamil
Nadu, the BCG vaccine was found to be ineffective in protecting the
adults against the disease. However, vaccination with BCG is believed
to be quite efficacious in preventing TB in children below the age of
15 and is undertaken as a part of the Extended Programme of Immunisa
tion (EPI).
An important first step in the control of the disease is the diagnosis,
especially of the smear-positive cases of pulmonary TB. Under the
NTP, both sputum examination
and X-ray are used as diagnostic
Table 1: Budgetary Allocation to
tools. Out of 100 cases diagnosed
National Tuberculosis Programme
on the basis of X-ray, 50 per cent
(Rs in crores)
are likely to be infectious in
Allocation
clinical situations; but out of 100 Year
infectious TB cases, about 20 1982-83
3.21
are likely to be missed by X-ray 1983-84
6.00
examination.
8.00
1984-85
11.00
In the past all over the world a 1985-86
13.50
major part of the TB budget was 1987-88
12.50
spent on hospitalisation. This 1988-89
12.00
1989-90
trend is now being reversed. The
15.25
NTP takes cognisance of the fact 1991-92
29.00
1992-93
that domiciliary treatment is as
Source:
NTI,
NTP
in
India,
1992-93.
effective as hospitalisation, but
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much more cost-effective as it entails less expenditure on infrastruc
ture, beds, staff, etc. Apart from money costs, psychological costs are
also reduced in the case of domiciliary treatment because patients
tend to be rejected by their families after hospitalisation due to the
stigma attached to the disease by the society. However, data reveal
that the numberofTB beds has increased in recentyears. Forexample,
in Maharashtra, the bed strength increased from 6,879 in 1987 to 8,207
in 1990.
The short course chemotherapy (SCC) is costlier in terms of the drugs
used, but is recognised world-wide as the most effective way of curing
TB. Another important reason for the increasing acceptance of SCC is
that it offers a possible solution to the problem of incomplete treatment.
While the standard regimen takes 18 to 24 months for a cure, the SCC
reduces the duration of treatment to six to eight months. A complete cure
is important not only from the individual patient’s point of view, but also
from the epidemiological angle because the source of infection persists
when cure is incomplete. The duration of treatment affects compliance
adversely as a steady drop in compliance is observed over time and the
relapse rate is a function of the months of treatment [Murray et al 1990].
The SCC which was introduced in 1983-84 is presently operational in 253
districts. During the Eighth Five Year Plan, more districts are being
brought under SCC.
Table 2: TB Infrastructure in India
Name of State
No of
Districts
No of
DTCs
No of
other
TB Clinics
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
All India
23
18
42
19
12
30
14
45
30
13
12
27
21
56
17
459
23
11
32
19
11
20
12
45
30
13
12
27
16
56
16
390
25
9
25
4
4
6
9
5
19
4
4
2
40
20
116
331
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No of
TB Beds
2,579
809
2,109
3,563
410
3,545
2,283
1,986
8,207
901
921
2,018
3,620
3,437
6,433
47,321
261
Expenditure on TB Control
The NTP outlay rose from Rs 6 crore in 1983-84 to Rs 15.50 crore in
1991-92. In percentage terms, the NTP outlay which formed 1.3 percent
of the centre’s total health plan outlay in 1983-84 peaked at 1.9 per cent
between 1985-86 and 1987-88. Subsequent years saw a decline in the
NTP budget to 1.3 per cent. The NTP which was the third largest disease
Table 3: Targets and Achievements of National Tuberculosis Programme
Year
Target for
Detection of
New TB Cases
(Lakhs)
Achievement
as Per Cent
of Target
10.00
12.50
13.75
14.00
14.50
15.00
15.00
16.00
16.50
17.00
17.50
18.00
100.00
96.00
91.00
97.00
97.50
104.00
104.00
104.00
91.00
73.20
88.20
NA
1982-83
1983-84
1984-85
1985-86
1986-87
1987-88
1988-89
1989-90
1990-91
1991-92
1992-93
1993-94
Achievement
Target for
as Per Cent
Conducting New
of Target
Sputum Exams at
PHIs (Lakhs)
No tareet laid down
34.00
34.00
34.00
34.00
34.00
34.00
34.00
34.00
34.00
34.00
34.00
35.00
50.20
59.50
63.90
71.00
73.90
72.40
64.20
70.70
68.30
NA
Source: National Programme for Control of Tuberculosis, National Institute of
Health and Family Welfase, New Delhi. As for (able 4 and 5.
Table 4: State-wise Detection of New TB Cases, 1992-93
States/Union
Territories
Andhra Pradesh
Assam
Gujarat
Haryana
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
268
Annual
Target
Achievement
1992-93
Per Cent
Achievement
90,400
39,100
1,48,200
31,200
85,200
46,600
1,22,800
2,36,500
41,300
43,400
46,360
1,18,940
2,97,500
93,200
65,517
17,975
1,58,238
31,058
65,653
27,275
52,473
2,34,147
28,367
44,764
33,557
99,034
2,56,861
51,113
72
46
107
100
78
59
43
99
69
103
72
83
86
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control programme after the National Malaria Eradication Programme
and the Leprosy Eradication Programme until 1991-92, was relegated to
the fourth place after kala azar that year. However, the year 1992-93 saw
a sizeable hike in the NTP outlay to Rs 29 crore apparently to provide for
HIV-related TB cases which would be in addition to the expected
incidence (Table 1).
Table 2 furnishes state wise figures on TB infrastructure available.
There were 390 DTCs and 331 other TB clinics operating in the 459
districts of the country by December, 1992 with a total bed capacity of
47,321. Most major states have DTCs functioning in all or nearly all the
districts. The notable exceptions are Assam, Bihar, Karnataka and Tamil
Nadu. Maharashtra has 8,207 beds which is the highest for any state,
followed by West Bengal with 6,433 beds; 57 districts in the country had
noTB beds, while 85 had 10 or fewer beds. 69 districts in three states, viz,
Bihar, MP and UP, had fewer than 10 or no TB beds.
II
Tuberculosis Control: An Assesment
A major problem encountered by any one wishing to look into disease
control programmes in India arises from paucity of data. It is noteworthy
that tuberculosis is the only major disease on which a national level
survey has been conducted. But the national survey of 1955-58, which is
widely used as a bench mark in the case of prevalence and incidence of
the disease, was neither geographically comprehensive, nor was the
Table 5: State-wise Position on Sputum Examination, 1992-93
States/Union
Territories
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
RJH
(New Series)
Annual
Target
Achievement
1992-93
Per Cent
Achievement
2,52,600
87,600
3,76,200
1,53,500
60,000
1,85,000
1,07,400
2,90,500
2,76,900
1,90,200
85,000
1,40,400
2,41,800
5,75,000
2,14,200
1,84,765
8,226
3,41,779
2,65,577
49,720
1,69,585
37,789
1,17,433
3,39,063
1,22,232
1,12,461
64,228
1,11,482
5,13,951
26,672
73
9
90
177
83
92
35
40
122
64
132
46
47
90
12
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269
sample size large enough to warrant conclusive generalisations. The
survey was confined to six cities viz, Delhi, Hyderabad, Madanapalle,
Trivandrum, Patna, and Calcutta, and 30 towns and 151 villages in their
vicinity. Thus, the survey contained no information on the central and
western parts and most of north India. All the subsequent surveys were
even more restricted in their geographical coverage and used such
differing methodologies as to render
comparisons meaningless. In view of this major constraint, it would be
difficult to say anything conclusive about possible reductions in the
prevalence of the disease and the role of NTP therein.
The official mortality figures are gross underestimates and are, there
fore misleading. Medically certified deaths form just about 1.7 percent
of total deaths in India. According to Health Information of India
published by the Ministry of Health and Family Welfare, reported cases
of death due to TB numbered 9380 in 1990 and 8773 in 1991. These
figures vary very widely from the estimates by the Comprehensive
Programme Review Team (1992), which placed the number of annual
deaths due to TB at over 657,000. Curiously, according to the official
figures, the total number of TB deaths in a comparatively efficient state
like Maharashtra was 905; on the other hand, Bihar reported three deaths,
UP 325 and MP 298. This is in spite of the extremely low completion rates
reported by the NTI for Bihar (20 per cent), and UP (35 per cent). These
states are also highly populated with known low levels of economic and
social development and therefore the low death figures are obviously the
result of apathy and sloppiness in
Table 6: State-wise Treatment
reporting on the part of these states.
Completion Rates
The fallout of such negligent un
der-reporting would be to gener
Rate
State
ate unwarranted complacency.
29
Andhra Pradesh
The NTP is one of the largest
31
Assam
disease control programmes in the
20
Bihar
country and has been in operation
27
Gujarat
for over four decades and yet it has
34
Haryana
not received the attention and scru
21
Karnataka
tiny that a programme of this mag
48
Kerala
47
nitude deserves. As is well known,
Madhya Pradesh
73
Maharashtra
increasingly larger expenditures
38
Orissa
have gone into the Family Welfare
37
Punjab
programme to the neglect and det
19
Rajasthan
riment of other health progrmmes
20
Tamil Nadu
leading to a spate of studies on the
35
Uttar Pradesh
working of the Family Welfare
10
West Bengal
schemes. Thus the scant attention
Source'. NTI Year Book, 1992-93.
that the NTP has received is com
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mon to all the disease control programmes in operation in India. There are
certain additional problems about TB. Given the social stigma attached to
the disease, most patients do not wish to admit that they have TB. Besides,
the outward symptoms of the disease subside quickly once the treatment
starts and this lulls the patient and the community into the false belief that
the problem does not exist any more. Further, as the disease does not strike
in an epidemic form, it does not draw attention to itself in a conspicuous
way.
At the time of launching the NTP, the long term objective of the
programme was stated to be the reduction of TB in the community
“sufficiently quickly” to the level that it “ceases to be a public health
problem”. The operational objective was to detect “maximum number of
TB patients” among out patients. Thus, the objectives were loose and
vague and couched in ambiguous terms. It is not clear whether the aim of
the programme was eradication or phased reduction. There was neither a
time frame, nor any quantitative criteria by which to assess the progress
made and identify achievements, lags and shortfalls. Evidently, spelling
out objective criteria and a time frame, and measuring the progress are
formidable tasks given the extreme data deficiency. However, the need
for some quantification has been recognised in recent years and the NTP
has been setting targets for new case-finding and sputum examinations.
The targets for new case-detec
tion have been continuously re
Table 7: Reported Cases of Death
vised upwards from 10 lakhs 1982Due to TB
83 to 14 lakhs in 1985-86 and fur
1990
1991
ther to 18 lakhs in 1993-94. The Name of State/
Union Territory
number of new cases detected reg
1250
1105
istered a sizeable increase from Andhra Pradesh
148
88
10.81 lakhs in 1982-83 to 16.16 Assam
3
NA
lakhs in 1990-91, but fell in the Bihar
617
228
subsequent years. The achievement Gujarat
Haryana
401
308
vis-a-vis the target for case detec
Karnataka
821
560
tion was 100 per cent in 1982 but Kerala
236
317
fell between 1983-84 and 1986-87. Madhya Pradesh
325
313
The next three years saw actual Maharashtra
905
1053
detections exceeding the targets. Orissa
1541
521
In the 90s, case-detection targets Punjab
95
167
330
190
have remained consistently un Rajasthan
649
326
fulfilled. For example, the achieve Tamil Nadu
298
227
ment was a bare 73 per cent of the Uttar Pradesh
268
327
West
Bengal
target in 1991-92 and rose to 88 per
8773
All India
9308
cent in 1992-93 (Table 3).
A state- wise picture of targets Source: Health Information of India,
1991, 1992.
and achievements in respect of de
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271
lection of new TB cases for 1992-93 (Table 4) reveals that the achieve
ment was not uniform across the slates. It exceeded the target in Gujarat,
Haryana and Punjab, and was over 75 per cent of the target in Bihar,
Karnataka, Maharashtra, Tamil Nadu and Uttar Pradesh; on the other
hand, the performance lagged far behind the targets in states like Assam
(46 per cent), Jammu and Kashmir (23 per cent), Madhya Pradesh (43 per
cent), and West Bengal (55 per cent).
No targets were set for sputum examinations before 1983-84. Since
that year the target al the all India level has been set al a constant 34 lakhs.
This target has not been met in any year and the achievement which was
a dismal 35 per cent of the target in 1983-84 rose in subsequent years to
hover erratically between 50-74 per cent (Table 3). Data at the state level
in respect of sputum examinations for 1992-93 reveal an abysmal perfor
mance in the case of Assam (9 per cent) and West Bengal (12 per cent)
with states like Kerala (35 per cent), Madhya Pradesh (40 per cent),
Tamilnadu (47 per cent), and Rajasthan (46 per cent) faring somewhat
better, but lagging far behind the targets set. Gujarat, Maharashtra and
Punjab exceeded the targets (Table 5).
Official reports rely on data on casefinding and diagnosis to monitor
the working of the NTP and ironically, there is no convention of using
cure rates to measure programme efficiency and estimate prevalence
rates; nor is it a feasible proposition to conduct periodic surveys on
disease prevalence given the financial, physical and manpower resources
required especially in the face of other more compelling health priorities
vying for attention. In the absence of decisive measures, other ways of
monitoring the disease situation would seem vague and devious. For
example, in a scenario of high default rates, simple detection figures can
hardly offer a meaningful guide to the actual epidemiological picture.
The treatment completion rate of 41 per cent at the all India level is
very low. Among the slates, this rale is highest at 73 per cent in
Maharashtra. No other state achieved a treatment completion rate of even
50 per cent. Bihar, Rajasthan, Tamil Nadu, Karnataka and West Bengal
Table 8: TB Expenditure, 1991-92 (Maharashtra)
(Rs in thousands)
Heads of Expenditure
BE
AE
Salaries
Travel
Office Expenditure
Motor
Materials and Supply
Total
10,170
800
260
435
33,320
45,005
11,267
1,072
354
530
42,533
42,533
AE as per cent of BE
110.79
134.00
136.15
121.81
- 81.16
94.51
Note:
BE Budgetary Allocation; AE Actual Expenditure.
Source: Government of Maharashtra, Performance Budget (1993-94).
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reported extremely low completion rates ranging between 10-20 per cent
(Table 6).
It is difficult to separate the effect of a natural decline of the disease
from that attributable to intervention in the form of NTP. NTP can at best
be only one among the several factors that influence the prevalence such
as nutritional levels, congestion, hygiene conditions and so on. However,
experts point out that there is virtually no tendency for the disease to
eliminate itself in the absence of intensive control measures [Murray et al
1990).
No studies are available al the all India level which offer definite proof
of a decline in the incidence of TB. But indirect evidence suggests such
a decline. For example, a longitudinal survey conducted in rural Banga
lore [Chakraborty et al 1992] found that the observed annual incidence of
infection was lower than the estimated annual risk rate. The annual risk
of infection declined from 1.1 per cent in 1961 to 0.61 per cent in 1985
representing a decline of about 41 per cent in 23 years or an average
annual decline of about 2.3 per cent. On the basis of a 50 year mathemati
cal iteration of the TB situation another study demonstrated considerable
impact of the programme on the problem of TB over a long term, even
though for single years the programme efficiency may fall far below
expectation [Balasanghameshwara et al 1992]. Further, clinicians have
recorded a decline in the observed incidence of milliary disease, TB
menangitis, etc [TAI 1968]. These studies indicate that the decline in the
observed incidence of TB may be attributable largely if not solely to the
NTP. A word of caution is imperative here as this conclusion is based on
limited evidence which may not be valid for the country as a whole.
Besides, the decline reported is much lower than the criteria suggested by
experts that a good TB programme should be able to reduce the annual
risk of infection by at least 5 per cent a year in order to halve the problem
of TB in 14 years [Slyblo 1991].
Resource Allocation for TB Control
Ideally, the process of budgeting should take into account the changing
population and age profiles, disease patterns, state wise prevalence rates,
the policy shift in emphasis to SCC, and projected supply, demand and
costs of drugs besides a host of other factors. Further, the normal process
of inflation has to be provided for. Some of the drugs indicated are not
produced indigenously and have to be imported. Foreign exchange
requirement in the face of the fluctuating rupee value and changing
international prices of drugs and the implications of relying on uncertain
foreign sources for drug supplies need to be worked out . There is no
indication of these factors being considered in an integrated exercise as
a prelude to the budgetary process.
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273
Krishnamurlhy (1993) notes that the Seventh Five Year Plan
allocation of Rs 60 crore was inadequate as the amount required for
diagnosis and treatment was over Rs 117 crore. Other studies have
also pointed to the inadequacy of the NTP budget, although there is a
wide variation in the estimated requirement. It is estimated that there
are 3 million sputum-positive cases and 12 million sputum-negative
X-ray suspects in India. Assuming that the cost of treating one
sputum-positive case on SCC is Rs 400 and the annual cost of treat
ment under a two-drug standard regimen (in respect of 80 per cent of
all suspect cases) is Rs 100, and the annual cost of a three-drug
standard regimen (in respect of 20 per cent of all suspect cases) is
Rs 300, Shanmugam et al (1992) estimate the cost of treatment of all
pulmonary cases at Rs 300 crore. This estimate does not include
outlays that would have to be incurred on case-finding and case
holding. Evidently, the present outlay of less than Rs 30 crore does not
even meet the cost of treatment, leave alone case-finding and case
holding and is thus grossly inadequate. Further it is expected that there
may be an additional 2,50,000 HIV-related TB cases annually by the
end of the 90s for which increased allocations will be required.
The paucity of resources leads to vital gaps in supply of drugs.
Streptomycin, which forms part of the standard regimen was found
to be unavailable in several DTCs due to the budgetary cuts in the
early 90s (TB Review Committee). The meagre allocations also affect
the purchase of fuel and maintenance of vehicles and this jeopardises
the supervising and monitoring of the PHIs so essential for the
programme.
Since the funding of the programme is shared between the centre
and stales with 50 per cent matching grants contributed by the centre,
poorer states which can not generate adequate resources on their own
and operate on low health budgets are at a distinct disadvantage. The
limited contribution of the centre in the face of already low health
budgets in these states further restricts the capacity of these states to
tackle the disease.
India’s total health budget works out to less than Rs 55 per capita. There
is also a growing tendency to make increasingly higher allocations to
family welfare vis-a-vis health within the health sector budgets in the
recent plans. The low allocations to the NTP have to be viewed in this
context.
Data reveal sudden spurts and cuts in budgetary allocations which
affect the smooth running of the programme (Table 1). For example, in
1985-86 there was a massive increase in the allocation to the TB
programme to Rs 11 crore compared to Rs 8 crore in the previous year.
The following year saw a further increase in the allocation. This was
perhaps to allow for the introduction of the SCC. However, in the
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subsequent budgets there was no evidence of increased allocations for
further coverage of districts under the SCC. On the contrary, budgets in
1988-89 and 1989-90 effected arbitrary, albeit marginal, cuts in alloca
tions. These cuts were in tune with the squeeze in government’s social
sector spending that characterised this period. Though marginal in money
terms, these cuts were much higher in real terms. Recent budgets have,
however, increased the outlay because it is feared that the spread of AIDS
would compound the TB problem. It would bear repeating here that
disease control programmes like the NTP are highly cost-effective and
arbitrary cuts in such budgets would result not only in human suffering
but also allocative inefficiency.
In the years 1990-91, 1991-92 and 1992-93 the allocations to NTP
were to the tune of Rs 15 crore, Rs 15.25 crore and Rs 29 crore
respectively. But actual expenditures remained lower at Rs 12.48 crore,
Rs 7.19 crore and Rs 24.95 crore. Such a disturbing discrepancy between
outlay earmarked and actual expenditure is a feature of the 90’s and is at
variance with the experience of the Seventh Five Year Plan wherein the
actual expenditure of Rs 61.76 crore was slightly higher than the amount
of Rs 61 crore earmarked. The actual expenditure which was 83 per cent
of the outlay in 1990-91 dipped to 47 per cent of the allocation in 199192 to rise to 86 per cent in 1992-93. As a result, achievement in respect
of detection of new TB cases fell from over 100 per cent of the target in
the years 1987-90 to 88-91 per cent in 1990-91, the figure further falling
to 73 per cent in 1991-92. Similarly, achievement in respect of sputum
examinations also fell from 72-74 per cent of the target in the late 80s to
less than 70 per cent in the early 90s.
A similar pattern of expenditure is evident in the states too. For
example, in Maharashtra in 1991-92, the actual expenditure was less than
the budgeted expenditure in the case of most of the disease control
programmes. While actual expenditure exceeded the outlay in the case of
malaria and cholera, actual expenditures were 44 per cent and 55 per cent
in the case of goitre and plague respectively. In all other cases, including
filaria, guinea worm, leprosy and TB, there was a shortfall ranging
between 4-8 per cent.
z
A detailed break-up of the actual expenditure pattern reveals an even
more disturbing picture. For example, in the case of Maharashtra (Table 7)
even though the actual expenditure on tuberculosis in 1991-92 was 94 per
cent of the budgeted outlay, actual expenditures exceeded the allocations
in respect of all the non-material components, viz, salaries, travel, office
expenditure and motor vehicles; on the other hand, a massive shortfall to
the tune of almost 20 per cent was recorded in respect of the most crucial
component of the programme, viz, materials and supplies. And, ironi
cally, despite this crucial shortfall, targets were achieved and in some
districts even exceeded.
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275
High Programme Costs
In a situation of increasing budgetary constraints, it is necessary to
identify some of the factors responsible for suboptimal utilisation of the
allocations, so that the limited resources available may be used more
efficiently. These factors range from diagnostic tests to treatment prac
tices and case-holding.
An X-ray test is estimated to cost 7-10 times more than a sputum test
[Naganathan et al 1974]. But the multi-purpose workers are reluctant to
collect sputum while patients are unwilling to be dubbed as suffering from
the dreaded disease on the basis of evidence provided by a mere sputum
test. As a result, in spite of the sputum culture examination providing sure
proof of TB in sputum-positive cases, there is an emphasis on the costlier
X-ray technique. Often, the sputum positive cases are put through X-rays
also after they have been examined by the sputum, possibly because the
patients have more faith in X-rays. Thus, during the Seventh Plan, of the
144.1 million symptomatics screened, 120.4 million (over 83 per cent)
were X-rayed while only 23.7 million (17 percent) were given the sputum
test. Such practices make the case-finding procedures unnecessarily
costly, thereby wasting the already limited resources. Many PHIs do not
have X-ray facilities and these refer the patients to DTCs. This further
adds to the burden on these centres.
Sometimes, only one or no sputum-smear is done before a person is
diagnosed as suffering from TB and put on anti tubercular treatment. At
others, treatment is started on the basis of radiological evidence which
may not be conclusive. There are other problems with regard to X-rays.
According to an assessment by ICORCI, only 74.8 per cent of suspects
were confirmed when a panel of X-ray readers reread the X-ray films.
Thus, at least 25 per cent of the suspects were found to be wrongly treated
even though they would not have been confirmed. Dependence on X-rays
leads to wastage of financial resources due to over-treatment apart from
creating avoidable operational and social problems.
SCC was introduced on a pilot basis in 1983-84 in 18 districts of the
country. By the firstquarter of 1993,252 DTCs and over 11,500 PHIs were
treating patients under the SCC [NTI Year Book, 1992-93]. Uncjer the
NTP, sputum-positive cases aged 15 years and above are eligible for SCC,
which is six to eight months duration as compared to 12-18 months in the
case of the standard regimen. The cost of drugs under SCC is high. As
against an annual cost of Rs 100 for a two-drug standard regimen (which
is applicable to 80 per cent of all suspect cases) and Rs 300 in the case of
three-drug standard regimen (applicable to 20 per cent of all suspect
cases), the cost of drugs under the SCC is estimated at Rs 400 [NTI 1992].
While exact cost estimates may vary, it is evident that SCC is much costlier
than the standard regimen and yet it is being extended on the hope that it
276
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would help reduce defaults. However, the Indian experience reveals that
there is no dramatic improvement in compliance rates even after the
adoption of SCC; while the percentage completing treatment under the
standard regimen is 40, the corresponding percentage in the case of SCC
is just 50 [NTI93]. This small increase in compliance is hardly commensu
rate with the increased cost. Patients with severe or complicated forms of
TB like meningitis or those with other complications like pneumothorax
are hospitalised according to the NTP guidelines. These patients instead of
receiving SCC often receive the standard regimen which has low efficacy
in the critical and retreatment cases. Hospital beds represent huge invest
ments of scarce resources. Longer occupancy of beds due to the use of
standard regimen than would be required under the SCC leads to suboptimal utilisation of the available beds.
Patient default is a major problem faced by TB programmes all over
the world. The causes of patient default are several. These include
ignorance and negligence, distance from the patient’s home to the facility,
cost and length of treatment, and quick subsiding of the symptoms after
initial treatment; non-availability of drugs at the government facilities,
and lack of motivation and accountability on the part of the medical team
may also aggrevate the problem.
In 1990,52 per cent of the TB patients in the country failed to complete
the requisite length of treatment. It is estimated that 5 per cent of the
patients drop out even before treament is started and 30-50 per cent miss
drug collection before the fourth month of chemotherapy [Uplekar and
Rangan 1995]. Incompletely treated patients develop drug resistance. 44
per cent of patients who collected less than 50 per cent of their drugs, 37
per cent of those collecting 50-79 per cent of the drugs, and 21 per cent
of those collecting more than 80 per cent but not the entire course, are
estimated to remain sputum-positive [Tuberculosis Research Centre
1990]. With incompletely treated patients turning chronic, no significant
impact is felt on the disease situation, while expenditures continue to be
incurred.
The criteria for discharge from treatment are not clearly specified in
NTP manuals. Given the high default rates, patient are required to
continue the treatment for the period he has not collected the drugs. So,
many patients end up receiving unnecessarily long treatment further
straining the limited manpower and financial resources available.
Negligible allocations to education and publicity have lead to the
persistence of ignorance regarding the disease on the part of the patients.
The government has failed to give adequate publicity to the NTP and the
need for regularity in treatment. Of the 191 publications of the ministry
of health and family welfare, only 12 related to TB and these were mostly
on BCG which is now part of the extended programme of immunisation
and not NTP. In the urban areas 40 per cent of the people did not know
RJH
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277
where the Government Health facility is located and 20 per cent did not
know that services under the NTP were meant to be free [Uplekar and
Rangan 1995].
When the expenditure patterns of the NTP are compared with that of
the National Malaria Eradication Programme (NMEP), the former appear
to be more efficient with emphasis on drugs and supplies rather than
salaries. It should be noted here that the NTP utilises the services of
multipurpose workers who are not directly employed and paid under the
programme. However, it has been observed that the multi-purpose
workers do not receive much training in procedures’relatcd to TB; nor do
they take much interest in TB work because they are not directly
employed under NTP.
There are other problems related to manpower. As of 1991, only 24 per
cent of the DTCs had a fully trained team with 66 per cent having trained
District tuberculosis Officers (DTO), 76 per cent with trained X-ray
technicians and 78 per cent with trained laboratory technicians. Such a
situation where there is physical infrastructure without the requisite
manpower leads to under-utilisation of the existing facilities.
Though India has the capability to produce all the anti tuberculosis
drugs, only a few are produced indigenously [Shanmugham et al 1992].
There is no continuity of policy regarding the regimens to be used under
the NTP. As a result, indigenous manufacturers are reluctant to produce
drugs in bulk in view of the uncertainty of demand. This leads to
dependence on imported drugs. Experts advocate the adoption of a long
term treatment policy valid for a decade or so, in order to facilitate placing
of bulk orders which would result in assured demand for the indigenous
manufacturers.
Expensive drugs like Rifampicin and Ethambutol have limited shelf
lives in the hot and humid weather conditions prevalent in India. Poor
packaging, lack of air conditioned vans and storage facilities, irregular
power supply and poor road conditions compound the problem and affect
the availability of the drugs in far flung areas. Quality control is another
area which has not received sufficient attention. Studies reveal that the
bioavailability of Rifampicin varies from one manufacturer to another and
even from batch to batch. India is poorly equipped in terms of quality
control laboratories. Monitoring of drug quality is not easy in a country of
India’s size especially because of the large number of small firms involved
in the manufacture of drugs in addition to the major manufacturers.
Under the DTP, anti-tubercular drugs are provided free of cost to the
patients. Drug producers who are mostly the smaller firms find it unprofit
able to supply drugs at the price fixed by the Government. As a result,
while adequate supplies are available in the open market at higher prices,
there is a shortage at the government facilities. The government units give
patients prescription for purchasing essential drugs like Isoniazid on their
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own. Thus the patients end up incurring high out-of pocket expenses,
which may in turn induce them to curtail the length of treatment.
According to a study in Maharashtra, 73 per cent of the rural patients
and 59 per cent of the urban patients first sought help from private
practitioners for diagnosis and treatment [Uplekar and Rangan, 1995].
Thus, there is considerable doctor-shopping before patients turn to the
public system and the presence of the private sector is overwhelming.
According to NTI estimates, less than 57 per cent of all cases of identified
TB are registered with the NTP. The implications of such wide spread
participation of the private medical practitioners are manifold and should
not be overlooked.
Dependence upon the private practitioner adds considerably to the out
of pocket expenses of the patient. Unlike Government care, where
diagnosis and treatment are free, in the case of private sector diagnosis,
X-ray, drugs and consultation have to be paid for. The private practitio
ners also tend to recommend costlier regimens than those suggested under
the NTP. It was found that many private practitioners were ignorant of the
drugs to be used and the duration of the treatment. Their dependence on
medical representatives as a source of information on drug treatment for
TB was high [Rangan 1994]. Often, the patients having spent consider
able time and money ultimately turn to the public facility. By this time,
as the infection spreads to others, the patient himself may have become
drug-resistant.
[The author is grateful to N H Antia for his constant encouragement and keen
interest in this work. Thanks are also due to M Uplekar whose insightful
comments have enriched this paper and Sheela Rangan for useful discussion.]
References
Anderson, Stig (1962): ‘Some Aspects of Economics of Tuberculosis in India’,
Indian Journal of Tuberculosis, 9(3).
Balasangameshwara, V H, A K Chakraborty and K Chaudhuri (1992): ‘A
Mathematical Construct of Epidermiological Time Trend in Tuberculosis - a
50 Year Study’, Indian Journal of Tuberculosis, 39(87).
Cntral Bureau of Health Intelligence: Health Information of India, Directorate
General of Health Services, New Delhi (Various issues).
Chakraborty, A K et al (1992): ‘Tuberculosis Infection in Rural Population in
South-India: 23 Year Trend’, Tuberculosis and Lung Disease, 73, pp 213-18.
Comprehensive Programme Review Team (1992): National Tuberculosis
Programme, Delhi.
Fox, Wallace and Nunn (1979): ‘The Cost of Anti tuberculosis Drug Regimens’,
American Review of Respiratatory Diseases, 120.
Fox, Wallace (1990): ‘Tuberculosis in India, Past, Present and Future’, Indian
Journal of Tunerculosist 37(VI5).
Government of Maharashtra: Performance Budget, (1993-1994).
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279
Greenwood ct al (1987): ‘A Prospective Study of the Outcome of Pregnancy in
a rural Area of Gambia, West Africa’, Bulletin of WHO, 65 (Quoted in Murray
ct al, 1990).
Indian Council of Medical Research (1959): Tuberculosis in India - A Sample
survey (1955-1958), Indian Council of Medical Research, New Delhi.
ICORCI: An Assessment of the National Tuberculosis Programme, Institute of
Communication, Operations Research and Community Involvement, Banga
lore.
Krishna Murthy, V V (1993): ‘Evaluation of the Progormance of National
Tuberculosis Programme during the VII Plan’, Indian Journal of Tuber
culosis, 40 (129).
Mankodi, K and K W Von der Veen (1984): Treatment Failure in India’s
National Tuberculosis Programme, Department of South and South Asian
Studies, University of Amsterdam, Working paper 40.
Murray, C J L, K Styblo and A Rouillon (1990): ‘Tuberculosis in Developing
Countries: Burden, Intervention and Cost’, Bulletin of International union
against Tuberculosis and Lung Disease, 65(1).
— (1993): ‘Tuberculosis’ in Jamison, Mosley, Measham and Bobadilla (eds)
Disease Control Priorities in Developing Countries, Oxford Medical Publi
cations.
Naganathan N, K Padmanabha Rao and R Rajalakshmi 91974): ‘Cost of Estab
lishing and Operating a Tuberculosis Bacteriological Laboratory’, Indian
Journal of Tuberculosis, 21(4).
Nagpaul, D R (1967): ‘Why Integrated Tuberculosis Programmes have not
Succeeded as per Expectations in many Developing Countries -A Collection
of Observations, Indian Journal of Tuberculosis, 29(3).
National Tuberculosis Institute (1991): Tuberculosis in India, NTI, Bangalore.
— (1992): ‘Issues in Anti tuberculosis Drug Supplies under National Tuber
culosis Programme, Newsletter, 28(3/4).
Pryer, J 91989): ‘When Breadwinners Fall Ill: Preliminary Findings from a Case
Study in Bangladesh’, IDS Bulletin, 20(2) (Quoted in Murray el al, op cit.
Radhakrishna, (1988): ‘Direct Impact of Treatment Programme on Totality of
Tuberculosis Patients’, Indian Journal Of Tuberculosis, 35.
Shanmugham M, Norbu Tsering and Prema Das (1992): ‘Issues in Anti-Tuber
culosis Drug Supplies under National Tuberculosis Programme’, NTI
Newsletter, 28 (3/4).
Styblo, K (1991): Selected Papers: Epidemiology of Tuberculosis, 24, Royal
Netherlands Association, The Hague.
Tuberculosis Research Institute: Annual Report (1990), Madras.
Uplekar, Mukund and Sheela Rangan (1995): Tackling Tuberculosis: The Search
for Solutions - Social and Operational Constraints in Tuberculosis Control
in Maharashtra, India, FRGH, Bombay. (Pre-publication).
Sujata Rao
Foundation for Research in
Community Health
R G Thadani Marg
Worli, Bombay.
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Family Experience of Epilepsy
Premilla D’Cruz
Any chronic illness is influenced by and influences the family
situation. Even as family responses effect the course of the disease,
the illness condition itself often transforms family relationships.
This is even more evident in the case of epilepsy, a condition to
which is attached a great deal of social stigma.
CHRONIC ILLNESS refers to a condition that interferes with daily
functioning for more than three months in a year, causes hospitalisation
of more than one month in a year or is likely, to do either of these [Perrin
in Patterson 1988]. Chronically ill individuals never return to perfect
health and generally spend their entire life coping with progressively
debilitating limitations [Patterson 1988]. In recent times policies of deinstitutionalisAtion and community care as well as the ideology of
familism in the face of decreased welfare are shifting the onus of care
giving to the family, making chronic illness a family event [Crotty and
Kulys 1986; Thompson and Doll 1982; Montgomery et al 1985; Kaye
and Applegate 1990; Dalal 1995].
For the family, the experience of a chronic problem signifies arrested
family development, with the attendent uncertainty, helplessness, anger,
depression and rejection. In the process of providing physical and
emotional care and support, the family has to restructure its routines,
roles, activities, finances, resources, time and developmental stages — a
stressful experience whose outcome veries with the nature of the problem,
the nature of the family and the unwell person [Dalal 1995; Hafstrom and
Schram 1984; Anderson 1989; Thomas 1982; Palfrey et al 1989; Patterson
1988].
Epilepsy is a disease that falls in the category of chronic illness.
Derived frojn the Greek word ‘epilepsia’, which means ‘taking hold of,
it is a disorder of the brain characterised by recurrent seizures that are
caused by transient, excessive and abnormal electrical discharges of
neuronal aggregates in the brain. These abnormal discharges, accompa
nied by an episodic, involuntary alteration in consciousness, motor
activity, behaviour, sensation and autonomic functions may involve a
small part of the brain (in the case of focal/partial seizures) or a much more
extensive area in both hemispheres (in the case of generalised seizures),
[O’Dougherty 1983]. While literature on the psychosocial aspects of
epilepsy exists, there is a surprising paucity of literature on the family
experience of epilepsy, despite growing recognition of family stress in
chronic illness.
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Review of Literature
By and large literature on the psychosocial experience of epilepsy is
western and patient-centred. Most studies reflect the stigmatisation,
marginalisation, discrimination and negative attitudes towards persons
with epilepsy. One study on public attitudes to epilepsy, conducted by the
American Institute of Public Opinion over a 30-year period, indicates
greater awareness of and the diminishing of prejudice towards epileptics
[Caveness and Gallup 1980]. A survey of public awareness, understand
ing and attitudes towards epilepsy in Hunan, China shows that while
awareness is very great, attitudes are negative [Lai et al 1988]. More than
half the sample objected to having their children play with epileptics in
schools and marry' them. Fifty-three per cent believed that epileptics
should not be employed in jobs like other normal persons. Bharucha
(1969) in India supports the view that epileptics in India are discriminated
against by relatives, teachers, employers, colleagues and friends.
While most epileptics evidence a normal IQ, studies in the area of
education indicate that many of them drop out of school because of
pressure from unsympathetic teachers and school authorities who
stigmatise them. They experience intellectual and cognitive problems
such as memory loss or inability to cope with scholastic demands;
parental or self-made decisions in the light of social pressures and
cognitive problems; negative reactions of classmates [Cummins 1949;
Davidson et al 1949; Samant et al 1973; Pazzaglia et al 1976; Nadkarni
1980]. Teachers appear to harbour negative attitudes to epileptic pupils,
questioning the latter’s capacity to perform at par with their non-epilcptic
contemporaries and demonstrating an unwillingness to teach such pupils
[Pazzaglia et al 1976]. Petit mal seizures are often mistaken for
inattentiativeness or day-dreaming and could be severely reprimanded.
The prejudice with which epileptics are treated is felt in the work place too
[Cummins 1949; Davidson et al 1949; Ryan et al 1980]. Though epilep
tics can be employed in any job except those involving heavy machinery,
driving or a shift system, most employers would rather not employ
epileptics. As a result, most epileptics feel the need to conceal their
condition from prospective employers [Davidson et al 1949; Nadkarni
1980] with the risk of being fired once the condition is known [Davidson
et al 1949]. In addition to problems in employment due to prejudice, the
low educational levels leave epileptics ill-equipped to compete in the job
market.
Epileptics face considerable set-backs when it comes to marriage.
Dansky’s study (1980) holds that the rate of marriage for epileptic males
and females is lower than the rate in the general population. Either the
development of social skills is so poor as to hinder interaction, or
prejudice rears its ugly head [Cummins 1949; Davidson et al 1949],
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lowering the chances of marriage. Consequently, most epileptics and
their families conceal the condition . This situation leads to problems
because the non-epileptic spouse feels deceived and cheated and may
decide to separate or divorce. India’s legal machinery, laying down
epilepsy as a ground for divorce under the Hindu Marriage Act and the
Special Marriage Act, gives an impetus to the perpetuation of discrimi
nation and stigmatisation [Desai 1978].
The effects of pregnancy on the epileptic patient are very unpredict
able and variable. In some instances, seizures increase; in others, they
decrease; in yet others, they remain at the prc-pregnancy frequency
[Knight and Rhind 1975; Schmidt 1982]. Epilepsy could begin during
pregnancy, either as eclampsic or non-eclampsic seizures [Knight and
Rhind 1975; Hopkins 1987]. It is important for the doctor concerned to
be informed and act according to the patient’s history. While anti
epileptic medication, can sometimes have teratogenic associations
leading to congenital malformations, it cannot be discontinued during
pregnancy, though it may be altered to prevent foetal anomalies [Meadow
1987].
Popular beliefs maintain that epileptics will give birth to epileptic
children. However, most epileptics have non-epileptic children and
evidence no problem in rearing them, provided the non-epileptic
spouse is supportive. The quality of family life depends on the attitudes
of the non-epileptic spouse to epilepsy and to the epileptic spouse. These
are transmitted to the children and in turn, affect their perceptions of
and relationship with the epileptic spouse. Lcchtenberg and Akner
(1984) show that uncompromising consistent disclosures of and healthy
attitudes to the condition by parents allow children to adjust to the
epilepsy while maintaining trust in and concern for both parents. On the
other hand, parents who are ashamed for their condition conceal it from
the children, incurring their anger and resentment when the condition is
discovered.
The growth and development of epileptic children is no different from
that of non-epileptic children in the areas and sequence of development,
developmental tasks and milestones, and they should be allowed to
participate in all the developmental tasks that go with their stage of life.
However, epileptic children tend to be overprotected by parents and
relatives because they are ‘special’ and ‘different’ [Davidson et al 1949;
Ounsted 1955; Bharucha 1969;Lerman 1977]. Termed as hyperpedophilia,
the condition arises because parents view epilepsy with anxiety, shame,
frustration and try to maintain it as a secret. They confine the children to
the home, depriving them of the opportunity to interact with others, to
learn social and other skills and to develop their potential and personality.
Thus, normal maturation is thwarted with a ripple effect on all areas
of life.
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Given the above scenario, it is small wonder that epileptics manifest
problems in psychosocial functioning and a general low well-being and
adjustment [Gupta and Yadav 1980; Dodrill et al 1984; Collings 1990]
which foster poor self-perceptions among them [Danesi 1984]/ The
ongoing review of literature, besides highlighting the pressing need for
interventions, draws attention to gaps. Indian literature is sparse, despite
an incidence rate of one per 200 population [Indian Epileptic Association
1991]. The family context is, by and large, overlooked, in spite of the
increasing recognition of the effects of chronic illness on the family. This
study, seeking to find out the family experience of epilepsy, is an attempt
to rectify the present situation.
Families and Epileptics
The study was exploratory in nature, demanding a qualitative method
with a case study design. These choices, in addition to being well-suited
to the nature of the topic under study, were also useful for analysis,
facilitating the uncovering of relationships between variables, which
could then be developed into hypotheses and further tested, thereby
allowing for theorisation.
Th£ sample, consisting of four married epileptic patients, their
spouses, children and members of their families residing in their
homes as well as their doctors, socal workers were chosen through
purposive sampling from the outpatient department (OPD) of a public
hospital in Bombay, India. While the four patients were chosen so as
to resemble each other on certain areas, there were also factors
considered that rendered each case unique. The areas of similarity
among the patients included the presence of grand mal epilepsy, a
monthly income between Rs 751 -1500, a pre-marital onset of epilepsy
and intact and on-going marriages. The areas of difference were firstly
in the time of revelation of the condition of epilepsy (revelation,
implying either the epileptic spouse verbally informing the non
epileptic spouse of his or her condition or the actual occurrence of a
seizure) ie, before or after marriage and secondly, with regard to the
sex of the epileptic spouse with both male and female patients being
covered. In accordance with these specifications, the sample included
one male and one female, whose revelation of epilepsy preceded
marriage and one male and one female, whose revelation occurred
after marriage.
The method of data collection comprised individual in-depth inter
views with the epileptic patient, the non-epileptic spouse, the children and
the family members residing in the home. Initially, separate interview
guides were constructed for the patient, the spouse, the children and the
family members. Subsequent to their being pre-tested on one case, a guide
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for doctors and social workers working with the patient and his/her spouse
and family was formulated.
While the researcher identified the cases at the OPD of the hospital, the
interviews were conducted at the patients’ residences. The researcher
paid four home visits per case, the first one being a rapport building
session with the patient, spouse, children and family. During the subse
quent visits, the interviews were conducted, each lasting for three hours,
on an average. All the data were recorded on audio-cassettes with the
consent of the interviewees and later transcribed.
Table 1: Labels Standardised Across the Cases and Used to Represent
Empirical Data
Label
Empirical Referent
Life change event
An event that changes status and/or brings certain roles.
Cultural values
Acceptance, tolerance, accommodation.
Negative attitudes
Anger, resentment, bitterness.
Positive attitudes
Concern, sympathy, understanding.
Emotional Bond
Unconditional acceptance and attachment.
Overprotcctivenes
Lowered demands and expectations, restrictions on
various areas of life.
Support
The material, informational, emotional, affectional and
financial sustenance that is provided through regular
and direct contact and that facilitates adaptive patterns
of behaviour.
Effects of providing
support
The increased roles and responsibilities that arise for the
provider of support, who in providing support, has to
perform his or her role as well as the case’s role
partially.
Vital roles
Roles that are pivotal in family functioning.
No subjective experi The problem is not subjectively experience, though it
objectively exists.
ence of the problem
Problem
An issue causing disequilibrium and demanding
settlement.
Other problem
The problem gives rise to further problems.
No other problem
The problem does not give rise to any further problem.
Developmental Stage The stage at which marriage is a developmental task.
Fear of marriage
prospects
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A fear that the case’s epileptic status hinders his/her
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On going into the field, modifications in methodology were invevitable. The interview guide for the children was used with children above
five years. Even so, owing to the cognitive level of the child in the 5-11
age group, it was difficult to gather data satisfactorily from them. Besides,
since two of the patients lived with their families of origin and one had
her family of origin residing in the adjacent house, they too were inter
viewed.
The large patient population attending the hospital OPD made it
difficult for doctors to have a personal relationship with each patient.
Being unable to provide case specific data, seven doctors were inter
viewed on the perceived effects of epilepsy on familial life in general.
With regard to the social worker, as none of the cases chosen for the study
had approached the hospital social worker, case specific information was
not possible. Hence an interview on the perceived effects of epilepsy on
familial life in general was conducted with the social worker, using broad
areas of the interview guide for doctors and social workers.
The data for each case were represented through a framework which
indicated the relationships between the variables. The framework using
empirical data was then refined using labels, which were standardised
across the cases to facilitate comparison while simultaneously retaining
the uniqueness of each case (Table 1). Based on this, data points for each
case were determined. These data points were then integrated across the
cases into four categories viz medical history, social history, positive
factors and negative factors, and the relationships between variables so
emerging were examined. The data, collected through the interviews with
the doctors and the social worker were used in formulating the recommen
dations of the study.
The findings of the study, formulated on the relationships between
variables, indicate that, families responded to the epileptic patient with
overprotectiveness. The presence of the family’s overprotectiveness was
determined by the combined existence of positive attitudes and the nature,
type, frequency and severity of the seizues. The overprotectiveness
resulted in the patient being inadequately prepared to assume his/her roles
which contributed to problems in the family. The nature, type, frequency
and severity of the patient’s seizures and their side effects and over
protectiveness led to the family prematurely terminating the patient’s
education which affected his/her occupational status and social mobility.
The combined interaction of the nature, frequency type and severity of the
patient’s seizures and their side effects, his/her inadequate role prepara
tion and vital role performance appeared to be necessary preconditions
for family problems to arise.
Families distinguished between the objective presence and sub
jective experience of problems. The existence of this distinction, trig
gered by the familial emotional bond, affected other problems, attitudes,
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support, effects of providing support and ovcrprotectivencss in the
family. Cultural values determined familial positive attitudes towards
patient while the factors underlying negative attitudes varied with each
case.
The presence of problems, positive attitudes and the nature, type,
frequency and severity of the seizures and their side effects triggered the
family’s support response. Support was initially provided to deal with the
seizures, but it expanded to include family problems as and when they
appeared. Family support reduced problems but did not eliminate them
altogether. The nature, frequency, type and severity of the patient’s
seizures and the nature of problems determined the levels of support to
be provided by the family. The size and the composition of the family
support system (a result of the size of the family, the ages of the family
members, life change events, the nature, type, frequency and severity
of the seizures and the presence of problems) worked along with the
emotional bond to influence the effects of providing support, the per
ception of problems, attitudes, other problems and overprotective
ness within the family. Family support and positive attitudes, present
throughout the patient’s life, coexisted with negative attitudes when the
latter arose.
In the absence of an emotional bond between spouses prior to mar
riage, the developmental stage of the patient appeared to be a sufficient
condition for the contemplation of marriage. The family of origin’s belief
that epilepsy would be cured by marriage promoted the decision that the
patient should get married. The patient’s seizures caused in his/her family
of origin a fear of his/her marriage prospects. This promoted non revela
tion of the condition of epilepsy prior to marriage, in the absence of an
emotional bond between the spouses. The type of marriage (ie, love or
arranged) along with the nature, type, frequency and severity of seizures
determined the spouses’ perception of problems, the genesis of other
problems, the effects of providing support, support, attitudes and
overprotectivenes.
The nature of the spouses marital decision was contingent on whether
the condition of epilepsy had/had not been revealed prior to marriage. The
reaction of the non-epileptic spouse to the non-revelation of the spouse’s
epilepsy prior to marriage Varied with her/his personality.
Fears or doubts about offspring having epilepsy did not act as a
major consideration in the desire to have children. Neither pregnancy
nor epilepsy had influenced each other— a relationship supported by
the literature but which according to the literature is not the only relation
ship between the two variables [Knight and Rhind 1975; Schmidt 1982].
The cognitive level of the offspring, contingent on their developmental
stage influenced the parental decision to reveal the epileptic condition
to them.
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Conclusion
While the findings demonstrate that the effects of epilepsy on the
family arise not due to the illness alone but also from other factors
surrounding the condition, they lend support to the literature cited in the
first section of this paper. Epilepsy, as also other chronic illnesses, does
affect the family.
Within the family, there is virtually no discrimination or negative
attitudes to the patient. On the other hand, overprotectiveness on the part
of the family can be seen as a form of discrimination. The study
demonstrates that it is not epilepsy per se that hinders the patient’s and the
family’s life. It is the presence of overprotectiveness, arising out of the
illness, that appears to play an important role in the patient’s preparation
and performance of roles and in his/her moving from one developmental
stage to another and this has an impact on his/her and the family — a
finding that is supported by previous studies such as Davidson et al
(1949), Ounstead (1955), Bharucha (1969) and Lerman (1977).
As regards education and employment, the data suggest that the
inability to complete these roles optimally is influenced by the family
members overprotectiveness rather than by the reactions of teachers and
employers and the capacities of patients. External factors have not been
given a chance to operate. Hence a comparison with related literature at
this point seems inappropriate.
The presence of the support system and its benefits indicates that
while marriage and family serve as support creation mechanisms, they
generate problems through their overprotectiveness. The support they
provide is basically to mitigate the problems that they themselves are
ultimately responsible for. None of the offsprings of the patients had
epilepsy — a finding that is supported by the literature. The findings also
support the literature that the quality of family life depends on the
attitudes of the non-epileptic spouse to epilepsy and to the epileptic
spouse and on the support that the former provides.
The findings of the study must be contextualised within the method
ology adopted, for a better insight into their relevance. The case study
design limits the attempt to generalise, with the sampling technique
introducing an element of bias. Another important point is the small
sample size. Given the time limit within which the study had to be
completed. Four cases were optimal. But, ideally, research subscribes to
no time-bound design and should this study be repeated, a larger sample
is definitely recommended.
The possibility of respondents’ confounding general problems, atti
tudes, support and coping with those affected by epilepsy cannot be ruled
out. Constant reminders that epilepsy was the focus of the discussion were
necessary, crea3ting a directive element in the interview. Additionally,
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given the demand for a historical understanding of the problem, respon
dents had to go back in time to provide information. For some of the
respondents, this process was difficult due to clouding of memory.
Details of events and perhaps whole events have probably been lost in the
process. For some of the respondents in whose lives problems were
evident, the interviews were either painful or cathartic or both.
In the final analysis, the value of the findings lie in the relations they
suggest between variables, which facilitate further research and
theorisation. Additionally, they also provide an empirical base for inter
vention. The pressing need for social workers to move out towards
patients and their families and towards communities to empower them
can no longer be ignored.
Clamping down on the overprotectivness response is also in order.
Since overprotectiveness is a buffer against the stigmatising effects of
being epileptic, work with parents should be accompanied by efforts to
increase community awareness in a bid to demystify and destigmatise the
condition.
While recommending revelation prior to marriage, written proof of
this is suggested. Given the clauses of the Hindu Marriage Act and the
Special Marriage Act [Desai 1978], epilepsy can be used as a grounds for
divorce. Allegations of non-revelation prior to marriage serve as a
catalyst to this process. Written proof that this condition has been
revealed prior to marriage may help turn the tide in the favour of the
epileptic spouse. Recognition that the clause that pronounces epilepsy as
a ground for divorce in the Hindu Marriage Act and the Special Marriage
Act [Desai 1978] is outdated and negates the faith that citizens have in
their law and order machinery must be created and accepted. Counselling
prospective spouses and their families about various aspects of epilepsy
should be made mandatory, in order to demystify the seizures, promote
positive attitudes, deal with problems and ensure support and task
oriented adaptive coping.
[This paper is based on the author’s M A research project. The author is grateful
to her guide, Vimla Nadkami, head, department of medical and psychiatric social
work, Tata Institute of Social Sciences, for her unstinting support and guidance
and to Rajshree Mahtani, Unit for Social Policy and Social Welfare Administra
tion, Tata Institute of Social Sciences, for her valuable assistance with the
analysis.]
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Hafstrom, J L and V R Schram (1984): ‘Chronic Illness in Couples: Selected
Characteristics, Including Wife’s Satisfaction with and Perception of Marital
Relationships’, Family Relations, Vol 33, pp 195-203.
Hopkins, A (1987): ‘Epilepsy and Pregnancy’, In A Hopkins, (ed) Epilepsy,
Chapman and Hall, London.
Indian Epilepsy Association (1991): ‘Epilepsy: Medical and Social Aspects’,
IEA, Bangalore.
Kaye, L W and J S Applegate (1990): ‘Men as Elder Caregivers: A Response to
Changing Families’, American Journal of Orthopsychiatry, Vol 60, pp 86-95.
Knight, A H and E G Rhind (1975): ‘Epilepsy and Pregnancy: A Study of 153
Pregnancies in 59 Patients’, Epilepsia, Vol 16, pp 99-110.
Lai, U, X Huang, Y C Lai, Z, Zhang, G Lui and M Yang (1990): ‘Survey of Public
Awareness Understanding and, Attitudes Towards Epilepsy in Henan Prov
ince, China’, Epilepsia, Vol 31, pp 182-187.
Lechtenberg, R and L Akner (1984): ‘Psychologic Adaptation of Children to
Epilepsy in a Parent’, Epilepsia, Vol 25, pp 40-45.
Lerman, P (1977): ‘The Concept of Preventive Rehabilitation in Childhood,
Epilepsy: A Plea against Overprotection and Overindulgence’, in K Penry,
(ed) Epilepsy: The Eighth International Symposium, Raven Press, New York.
Meadow, R (1987): ‘TheTeratogenic Associations of Epilepsy and Anticonsultant
Drugs’ in A Hopkins (ed) Epilepsy, Chapman and Hall, London.
Montgomery, R J V, J G, Gonyea, N, Hooyman (1985): ‘Caregiving and the
Experience of Subjective and Objective Burden’, Family Relations, Vol 34,
pp 19-26.
Nadkami, V V (1980): ‘Having Epilepsy is a Problem No Matter Where You
Live’, TISS, mimeo, Bombay.
290
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O’Dougherty, M M (1983): ‘Counselling the Chronically Ill Child’, Lewis,
Vermont.
Ounstead, C (1955): ‘The Hyperkinetic Syndrome in Epileptic Children’,
Lancet, Vol 2, pp 303-311.
Palfrey, J S, D K, Walker, J A, Butler, J D, Singer (1989): ‘Patterns of Response
in Families of Chronically Disabled Children’, American Journal of
Orthopsychiatry, Vol 59, pp 94-104.
Patterson, J M (1988): ‘Chronic Illness in Children and the Impact on Families’
in C S Chilman, E W Nunally and F M Cox (eds) Chronic Illness and
Disability, Sage, USA.
Pazzaglia, P and L Frank and L, Pazzaglia (1976): ‘Record in Grae School
of Pupils with Epilepsy: An Epidemiological Study’, Epilepsia, Vol 17,
pp 316-366.
Ryan R, K, Kemner, A C Emlen (1980): ‘The Stigma of Epilepsy as a SelfConcept’, Epilepsia, Vol 21, pp 433-444.
Samant, J M, V M, Lala, S, Ravindranath, A D, Desai (1973): ‘Social Aspects of
Epilepsy’, Neurology India, Vol 21, pp 165-174.
Schmid, D (1982): ‘The Effect of Pregnancy on the Natural History of Epilepsy’,
in D Janz et al, (eds) Epilepsy, Pregnancy and the Child, Raven Press,
New York.
Thomas, D (1982): The Experience of Handicap, Methuen, London.
Thompson, E H and W, Doll (1982): ‘The Burden of Families Coping with the
Mentally III: An Invisible Crisis’, Family Relations, Vol 31, pp 379-388.
Premilla D’Cruz
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Soonawala Agiary Marg
Mahim, Bombay 400016.
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Document
The Leeds Declaration
Reorienting Public Health Research
NEW approaches to understanding and managing public health problems
are urgently required. Classical and traditional methods provide instru
ments which may be too blunt to address all the complexities of today’s
health problems. Many methods are available from different fields which
can and should play complementary roles. At present these remain seriously
underutilised or are not recognised as having a contribution to make.
At an international workshop in Leeds, UK, in June 1993, it was agreed
that a reorientation of public health principles were urgently needed. This
declaration is the result.The academic and service public health practitio
ners who have collaborated to produce the Leeds Declaration have done
so in the expectation that it will be used as a focus for discussion and
debate in the widest arena.
The Declaration
* We are most likely to be able to improve the nation’s health if we
can pinpoint and address economic, social and political reasons - the
root causes that affect people’s health - instead of blaming individuals
for problems over which they have no control.
* We need to know what makes people healthy as well as what makes
them ill. We need to find out why some people stay fit despite their
exposure to adverse circumstances.
How do we find out what we need to know?
* Classical investigative and statistical methods do not provide the
whole story. The information that people have about their health and
their lives is entirely valid and needs to be taken seriously.
* There are many approaches to investigating the causes, outcomes
and means of fighting ill health. There are a variety of methodologies
which can be utilised in conjunction with epidemiology in dealing with
the complexities of Current public health problems.
* Gathering information by talking to people about the reality of their
lives demands the same rigorous standards as those applied to the
collection of statistics.
RJH
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293
*
Research funding should be allocated according to the principles
outlined in this Declaration
Who should we work with?
Lay people do not need professionals to tell them that being
out of work, on low incomes and/or living in poor housing can affect
their health. We will work with lay people to jointly define
health and to combine personal knowledge & experience with a
variety of research methods rigorously applied to address ill
health.
* A wide range of people working in health? social sciences and
other related fields have equally valuable insights into the causes
of and solutions to ill health.
What should we do with the information we receive?
* Research of itself will do nothing to change people’s lives. We need
to ensure that what we discover about the causes of ill health is fully
used to promote better health.
The Leeds Declaration is the direct outcome of an international
workshop that took place in the Nuffield Institute of Health in June
1993. The purpose of the workshop was to consider the limitations of
current established approaches to public health research. The key
concern was to explore the validity of promoting a broader research
framework which could handle increasingly complex health prob
lems. The invited academic and service participants represented a
range of public health disciplines including sociology, economies,
psychology, epidemiology and public health medicine.
The participants felt strongly that although epidemiology has given
good service in developing a robust knowledge base for effective
public health practice, contemporary public health problems had
exposed the limitations of the pure epidemiological approach. Many
distinguished public health researchers and writers have already given
serious thought to these issues and their work formed the basis for the
workshop discussions [1-8].
Ultimately, the workshop gave a mandate to a small subgroup to
produce a cohesive, summary statement which would clearly reflect
the focus of the discussion and which could promote action. This has
been entitled the ‘Leeds Declaration’ and embodies the essence of the
work discussions. It focuses on the need for a comprehensive frame
work to public health research, for professionals to take serious
account of the views of the lay public and for an approach that will
294
RJH (New Series)
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1995
build on and integrate epidemiological principles and practice into a
wider conceptual and methodological framework.
Since the workshop, there has been a national one-day conference
(November 1993) to share the content of the Declaration with many
NHS managers, public health physicians and academics. Most re
cently (September 1994) - and following a rewrite of the Declaration
into more accessible language - this was discussed with a small invited
group of senior managers and public health physicians to test out the
validity of application to NHS effectiveness. Managers and public
health professionals are becoming increasingly aware of the fact that
there are serious limitations to traditional research approaches and
that there is a definite need for the integration of a variety of ap
proaches and methodologies.
[Extracted from an article by Frada Eskin of the same title in Critical Public
Health Vol 5, No 3, 1994].
References
Brownlea, ‘A From Public Health to Political Epidemiology’. Soc Sci
Med. 1 SD, 57-67 . 1981.
[2] Blane, D, ‘Real Wages the Economic Cycle and Mortality in England and
Wales, 1870-1914’ International Journal ofHealth Services 20,1,43-52,
1990.
[3] Paterson, K, ‘Theoretical Perspectives in Epidemiology—A Critical
Appraisal’ Radical Community Medicine 8, 21-9, 1981.
[4] Draper, P, ‘Health and Wealth’, Royal Society of Health Journal 97,
121-6, 1977.
[5] Brown, V A, ‘Towards an Epidemiology of Health: A Basis for Planning
Community Health Programs’ Health Policy 4, 31-340, 1985.
[6] McKinlay.J B,‘The Promotion of Health Through Planned Sociopolitical
Change: Challenges for Research and Policy’ Soc. Sci Med 36,2, 109-17,
1993.
[7] Scott, S A, ‘Building the New Public Health: A Public Health Alliance
and a New Social Epidemiology.’ In C J Martin and D VMcQueen (eds)
Readings for a New Public Health. Edinburgh University Press, 1989.
[8] Community Health Information Section, Health Inequalities in the City
of Toronto. Toronto: Department of Public Health, 1991.
[1]
Back Volumes of Radical Journal of Health and Socialist Health
Review are available at Rs 150 per volume
RJH
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295
Communications
Utilisation of Maternal Health Services
Report from Rajasthan
Maternal health care services, both private and public are poorly
utilised, especially in tribal districts.
EVERY year more than 150 million women become pregnant in the
world. The WHO estimates that at least 23 million of these develop
complications which require skilled treatment. Deaths of women and
babies in child birth can be prevented through a combination of several
interventions. First, maternal deaths can be reduced by reducing the total
number of pregnancies. Family Planning information and services can
help avoid births that are unwanted, too early, to close together and too
late. Such high risk fertility patterns contribute considerably to high
numbers of maternal and neonatal deaths. However, family planning can
provide only part of the solution to the problem because this does not
reduce the risk associated with each pregnancy. To do this requires that
all women receive appropriate care during pregnancy and delivery and
every baby receives special care in the first critical hours and days of
life. The health of pregnant women can be improved through effective
prenatal care which also increases a mother’s chances of giving birth
to a healthy baby. Regular monitoring during pregnancy can help to
ensure that complications are treated early before becoming life-threat
ening emergencies.
However, pregnancy is an ongoing risk process, and even the most
effective screening currently available cannot predict accurately which
individuals will develop complications. The presence of a trained atten
dant during labour and delivery can ensure that if problems arise, skilled
help is available to treat them or, if that is not possible in the circum
stances, to transfer the women to a higher level of care such as a district
hospital. Because complications and emergencies can happen to any
woman at any stage of the pregnancy, maternal health care requires a
system that provides the essentials of prenatal care while simultaneously
assuring that woman and their families know where to seek help for
complications and that skilled assistance is available to all women as
close as possible to where they live.
The present study was carried out in two districts of the state of
Rajasthan; Ajmer (non-tribal) and Udaipur (tribal) during January 1994.
296
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The sample was selected by probability proportionate to size (PPS)
technique. In PPS technique (for a specific area) the probability of
inclusion in the sample are directly proportionate to size of its population.
In the process of selection of sample as per PPS, list of city-wards and
villages with cumulative population was prepared for 1991 census data of
these two districts. The total population of a district was divided by
number of required sample units (eg 30 in this case) to find the sampling
intervals. Then a random number was generated between 0 to sampling
interval. The village with this cumulative population was selected as the
first village under sample. To find subsequent sample villages, sampling
interval was added into random number and the village with correspond
ing cumulative population was once again taken in the sample. The
process continued till the required number of sample units were finally
chosen.
Data was collected from the respondents (mothers of children, below
one year of age) on the maternal care services utilised by them during their
last pregnancy on the following: pregnancy registration, ante-natal care
check ups, place of delivery and attendant for delivery. Based on simple
random sampling 10 respondents, were selected from each cluster and by
thus comprising a total sample of 300 respondents from 30 clusters in
each district.
The results of the present study are discussed in the following section.
The utilisation of maternal health care services by the respondents in the
study area are discussed on these aspects; i) registration of pregnant
women, ii) coverage of ante-natal care services, iii) deliveries conducted
by trained personnel.
Registration of Pregnant Women
The pregnancy registration is essential for better delivery, health of
mother and baby. The present study shows that at the district level, a
greater percentage of pregnant women in non-tribal district (Ajmer) were
registered than in tribal district (Udaipur); 60 per cent in tribal district and
77.3 per cent in non-tribal district.
The relative utilisation of different types of institutions for registration
purposes by pregnant women was categorised in public hospital/dispensary, sub-centre/health worker and other institutions including private
and charitable/voluntary organisation. Table 1 shows that in the tribal
district (Udaipur) 48 per cent of pregnant women were registered at public
hospitals and dispensaries followed by sub-centres and health workers
(about 37 per cent), and the remaining 15 per cent at other institutions. In
the case of non-tribal district (Ajmer), 57 per cent of pregnant women
were registered with public hospitals and dispensaries; followed by 37 per
cent with sub-centres and health workers and the remaining about 5-6 per
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297
cent with other institutions. There was wide variation with regard to the
utilisation of hospitals for the purpose of registration.
Coverage of Ante-Natal Care (ANC) Services
Ante-natal care services during pregnancy are very important both for
the mother’s health as well as of the baby she is carrying. The present
study shows that at the district level, a greater percentage of pregnant
women in non-tribal district (Ajmer) had gone for ante-natal care check
ups compared to tribal district (Udaipur). Data presented in Table 2 shows
that out of 300 respondents in each district, 232 (77.3 per cent) in nontribal district (Ajmer) and 180 (60 per cent) in tribal district (Udaipur) had
gone for ante-natal care check-ups. But again when enquired only from
those who had undergone the ante-natal care check-up (232 and 180 in
non-tribal and tribal district respectiely), about how many times she
visited any health care facility for the ante-natal care check-ups (232 and
180 in non-tribal and tribal district respectively)], about how many times
they had visited any health care facility for the ante-natal care check-up
around 38 per cent in non-tribal district (Ajmer) and 55 per cent in tribal
district (Udaipur) reported no more than two visits to any health care
facility in the course of their pregnancies. It was also observed (Table 2)
that the maximum percentage of pregnant women in non-tribal district
(62 per cent) compared to the tribal district (45 per cent) were visiting the
facility at least three times or more than three times during the course of
their pegnancy for ante-natal care check-ups.
It is normally assumed that a pregnant woman should receive at least
the minimum dose of around 90-100 iron and folic acid (IFA) tables.
Table 1: Percentage Distribution of Respondents Classified by Pregnancy
Registration and Place of Registration
Pregnancy
Registration
After you came to know that you are pregnant
did you register yourself with Health Worker
(HW) or any other health institution
In case of yes, mention institution
298
RJH
Yes
No
Total
(N)
Hospital
SC/HW
Other
Total
(N)
(New Series)
Non
Tribal
Tribal
77.7
22.7
100.0
(300)
57.0
37.5
5.5
100.0
(232)
60.0
40.0
100.0
(300)
48.0
36.8
15.2
100.0
(180)
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Table 2 depicts that the amount of IFA tablets received by the pregnant
women were not satisfactory. The data shows that in non-tribal district
(Ajmer) out of all about 40 per cent registered pregnant women (232), and
in tribal district (Udaipur) about 39 percent of registered pregnant women
(180) received sufficient amount of90-100 IFA tablets. About 60 per cent
of the registered pregnant women, who claimed that they had gone for
ante-natal care check ups, did not receive the sufficient amount of IFA
tablets in both districts. This shows, that the frequency of visiting the
health care institutions for ante-natal check-ups is not the only important
factor, but the quality of services as well.
Anti-tetanus injections taken during pregnancies help minimise
maternal mortality. Data presented in Table 2 shows that in non-tribal
district (Ajmer), out of 232 registered pregnant women (who claimed
that they had undergone ante-natal care check ups), about 23 per cent
were did not receive the sufficiient amount of tetanus toxide. This
findings also supports the previous one, that the quality of services are
very poor.
Deliveries conducted by trained personnel ensure fewer complications
and problems faced during child birth. The present study gathered
information regarding the place of delivery and the person who actually
Table 2: Percentage Distribution of Respondents Availing Ante-natal Care
Services in Non-tribal and Tribal Districts
District
Non-Tribal Tribal
Ante-Natal Care Services
Yes
No
Total
(N)
< 3 times
> 3 times
Total
(N)
Nil
30
60
90-100
Total
(N)
One
Two
Booster
Total
(N)
Did you undergo ANC check-ups?
I If yes, how many times?
II No. of IFA tablets received
III No of TT received
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1995
77.7
22.7
100.0
(300)
37.9
62.1
100.0
(232)
16.3
19.1
24.5
40.1
100.0
(232)
15.9
73.7
10.4
100.0
(232)
60.0
40.0
100.0
(300)
55.0
45.0
100.0
(180)
0.0
22.8
37.8
39.4
100.0
(180)
22.8
75.5
1.7
100.0
(180)
299
conducted the delivery. Table 3 presents the percentage distribution of
respondents by the place of delivery and the attendant for delivery for
non-tribal and tribal districts in Rajasthan.
The present study shows that in the case of non-tribal district
(Ajmer), out of 300 pregnant women, 176 (about 59 per cent) reported
that their last delivery took place at home but in case of tribal district
(Udaipur) out of 300 pregnant women, 258 (about 86 per cent) delivered
at home during their last delivery. The study thus reports that the most
popular and acceptable place of delivery was home, in both non-tribal or
tribal districts, but again in this case the percentage is much higher in
tribal district.
Table 3 also presents the percentage distribution of respondents by the
attendant for the delivery. Information was gathered about the person who
actually conducted the delivery. The study shows that in non-tribal
district (Ajmer), the health functionary (doctor/LHV/ANM) conducted
45.3 per cent of the deliveries and trained dais conducted 2.3 per cent of
the deliveries. In case of tribal (Udaipur) district, the health functionaries
(doctor/LHV/ANM) conducted 18.4 per cent of the deliveries and trained
dais 17.3 per cent of the deliveries. Table 3 also depicts that the deliveries
conducted by untrained dais were 41.7 per cent and 47.7 per cent out of
the total deliveries conducted in non-tribal (Ajmer) and tribal (Udaipur)
district, respectively. The data depicted in the table also show that the
deliveries conducted by the relatives were 10.7 per cent and 16.7 per cent
in non-tribal and tribal districts respectively.
When we analyse the data for trained and untrained persons who
conducted the deliveries in each district, deliveries conducted by trained
Table 3: Percentage Distribution of Respondents by Place of Delivery and
Attendant in Non-tribal and Tribal Districts
Delivery Services
District
Non-Tribal Tribal
Home
SC
Hospital
Total
(N)
Relatives
Dai
Trained Dai
HW/LHV
Doctor
Total
(N)
Where did you deliver?
Who attended your delivery?
300
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(New Series)
58.7
5.3
36.0
100.0
(300)
10.7
41.7
2.3
4.0
41.3
100.0
(300)
86.0
0.0
14.0
100.0
(300)
16.7
47.7
17.3
4.7
13.7
100.0
(300)
Vol 1:4
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personnel (ie, trained dai, HW/LHV/doctor) were found to be 47.6 per
cent and 35.7 per cent in non-tribal (Ajmer) and tribal (Udaipur) district
respectively. The possible reason for the same is that in tribal (Udaipur)
district the tribal pockets like Jhadol (Phalasia), Kotra, Dhariyawad and
Rishbdeo, have problems in accessing trained personnel for conducting
deliveries in scattered areas.
The findings from the study suggest that maternal health care services
either through public or private sector are underutilised. The situation in
tribal and non-tribal districts is not satisfactory but is very bad in tribal
areas. The study suggests the adoption of area specific approach to
improve the health status of the women and to reduce the incidences of
IMR and MMR. Area specific strategies would ensure better results and
outcome.
References
Government of India/NORAD Review Mission (1990): The All India Post
Partum Programme (Sub-district Level), New Delhi.
Chandra, Mridula (1992): Training Intervention Project for AIHPPP at Sub
district Level in Rajasthan: Mid-Term Monitoring Survey Report, Indian
Institute of Health Management Research, Jaipur, India.
Trivedi, S K and Sodam, P R (1994): Training Intervention Project for AIHPPP
at Sub-district Level in Rajasthan: A Report on Project Monitoring Indicators
(1993-94), Indian Institute of Health Management Research, Jaipur, India.
— (1994): Training Intervention Project for AIHPPP at Sub-district Level in
Rajasthan: Annual Report for Third Year (1993-94), Indian Institute of
Health Management Research, Jaipur, India 1994.
-P R Sodani
IIHM
1, Prabhu Dayal Marg
Near Sanganer Airport
Jaipur -302 011.
We invite reports on current developments field surveys,
conferences and seminars for the ‘communications’
section. The ideal length would be about five pages
of the RJH including tables and references. Please keep
references and tables to a minimum. We would
appreciate the material in a wordprocessed format
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301
Interpreting Demographic Data
SRS, 1993
The Sample Registration Survey data emphatically point to the
great variation in health indicators across states. Is there a case
for increasing the sample size to capture the details?
IN the absence of complete civil registration of births and deaths in our
country (with the exception of Kerala and large towns and metropolitan
cities), Sample Registration Survey (SRS) figures have been the most
reliable source of demographic data for over two decades. A few important
facts about SRS data must be mentioned before we proceed to interpret
them. Though it is the most reliable data, SRS is only a sample survey
and hence cannot be as accurate as complete civil registration. Secondly,
SRS data is available only at the slate level. We know from other sample
surveys that there are wide variations among the different districts of
a state. For example, sample surveys in Tamil Nadu indicate that, during
1991-93, CBR among districts ranged from 14 (per 1000 population)
to 23, while the state average has been around 20. Thirdly, as demo
graphic trends do not change overnight, it is advisable to look at long
trends instead of arriving at conclusions by looking at the figures of the
last two or three years.
With these precautions, let us proceed to interpret the 1993 SRS
data. The first thing to do is not to get euphoric about the fall in
CBR and IMR in 1993 compared to the 1992 figures. As mentioned
above, it is better to look at long term trends. A further refinement is
to use the averages for three consecutive years rather than single
year data. This helps in minimising deviations in the data that may
occur due to sampling errors or poor quality of data collection in a
particular year.
Using SRS data from 1971, I have calculated three year averages
for CBR and IMR (1971-73, 1981-83, and 1991-93) for the country
and for selected states (Table 1). This indicates clearly the difference
between the states of India. In Kerala, the CBR has declined by about
42 per cent between 71-73 and 91-93 (col 8). For the same period,
the decline is about 36 per cent in Tamil Nadu and 19 per cent for
the country. The declines in MP (10 per cent), UP (17 per cent) and
Rajasthan (16 per cent) are somewhat lower than the national average.
However, the decline in Bihar (3 per cent) is negligible and this
indicates that all the northern ‘BIMARU’ states cannot be considered
to be similar, assuming that the quality of SRS data is uniformly
reliable across the states.
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Table 1: Crude Birth Rate (SRS) (1971-93)
CBR
CBR
CBR
Per Cent Change
Ratio
Average Average Average 1971-73 1981-83 1971-73
of
for
for
for
to
to
to
Col(7)/
1971-73 1981-83 1991-93 1981-83 1991-93 1991-93 Col(6)
(6)
(9)
(3)
(4)
(5)
(7)
(8)
SI.
No.
(2)
(1)
1
Kerala
2 Tamil Nadu
3 Uttar Pradesh
4 Madhya Pradesh
5 Rajasthan
6 Bihar
7 , India
30.5
31.3
43.3
38.6
40.9
32.4
36.0
17.7
20.2
35.8
34.7
34.3
31.6
29.0
25.6
27.9
38.9
38.2
38.4
37.9
33.8
-16.1
-10.9
-10.2
-1.0
-6.1
+ 16.9
-6.1
-30.9
-27.6
-7.9
-9.2
-10.7
-16.6
-14.2
-41.9
-35.5
-17.3
-10.1
-16.1
-2.5
-19.4
+1.9
+2.5
+0.8
+9.2
+ 1.8
-0.9
+2.3
Table 2: Infant Mortality Rate (SRS) (1971-93)
Per Cent Change
Ratio
IMR
IMR
IMR
of
Average Average Average 1971-73 1981-83 1971-73
to
to
Col(7)/
for
for
to
for
1971-73 1981-83 1991-93 1981-83 1991-93 1991-93 Col(6)
(9)
(8)
(5)
(6)
(7)
(4)
(3)
SI.
No.
(2)
(1)
1
2
3
4
5
6
7
Kerala
Tamil Nadu
Uttar Pradesh
Madhya Pradesh
Rajasthan
Bihar
India
59
114
189
151
130
—
134
33
87
151
134
105
110
107
•
15
57
96
109
84
71
78
-44.1
-23.7
-20.1
-11.3
-19.2
—
-20.1
-54.5
-34.5
-36.4
-18.7
-20.0
-35.5
-27.1
-74.6
-50.0
-49.2
-27.8
-35.4
—
-41.8
1.2
1.5
1.8
1.7
1.0
—
1.3
Table 3: Female Literacy Rate Census 1971, 1981, 1991
SI.
No.
(2)
(1)
1
2
3
4
5
6
7
Female Female Female
Literacy Literacy Literacy
Rate for Rate for Rate for
1971
1981
1991
(4)
(3)
(5)
Kerala
54.31
Tamil Nadu
26.86
Uttar Pradesh
10.55
Madhya Pradesh 10.92
Rajasthan
8.46
8.72
Bihar
18.70
India
RJH
(New Series)
65.73
34.99
14.04
19.48
11.42
13.62
24.82
Vol 1:4
86.93
52.29
26.02
28.39
20.84
23.10
39.42
1995
Per Cent Change
1971
1971
1981
to
to
to
1991
1981
1991
(8)
(6)
(7)
21.03
30.27
33.08
78.39
34.99
56.19
32.73
32.25
49.44
85.33
45.74
82.49
69.60
58.82
60.06
94.68
146.6
159.9
146.3
164.9
110.8
Ratio
of
Col(7)/
Col(6)
(9)
1.5
1.6
2.6
0.6
2.4
1.2
1.8
303
Column 9 of Table 1 compares the declines in CBR during the decade
of 1970s with that during the 1980s. For Kerala, Tamil Nadu, Rajasthan
and India, the fall in birth rate during the 80s is around twice the decline
during the 70s. That is, the fall in CBR has accelerated during the 80s and
one can hope for further declines during the 90s. In Uttar Pradesh, the
decline in CBR seems to have slowed down during the 80s, when
compared to the decline in the 70s. The trend for Bihar is difficult to
interpret, as the CBR went up sharply during the 70s and declined again
during the 70s. One can only hope that the declining trend in the most
recent decade (80s) will continue during the 90s. The trend for Madhya
Pradesh has to be interpreted carefully: the ratio of over 9 in column 9 is
due to the fact the decline in CBR during the 70s was very small and not
because the decline during the 80s was large (which it is not). Similar
calculations can be done for all the states and this would be a better
indicator of trends in birth rates rather than the difference between 1992
and 1993.
Table 2 is a set of similar data for IMR for selected states and the
country as a whole. Once again, Kerala tops the list with a decline of
nearly 75 per cent between 197*1-73 and 91-93. This is all the more
remarkable because even during 71 -73. the IMR of Kerala was quite low
(59 per 1000 live births), in fact, lower than the current (91-93) IMR in
most states. In Tamil Nadu and UP. the decline is around 50 per cent while
it is about 42 per cent for the country. The decline in Rajasthan (35 per
cent) and in MP (28 per cent) are also considerable. For Bihar, figures for
earlier years are not available but the decline from 1981-83 to 91-93 is
35.5 per cent, lower than the decline in Kerala, but about the same as in
Tamil Nadu ^pd UP (col 7).
Column 9 of Table 2 compares the declines in IMR during the 70s with
the declines in the 80s. A significant fact is that the decline in IMR seems
to have accelerated considerably during the 80s in both UP and MP. Even
for the country as a whole, the decline in IMR has slightly accelerated
during the 80s. Considering the fact that declines in IMR seem to result
in declines in birth rate, programmes focusing on MCH care need to be
intensified.
Table 3 is a similar table for female literacy; but the data is from the
censuses of 1971,81 and 91. A quick glance at Table 3 shows that female
literacy rates have more than doubled between 1971 and 1991 for the four
large states (except Kerala and TN) and for the country (col 8). This is
partly because of the very low level of female literacy in the base year of
1971. Further, in 1991, the female literacy rates of UP, MP, Rajasthan and
Bihar were still below 30 per cent compared to 39 per cent at the national
level, 52 per cent in Tamil Nadu and 87 per cent in Kerala.
A more useful indicator is the comparison of the rise in female literacy
rates in the 70s with that during the 80s. This analysis reveals that both UP
304
RJH (New Series)
Vol 1:4
1995
and Rajasthan have registered remarkable achievements during the
1980s compared to the progress during the 1970s. If this trend is main
tained, especially rates in these two states may be close to 50 per cent by
the time of the next census in 2001. The progress in Bihar during the 80s
is only slightly more than the progress during the 70s. However, the
Annexure 1.1: Estimated Annual Birth Rate, Death Rate and Infant
Mortality Rate, 1993 (Provisional) SRS
States/UTs
(1)
Infant Mortality Rate
Death Rates
Birth Rates
Com- Rural Urban Com- Rural Urban Com- Rural Urban
bined
bined
bined
(10)
(8)
(9)
(6)
(7)
(2)
(4)
(5)
(3)
24.1
Andhra Pradesh
29.5
Assam
Bihar
U1
28.0
Gujarat
30.6
Haryana
Karnataka
25.5
17.3
Kerala
33.4
Madhya Pradesh
25.0
Maharashtra
27.2
Orissa
26.3
Punjab
33.6
Rajasthan
19.2
Tamil Nadu
36.0
'Uttar Pradesh
25.6
West Bengal
Arunachal Pradesh 27.6
14.6
Goa
Himachal Pradesh 26.7
20.3
Manipur
28.5
Meghalaya
20.0
Nagaland
23.7
Sikkim
23.3
Tripura
21.6
A&N Islands
18.0
Chandigarh
D&N Haveli (Rural) 33.6
25.4
Daman & Diu
21.8
Delhi
25.7
Lakshadweep
15.5
Pondicherry
28.5
All India*
24.3
30.4
33.0
29.1
32.0
26.7
17.3
35.9
27.0
27.7
27.7
33.5
19.3
37.2
28.6
27.7
13.1
27.4
20.2
30.7
18.8
24.4
24.0
21.0
14.2
33.6
26.8
25.0
24.2
15.3
30.3
23.4
23.4
25.5
25.8
26.4
23.1
17.2
24.3
22.6
23.1
22.6
26.3
19.0
30.9
17.7
27.4
16.8
19.6
20.6
17.6
24.4
19.1
19.5
23.3
18.3
—
24.2
21.6
27.4
15.6
23.5
8.4
10.2
10.6
8.1
7.8
8.0
6.0
12.6
12
12.2
7.9
9.0
8.0
11.4
L2
8.6
6.6
8.6
4.8
5.8
4.2
6.4
6.3
5.5
3.6
12.2
8.6
4.1
6.2
6.1
9.2
9.5
10.7
11.4
8.9
8.7
9.5
6.0
13.9
9.3
13.1
8.8
10.1
9.2
12.2
8.5
9.9
7.7
9.0
5.1
7.7
4.4
7.1
6.7
6.1
4.5
12.2
8.0
7.3
6.3
7.2‘
10.5
5.4
6.7
5.0
6.7
5.5
5.2
5.8
7.6
4.7
6.1
5.5
5.0
5.7
7.9
4.1
1.1
4.9
5.5
4.2
2.7
3.7
1.9
4.6
3.5
3.5
—
9.1
3.9
6.1
5.6
5.7
64
81
70
58
65
67
13
106
50
110
55
82
56
93
58
70
84
73
65
69
79
15
113
63
115
60
87
66
98
64
46
57
41
42
53
41
7
68
31
69
39
56
38
67
32
63
65
36
74
82
45
* Excludes Jammu and Kashmir
- No Urban samples
Source'. SRS Rates by RG, India
RJH
(New Series)
Vol 1: 4
1995
305
Annexure 1.2: Differences in Birth and Infant Mortality Rate between 1993
(P) and 1992 and Total Fertility Rate between 1992 and 1991
(SRS Estimates)
States/UTs
Infant Mortality Rate Total Fertility Rate
Birth Rate
1992 Increase 1993 1992 Decrease 1992 1991 Increase
(+)/Decr(+)/Decr(+)/Decr- (P)
ease(-)
ease(-)
ease(-)
in 1992 as
in 1993 as
in 1993 as
Compared
Compared
Compared
to 1991
to 1992
to 1992
(col 8(col 5-col 6 )
(col 2-col 3)
col 9)
(10)
(9)
(7)
(8)
(6)
(4)
(5)
(2)
(3)
1993
(P)
(1)
Andhra Pradesh 24.1
29.5
Assam
32.1
Bihar
28.0
Gujarat
30.6
Haryana
Karnataka
25.5
17.3
Kerala
Madhya Pradesh 33.4
25.0
Maharashtra
Orissa
27.2
26.3
Punjab
Rajasthan
33.6
Tamil Nadu
19.2
36.0
Uttar Pradesh
25.6
West Bengal
Arunachal
Pradesh
27.6
14.6
Goa
Himachal
26.7
Pradesh
Manipur
20.3
Meghalaya
28.5
Nagaland
20.0
23.7
Sikkim
Tripura
23.3
A&N Islands
21.6
Chandigarh
18.0
D&N Haveli
(Rural)
33.6
Daman & Diu 25.4
Delhi
21.8
Lakshadweep
25.7
Pondicherry
15.5
All India*
28.5
24.5
30.8 •
32.3
28.1
32.0
26.3
17.7
34.9
25.3
27.8
27.1
34.9
20.7
36.3
24.8
(-)0.4
(-)1.3
(-)0.2
(-)0.1
(-)1.4
(-)0.8
(-)0.4
(-)1.5
(-)0.3
(-)0.6
(-)0.8
(-)1.3
(-)l-5
(-)0.3
(+)0.8
26.6
14.7
(+)i.o
(-)o.i
28.1
19.5
29.8
19.2
22.0
23.1
20.0
15.6
(-)1.4
(+)0.8
(-)1.3
(+)0.8
(+)L7
(+)0.2
(+)1.6
(+)2.4
37.8
24.6
26.0
25.0
19.8
29.2
(-)4.2
(+)0.8
(-)4.2
(+)0.7
(—)4.3
(-)0.7
64
81
70
58
65
67
13
106
50
110
55
82
56
93
58
74
71
76
73
67
75
73
17
104
59
115
56
90
58
98
65
79
(-)7
(+)5
(-)3
(-)9
(-)io
(-)6
(-)4
(+)2
(-)9
(-)5
(-)l
(~)8
(-)2
(-)5
(-)7
(-)5
2.8
3.4
4.6
3.2
3.8
2.9
1.7
4.4
2.9
3.1
3.1
4.5
2.2
5.2
2.9
3.0
3.5
4.4
3.1
4.0
3.1
1.8
4.6
3.0
3.3
3.1
4.6
2.2
5.1
3.2
(-)0.2
(-)0.1
(+)0.2
(+)0.1
(-)0.2
(-)0.2
(-)0.1
(—)0.2
(—)0.3
(-)0.2
NIL
(-)0.1
NIL
(+)0.i
(-)03
3.1
3.1
NIL
3.6
3.6
NIL
(P): Provisional; *: Excludes Jammu and Kashmir
Source: SRS Rates by RG, India
306
RJH
(New Series)
Vol 1:4
1995
performance of MP should be a cause for concern — because the progress
during the 80s is less than that during the 70s.
It may be worthwhile to examine the feasibility of increasing the SRS
sample size in districts with low female literacy, high IMR and high CBR,
so that district level figures for the vital indicators are available. This
would yield reliable data for the policy makers to formulate district
specific strategies to bring down the IMR and the CBR.
Another thing that can be done is to commission NFHS type of surveys
once in three years, so that time series data is available for a large number
of health and fertility indicators. Since NFHS was done in 1992, Tamil
Nadu has already commissioned the next survey for 1995, with funding
from the DANIDA Health Care Project. While the data from NFHS 1992
is at the state level, the TNFHS 1995 data will be available for five
geographic zones of the state. The cost of carrying out a district level
Annexure 1.3: Differences in Total Fertility Rate between 1992 and
1991 - SRS Estimates
States/UTs
(1)
Total Fertility Rate
Total Fertility Rate
Total Fertility Rate
(Urban)
(Rural)
(Combined)
1992 1991 Increase 1992 1991 Decrease 1992 1991 Increase
(+)/Decr(+)/Decr(+)/Decrease(-)
ease(-)
ease(-)
in 1992 as
in 1993 as
in 1992 as
Compared
Compared
Compared
to 1991
to 1991
to 1991
(col 8-col 9)
(col 5-col 6)
(col 2-col 3)
(10)
(9)
(5) (6)
(7)
(4)
(8)
(2)
(3)
Andhra Pradesh 2.8
Assam
3.4
Bihar
4.6
Gujarat
3.2
Haryana
3.8
Himachal
Pradesh
3.1
Karnataka
2.9
Kerala
1.7
Madhya Pradesh 4.4
Maharashtra
2.9
Orissa
3.1
Punjab
3.1
Rajasthan
4.5
2.2
Tamil Nadu
Uttar Pradesh
5.2
West Bengal
2.9
3.6
India*
3.0
3.5
4.4
3.1
4.0
(-)0.2
(-)O.l
(+)0.2
(-)0.1
(-)0.2
2.9
3.6
4.8
3.4
4.1
3.1
3.6
4.5
3.2
4.3
(-)0.2
NIL
(+)0.3
(+)0.2
(-)0.2
2.3
2.1 3.4
2.7
2.7
2.5
2.1
3.5
2.9
3.0
(-)0.2
NIL
(-)0.1
(-)0.2
(—)0.3
3.1
3.1
1.8
4.6
3.0
3.3
3.1
4.6
2.2
5.1
3.2
3.6
NIL
(-)0.2
(-)O.l
(-)0.2
(-)O.l
(-)0.2
NIL
(-)O.l
NIL
(+)0.1
(-)0.3
NIL
3.1
3.1
1.7
4.7
3.3
3.2
3.2
4.8
2.3
5.6
3.4
3.9
3.2
3.3
1.8
4.9
3.4
3.4
3.2
4.9
2.3
5.4
3.8
3.9
(-)O.l
(-)0.2
(-)0.1
(-)0.2
(-)O.l
(—)0.2
NIL
(-)O.l
NIL
(+)0.2
(-)0.4
NIL
2.2
2.4
1.7
3.0
2.3
2.3
2.7
3.3
2.0
3.8
1.9
2.6
2.0
2.5
1.7
3.4
2.5
2.3
2.8
3.7
2.0
3.7
2.1
2.7
(+)0.2
(-)0.1
NIL
(-)0.4
(-)0.2
NIL
(-)0.1
(-)0.4
NIL
(+)0.1
(-)0.2
(-)0.1
*: Excludes Jammu and Kashmir
Source: SRS of RGI.
RJH
(New Series)
Vol 1:4
1995
307
survey would be too high in view of the tremendous increase in the
sample size.
The data in the three tables can be calculated for all the states and
regression equations can be written and solved for the following three
combinations of variables: female literacy and IMR, female literacy and
CBRand IMRandCBR. Similar exercises with such data clearly indicate
that improving female literacy rates (through literacy campaigns and
primary schools) and reducing IMR (through an effective primary health
care system) are essential strategies in bringing down the birth rates to
replacement level; focusing primarily on a contraceptive target based
family planning programme may not be sufficient. A further refinement
at the state level is to do similar analyses separately for rural and urban
areas. (Tables 1, 2 and 3 have used only combined data.)
-S Ramasundaram
Health and Family Welfare Department
Government of Tamil Nadu
4th Floor, New Building
Secretariat
Madras 600 009
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308
RJH
(New Series)
Vol 1:4
1995
Review Article
Sustainable Development
A Limited Framework
KJ Joy
Tending the Earth: Traditional, Sustainable Agriculture in India
by Winnin Pereira; Earth Care Books, Bombay; 1993; pp 315; Rs 150.
AS the title itself suggests, the book under review is one of the more
recent additions to a growing body of literature dealing with sustainable
agriculture and traditional agriculture practices in India. This is a re
flection of the growing number of people who are becoming critical about
the consumerist, high fossil material and energy input based, centralised
components of the capitalist developmental model.
Over the last decade or so many fundamental problems have become
visible due to the conversion of agriculture from mainly use-value
production. Because of this, even to meet subsistence needs, people have
to go through commodity market system and it has affected various
segments of the rural society differently. Agriculture has come to be
dependent on infrastructure developed by and inputs coming from indus
try. In this type of production system, natural and common resources like
land, water, forest, etc, are seen only in terms of their extractive uses and
not as healthy conditions of production which are necessary for the
sustainability of production and of life. The large-scale droughts, deser
tification, floods, water logging, salination, widespread drinking water
shortage, decrease in the primary productivity of land and erosion of the
subsistence base of vast sections of people are all manifestations of the
unsustainable nature of the production system. This human-nature rela
tionship which has become all the more problematic with the capitalist
transformation of agriculture, forms the central theme of Tending the
Earth.
In the first section (the book has not been divided into various
sections), the author has tried to spell out what he means by sustainability
and social justice, defining them in the Indian cultural context which is
seen as a synonym for unsustainability. Among the various factors which
are contributing to unsustainability, the author has given a detailed
analysis of the relationship between the various types of ‘diversions’ that
are taking place, specially in the context of economic liberalisation and
globalisation, of resources like land, water and fertiliser from “direct food
production to other non-essential sector of agro-industrial system”.
Diversions of food takes place in many ways: food processing and
RJH
(New Series)
Vol 1:4
1995
309
transportation, dependent on unlimited access to subsidised energy, has
resulted in the wide separation of production and consumption points.
The author points out, “A basic need — food — which was simply,
cheaply and sustainably furnished earlier is now made complicated,
expensive and an unsustainable product by commercialisation... prevent
ing people from direct access to their own food unless they have money
to buy it back”; and the situation gets aggravated because of the wastage,
loss of nutrition and diversity, cost escalation and health hazards caused
by processing and packaging.
The second section provides a detailed account of the production
system, particularly the agriculture and village-based processing, that
was prevalent about 100 years ago in the Khandesh region comprising the
present Dhule and Jalgaon districts. The author has gone into a detailed
analysis of the various facets of the production system of Khandesh —
land use, cropping system, traditional practices like crop rotation, inter
cropping, recycling of wastes, irrigation systems, integration of livestock
with agriculture, post harvest processing of th eproduce, etc. The pasture
and forest commons were integrated with agriculture and they provided
an enormous range of plant and animal products like food supplements,
fodder, fuel and crop nutrients.
Though the author refers to the traditional irrigation practices that
were prevalent in Khandesh, specially the bandharas (bunds) that date
back to the time of Faruki kings (1370-1600), it is quite surprising that he
does not mention the famous phad system by name which was in vogue
in parts of Khandesh (Dhule district) and Nashik district at least from 17th
century. The phad system offers an interesting case of how people
collectively managed irrigation water in terms of crop planning, opera
tion and maintenance of the system and social discipline in the use of
irrigation water [Datye and Patil 1987]. According to the author, imposi
tion of water tax by the British was one of the reasons for the neglect of
the irrigation system as the “farmers preferred to take the risk of a good
monsoon producing adequate yields of suitable crops, rather than grow
irrigated ones for which they had to pay water tax”.
In this section the author also takes up two basic crops — rice and
cotton — for a detailed analysis; shows how the various traditional
practices associated with sowing, irrigation, fertilisation, weed and pest
control, harvesting and village-based processing of the produce have
been sustained over a long period of time. Rab, burning of the plot where
the rice saplings are grown prior to transplantation with cowdung and a
thick layer of leaf matter, was widely practised in Konkan. This treatment,
though on the decline, is still in use and it helps to manure the nursery
beds, kill weed seeds and probably some of the pathogenic soil organisms
also. According to the author, the destruction of all these traditional
systems and practices, which are ‘inherently’ sustainable, began with the
310
RJH
(New Series)
Vol 1:4
1995
policies of the British — first to enclose the forests and commons and
second, to treat Indian agriculture as suppliers of raw materials for the
British industry. Cotton is the classic example of this. All these resulted
in (a) transfer of control from the users to distant authorities who had no
interest in sustainability; (b) reduced the nutrient availability for the
agricultural system; and (c) destroyed the village based agro-industrial
system by depriving them of raw materials and market. This caused
widespread rural unemployment and migration to cities.
The third section, which also forms the major part of the book, is a
detailed narration about “the basic resources available for agriculture and
technology developed to use them” by the farming communities. It deals
with all the important resources like energy, air and land, water, genetic
heritage, knowledge and skills and also various practices related to
recycling of nutrients, methods used by farmers to maintain the fertility
of the soil, crop protection including biological pest control methods,
cover crops to minimise risks, etc. Animal husbandry is also dealt with in
this section as it has been an integral part of traditional agriculuture.
Though the author gives productivity figures for certain crops like rice,
which at least in some cases compare favourably with the productivity
achieved under the green revolution package, he does not offer any norms
with regard to the use of organic matter, in the form of farm yard manure
(FYM), cowdung, crop residue, or green manure which is re-circulated
within the ecosystem. This has been one of the strong points of traditional
agriculture and also the most affected under the high input based agricul
ture.
The book also has a small section which suggests that going back to
traditional agriculture and industry and the traditional practices associ
ated with them is the only way for a transition from the present unustainable
mode of development to a sustainable one. The author has used the
allegory of the bull standing on four legs in the Krita Yuga, on three in the
Treta, on two in the Dvapara and only on one in the Kali Yuga to depict
the progressive degradation of the human-nature relationship over time.
The author feels that we have two options — either to set the bull back on
its four legs or to let it collapse completely.Js our choice really restricted
to these either-or-options?
Mutually Exclusive Options
The author is highly critical, and rightly so, of the type of research
activities undertaken by the research establishments and managed by
‘experts’ which tend to neglect the value of experimentation by farmers.
In this context Prayog Parivar — a network of farmer experiencers in
Maharashtra initiated by S A Dabholkar — could be a good recent
example of farmer experimentation (the author does not mention Prayog
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Parivar). Prayog Parivar has tried to overcome the limitations of main
stream agriculture research. It has also shown that farmers can learn in an
unstructured way by experimenting themselves. They have sustained this
process of learning for more than a decade or so. However, such efforts
cannot be seen as alternatives to the university-level research as the author
tends to make it an either-or case. Actually the experience gained from
farmer experimentation should be able to set the agenda for the university
level research and the efforts should be to evolve a more participatory and
integrated approach to agriculture research. In this process, the contribu
tion of pro-people scientists and technologists from both research estab
lishments as well as outside and of development activists concerned with
these issues, could be very significant.
In fact, this also bring us to the wider question of science and
technology and their role in the development process. The advocates of
traditional science and technology in their criticism of western science
(and this straight jacketing of science into western and Indian is not very
convincing) often tend to take an anti-science stance though it is not
explicitly stated. This type of an undercurrent can be seen in this book
also. This is not a position one can possibly agree to: science has
sufficiently brought forward that nature is not a passive substance and that
the universe is a single, active inter-related system in which humans have
to co-habit with nature. However, the problem is that the full implications
of this have not even been absorbed by the scientific community and it has
had very little impact on the dominant social outlook towards nature. It
still sees nature as a passive substance to be acted upon and sees the role
of science and technology as one of merely making it easier for the
humans to control, conquer and shape nature according to their whims
and fancies. This distinction between the possibilities brought forward by
science and the choices that are made in developing technologies by the
capitalist, patriarchal and brahminical state is very important if science
and technology have to contribute positively towards a healthy co
habitation of humans and nature. For example it is true that the green
revolution packages (or capitalist agriculture) and the technologies asso
ciated with them have been developed on the basis of modern science.
However, it is equally true that recent findings and insights provided by
modern science with regard to various aspects related to biomass produc
tion like plant physiology, critical stages of plant growth, role of micro
organisms, nutrients, crop-water requirement and effects on crop produc
tivity, photosynthesis, crop diseases, pests and integrated pest manage
ment, etc, would definitely contribute in a great way to the development
of alternative regenerative agriculture.
However, if science has to play such a positive role, then, it has to
develop through an interactive process between abstract thinking and
experience, knowledge acquired through prodution. If such interaction
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does not take place then abstract thinking remains alienated from produc
tion; on the other hand, the potential for the development of knowledge
that exists in the actual production gets stifled and it remains localised,
individual experience. This is what exactly that happened in India —
caste and baluthedari system denied the toiling sections, the bahujansy
involved in actual production, the right to learn and as a result the artisans
remained where they were and could make very little contribution
towards new technology development. Whatever skill-base they had
remained restricted along caste lines. The process which took place in
Europe was rather different from this; and that is why we find many
scientists with artisan background or who were involved in actual pro
duction. This serious limitation, imposed by the social system, cannot be
brushed aside when we talk of Indian traditional science and technology.
The author has created this either-or situation, as mentioned above, in
many other areas too and water is a glaring example of this. The author
analyses many of the traditional irrigation systems and he quotes innu
merable examples of the oft quoted tank systems specially in peninsular
India — as examples of sustainable irrigation systems. However, the
analysis does not provide any new insight than what is already said about
the tank systems. In a recent study Vaidyanathan (1992) makes an
interesting distinction between simple, rainfed tanks and system tanks —
the first being tanks built in a series along the course of the smaller rivers
or tributaries where each tank gets its supplies from its immediate
catchments as well as from the surplus flowing from upstream tanks; and
the second type of tanks are those which have access to water from a wider
catchment, or diverted from streams/rivers with the help of anicuts
(diversion weirs) and increasingly in recent times, from large storage
reservoirs. Because of this, system tanks are replenished more than non
system tanks; they have had more secure deliveries and have not been
affected as much as independent tanks by the fluctuations in rainfall. Very
often any discussion on tank irrigation (or smaller water sources) seems
to gloss over some of the important issues like relative submergence,
irrigation efficiency, reliability of supply, etc. Vaidyanathan’s study
reveals very clearly that small water bodies, merely by their characteris
tics of being physically small, do not posses any intrinsic merit over large
sources. On the contrary they show higher submergence (though there is
a qualitative difference between the decentralised, local submergence
and the submergence caused by big dams); higher costs per ha of
additional capacity generated; and greater evaporation losses than larger
water bodies. The study also shows that the gross delta per ayacut (area
irrigated) is high, of the order of 1000 mm or more, which is not very
different from the order of gross delta in large systems, except for
sugarcane dominated areas. Therefore, there is considerable scope to
improve water efficiency through proper crop choices and practices and
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extend irrigation to those who have no access to water presently. One of
the suggestions which the study has given for improving the tank
irrigation is to exploit the possibilities of using tanks in conjunction with
large canal systems with a priority to assure reliability of water supplies
to the existing tanks and they cannot be seen as exclusive alternatives to
large storages.
If performance of large systems has been poor, the small systems have
not been very much better off except where NGOs or farmers’
organisations/movements have been able to bring about a change in
perspective and functioning. For example, a couple of years back, the
people of Chinchani (Sangli district, Maharashtra) had to resort to various
forms of agitations, including an year long sara-bandi agitation (not
paying revenue to the government), to get their share of water released
from the Pare minor irrigation tank aind that too under police protection.
The struggles to restructure the smaller systems are also necessary as the
struggles against the destructive content of big dams; the fight is against
the powerful within the village itself — the tragedy is that very often
environmentalists and advocates of small systems do not realise the
significance of such struggles and do not want to go beyond the big vs
small conroversy. The book under review also echoes the limited ‘small
vs large’ perspective. A recent study has shown as how to integrate large
sources (exogenous water) with small water sources (local water) and
manage the water systems in a decentralised, equitable and sustainable
manner [Paranjape and Joy 1994],
Limited Perspective
The author has tried to capture the various nuances of traditional
agriculture giving a detailed account of hundreds of traditional practices
covering a wide range of situations (both in terms of space and time).
However, the framework which the author uses to understand the issue of
sustainability in general and agriculture in particular, is very limited.
Because of this, sustainability is equated with going back to the traditional
mode of agriculture and minimum human intervention in nature. Though
the traditional agricultural practices have contributed to a great extent to
the sustainability of the agricultural production system, how does one
look at these practices in the changed socio-economic context? To put it
differently the issue is whether traditional practices can assure liveli
hoods to all, specially in the degraded ecosystems, within a socially
acceptable time span.
To answer this we have to go beyond the framework the book offers
— of going back to traditional agriculture and village-based processing
— and understand issues like livelihood, sustainability, equity and selfreliance in the alternative framework of regenerative agriculture and
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biomass-based, decentralised agro-industrial development which has the
potential to go beyond subsistence to sustainable prosperity. In brief, this
alternative approach is based on: a) primary biomass productivity as its
starting point and sustainable enhancement of that productivity; b) the
critical role played by resource assessment, matching resource availabil
ity to needs and strategic use of limited external inputs to optimise the
sustainable productivity gain by appropriate technological choice; c)
creating equitable access for the rural poor and disadvantaged sections,
especially the women, to the biomass production facilities (including
water and land/wasteland) and biomass product as well as local materials
and renewable energy sources; d) taking account of non-farm livelihood
activities that are possible; e) creating institutional arrangements and
conditions for assistance and cost recovery which would provide incen
tive for primary productivity enhancement, optimal use of external
resources, access to productive resources for the rural poor and disadvan
taged sections, especially the women; and f) making possible a transition
to an energy self-reliant, dispersed, industrial system of production and
livelihoods.
Sustainability is often equaled with environmental conservation (or
minimum intervention in nature as the author puts it) like soil and water
conservation, environmental protection, tree cover, etc. There is more to
sustainability than all these; and it is necessary toestablish its relationship
with ecosystem productivity as well as the use of external input. In this
context the distinction between primary and secondary productivity of an
ecosystem is very crucial. Primary productivity of an ecosystem is the
productivity that an ecosystem will have if all external inputs were to be
withdrawn from it. Secondary productivity is the increment in productiv
ity that results from the use of external inputs. Aggregate productivity, or
what is actually harvested, is the sum of primary and secondary produc
tivity. Increasing aggregate productivity need not necessarily mean a
rising primary productivity. In fact, though high input agriculture has
often led to rising aggregate productivity, there is ample evidence to show
that this has been al the cost of primary productivity (the trend towards
stagnation in yields despite higher and higher amounts of external inputs
is a clear indication of this).
Looking at sustainability this way means that sustainable’practices are
thus not necessarily practices that deny the use of external inputs and the
associated increment in productivity. In fact, without taking advantage of
secondary productivity, it would be difficult to ensure the livelihoods of
the rural poor in India, and external inputs are necessary to increase
ecosystem productivity that is falling due to environmental degradation.
However, the level and manner of external input use should not result in
a disruption of the basic productivity conserving and enhancing biologi
cal cycles and processes within the ecosystem or used, as the author puts
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it, “within their regeneration limits’’. This type of a practice is very close
to what is now increasingly being called low external input sustainable
agriculture (LEISA) practices [see Coen Reijntjes, et al 1992]. Modem
sustainable resource use thus means sets of practices which conserve and
possibly enhance primary productivity. Thus, the set of sustainable
practices includes but is not limited to organic farming methods or rainfed
farming.
Studies have shown that with this type of a strategy it is possible to
generate at least three tons of surplus biomass per family after meeting all
subsistence needs of food, fodder, fuel and the recycling of about onethird of the biomass product for the agricultural crop area. This surplus
biomas has an important role to play in creating non-farm incomes to the
resource poor and in moving towards energy self-reliance.
This requires an informed technological choice in all income genera
tion and developmental activity. There is now a very large basket of
innovative technologies in many different areas (LEISA techniques
comprise one example in the area of biomass production) which, a)
maximise the component of local materials and incomes, b) bring down
the noir-renewable energy component (as energy and as materials)
substantially, typically by a factor of five, and c) represent greater
opportunities for skill development and non-farm income generation
avenues for the rural poor.
Quite unlike the framework which the author provides, in this alterna
tive framework, the process of skill building and technology development
concentrates not only on the artisan and craft traditions of the people,
which do remain an important starting point. It also aims to involve all the
resource-poor sections of the rural society (poor farmers, labourers, craft
persons and women) into a process of development which on the one
hand, leads to a general raising of skills (and the development of new
skills) for all the sections, and on the other hand, also leads to the
development of a stratum of skilled personnel in innovative applications,
capable of management of resources and motivated by the understanding
of social need. This stratum — a new producer class - is from all sections
of the rural poor and possess skills which are not as bound by craft and
caste traditions.
This also'brings us to the other major limitation of the book — social
relations of production. In fact, the whole aspect of social relations of
production that characterised the traditional production system is entirely
missing from the author’s analysis of sustainability, traditional agriculural
production system and the knowledge and skill base as well as the
numerous practices. Unless we take into account the exploitative social
relationships underlying a particular production system how can we call
that system socially sustainable? For example, the baluthedari system
around which the production was organised at the village level had the
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peasants (in Maharashtra mostly the maratha-kunbi caste) at the centre of
the production system and the baluthedars (artisans) rendering caste
based services to the peasants. In return for the services the baluthedars
were given bait — remuneration in kind. However, everyone knows that,
at a social plane, baluthedari system was based on hierarchy and exploi
tation — one’s birth deciding one’s position in the production system and
one’s access to knowledge and skills. Often this exploitative nature of the
production system is missing from the writings of those who advocate
going back to traditional systems or eulogise the self-reliant (or selfsufficient?) Indian village systems. It is not to suggest that the author’s
central concern is nature per se and the humans are pushed to the
periphery (as many of the ‘elite environmentalists’ do). The only conten
tion here is that sufficient clarity on the part of the author with regards to
social relations of production is not visible in his analysis of the traditional
systems; nor in the solutions he has offered. To put it differently, both the
traditional as well as western (capitalist development would be a more
appropriate term) models of development have to be seen not only in
terms of human to nature relation alone (natural resource base of produc
tion, conditions of production, science and technology) but also in terms
of human to human relations also. Human to human relation so far has
been exploitative. This exploitative nature of the traditional system
cannot be seen as something ‘unfortunate’ (as the author would have us
believe!) but should be seen as an integral part of the system itself. The
question of social relations of production becomes all the more important
because the book under review does not restrict itself to the traditional.
practices alone but offers a framework to understand sustainable devel
opment and an approach, though limited, for a transition to sustainability.
Despite some of the above mentioned limitations, the book does make
a significant contribution to the debate on sustainable development as it
has tried to make a very comprehensive critique of the present unsustainable
mode of development. Also, the author has tried to document the
traditional practices in one place and the reader would be quite taken
aback to read about such wide ranging traditional practices. It really
shows the type of meticulous research and efforts that have gone into the
writing of this book. The author’s concern for the protection of the
commons and the access for the resource poor to productive resources like
land and water could be better appreciated if we see it in the overall
context of privatisation, commercialisation and degradation of all com
mon pool resources — a process which is being accentuated by economic
liberalisation and globalisation.
It has to be also emphasised here that traditional practices do have a
role in the alternative framework suggested above. However, each set of
practice has to be assessed against this alternative framework to find out
its relevance or to see how it can be integrated with the knowledge that has
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now become available on various aspects related to biomass production.
Instead of going lock, stock and barrel over traditional practices, what is
needed is a process of participative experimentation by fanners of
abstracting the inscribed principles of such management (like nutrient
management, water management, etc) from traditional practices, absorb
ing them on the basis of a reorientation of modern knowledge, and re
applying them to the changed social and environmental contexts that we
face today.
We would end this review with a quotation from Marx which very
succinctly summarises the contradictions as well as the unsustainable
characterof the capitalist production system. The tragedy is that no debate
on sustainable development — both by environmentalists and Marxists
— takes note of this quotation or its significance. Marx says,
Capitalist production, by collecting the population in great centres, and
causing an ever-increasing preponderance of town population, on the one hand
concentrates the historical motive power of society; on the other hand, it
disturbs the circulation of matter between man and soil, ie, prevents the return
to the soil of its elements consumed by man in the form of food and clothing;
it therefore violates the conditions necessary to lasting fertility of the soil. By
this action it destroys at the same time the health of the town labourer and the
intellectual life of the rural labourer. But while upsetting the naturally grown
conditions for the maintenance of that circulation of matter, it imperiously
calls for its restoration as a system, as a regulating law of social production, and
under a form appropriate to the full development of the human race...
Moreover, all progress in capitalistic agriculture is a progress in the art, not
only of robbing the labourer, but of robbing the soil; all progress in increasing
the fertility of the soil for a given time is a progress towards ruining the lasting
sources for that fertility. The more a country starts its development on the
foundation of modem industry, like the US for example, the more rapid is this
process of destruction. Capitalist production, therefore, develops technology,
and the combining together of various processes into a social whole, only by
sapping the original sources of all wealth — the soil and the labourer (Capital,
Volume I).
References
Paranjpe S and K J Joy (1994): Alternative Restructuring of Sardar Sarovar
Project: Not Destructive Development but Sustainable Prosperity.
Reijntjes, Coen et al (1992): Fanning for the Future: An Introduction to Low
External Input and Sustainable Agriculture, Macmillan and ILEIA, Nether
lands.
Vaidyanathan A (1992): Strategy for Development of Tank Irrigation, MIDS.
KJ Joy
22 Rahul Apartments
Marutrao Gaikwad Nagar
Aundh, Pune 411 007
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Radical Journal Health
New Series
Index
Volume 1,1995
E: Editorials
C: Communications
D: Discussion
DP: Discussion Paper
R: Book Reviews
F: Facts and Figures
RA: Review Article
Nol: Pp 1-80; No 2: Pp 81-168
No 3: Pp 169-244: No 4: 245-322
Atomised Approach (E)
Aditi Iyer
Beyond Economics (E)
Charter of Demands on Family Planning Programme (D)
Cultural Relativism, Ethical Imperialism and
Reproductive Rights(DP)
Ruth Macklin
Demographers and Population Policies (R)
Malini Karkal
Disease,Death and Local Administration Madras City in Early 1900s
V R Muraleedharan and D Veeraraghavan
Family Experience of Epilepsy
Prcmilla D’Cruz
Gender Politics in Mental Health Care in India
Bhargavi V Davar
Government Expenditure on Health Care (R)
Brijesh C Purohit
Growing Exports, Sick Workers (E)
Millie Nihila, Padmini Swaminathan
Health and Welfare: Comparative Indices (F)
Sandeep Khanvilkar
Health, Dirt and Images of Organic Food
Rahul Srivastava
Health Expenditure Patterns in Selected Major States
Ravi Duggal
Health RescarchrStrengths and Weaknesses (R)
Ramila Bisht, Nilambari Gokhalc
Health Status of Children (F)
‘If You Can’t Have Bread...’ (E)
Padma Prakash
Indian Criminal Law and Industrial Offences: Critiques
and Case Studies
Sapna Malik
Indian Practitioners of Western Medicine:
Grant Medical College, 1845-1885
Mridula Ramanna
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3
5
63
153
228
9
281
183
150
174
79
209
37
233
240
81
253
116
319
Injured Psyches: Survivors of Bhopal Disaster (C)
Satinath Sarangi
Interpreting Demographic Data (C)
S Ramasundaram
Making Way for Price Rise: New Drug Policy (C)
Wish was Rane
Managing Resources (E)
V R Muraleedharan
Market, Health and Ideology (C)
Ravi Srinivas
Market Reform in Health Care (E)
Amar Jesani
Plague.The Subaltern Experience (C)
A R Venkatachalapathy
Profitable and Now Legal (E)
Sandhya Srinivasan
Public Health Budgets :Recent Trends
Ravi Duggal
Reproductive Rights and More
Lakshmi Lingam
Status of Indian WomemProduction and Reproduction (F)
Asha Vadair and Sandeep Khanvilkar
Structural Adjustment and Health Policy in Africa
Rene Loewenson
Sustainable Development: A Limited Framework (RA)
K J Joy
Symptoms of Distress
Padma Prakesh
TB Epidemics: Symptoms of a Larger Malaise (D)
Through a Bhopal Prism (E)
Padma Prakash
Understanding Mental Distress:
Contributions of Frankfurt School
Parthasarathi Mondal
Utilisation of Maternal Health Services:
Report from Rajasthan (C)
P R Sodani
Victims or Perpetrators? (R)
Sandhya Srinivasan
Women, Health and Development
Malini Karkal, Manisha Guple and Mira Sadgopal
Women’s Testimonies vs Medical Opinion (R)
Swatija and Chayanika
66
302
145
87
224
170
221
84
177
136
162
49
309
251
237
7
89
296
76
25
71
Author Index
Anonymous
Beyond Economics (E)
Charter of Demands on Family Planning Programmc(D)
320
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Health Status of Children
Bisht, Ramila and Nilambari Gokhale
Health Research: Strengths and Weaknesses (R)
Chayanika and Swatija
Women’s Testimonies vs Medical Opinion (R)
Davar, Bhargavi V
Gender Politics in Mental Health Care in India
D’Cruz, Premilla
Family Experience of Epilepsy
Duggal, Ravi
Health Expenditure Patterns in Selected Major States
Public Health Budgets: Recent Trends
Gokhale, Nilambari and Ramila Bisht
Health research: Strengths and Weaknesscs(R)
Gupte, Manisha, et al
Women, Health and Development
Iyer, Aditi
Atomised Approach (E)
Jesani, Amar
Market Reforms in Health Care (E)
Medicos’ Strike Relevant Issues
Joy, K J
Sustainabile Development: A Limited Framework (RA)
Karkal, Malini
Demographers and Population Policies (R)
Karkal, Malini, ct al
Women, Health and Development
Kaul, Sunil
TB Epidemics: Symptoms of a Larger Malaise (DP)
Khanvilkar, Sandeep
Health and Welfare: Comparative Indices(F)
Khanvilkar, Sandeep and Asha Vadair
Status of Indian Women: Production and
Reproduction(F)
Lingam, Lakshmi
Reproductive Rights and More
Locwenson, Rene
Structural Adjustment and Health Policy in Africa
Macklin,Ruth
Cultural Relativism,Ethical Imperialism and
Reproductive Rights (DP)
Malik, Sapna
Indian Criminal Law and Industrial Offences: Critique
and Case Studies
Mondal, Parlhasarathi
Understanding Mental Distress: Contributions
of Frankfurt School
RJH
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240
233
71
183
37
177
233
25
2
171
228
25
237
79
162
136
49
153
253
89
321
Muraleedharan, V R
Managing Resources (E)
Muraleedharan V R and D Veeraraghavan
Disease, Death and Local Administration: Madras City
in Early 1900s
Nihila, Millie and Padmini Swaminathan
Growing Exports, Sick Workers
Prakash, Padma
Through a Bhopal Prism (E)
‘If You Can’t Have Bread’ (E)
Symptoms of Distress (E)
Purohit, Brijesh C
Government Expenditure on Health Care (R)
Ramanna, Mridula
Indian Practioners of Western Medicine:
Grant Medical College, 1845-1885
Ramasundaram S
Interpreting Demographic Data
Rane, Wishwas
Making Way for Price Rise: New Drug Policy (C)
Rao, Sujata
Economic Aspects of TB Control in India
Sadgopal, Mira et al
Women, Health and Development
Sarangi, Satinath
Injured Psyches: Survivors of Bhopal
Disaster (C)
Sodani, P R
Utilisation of Maternal Health Services:
Report from. Rajasthan (C)
Srinivasan, Ravi
Market, Health and Ideology (C)
Srinivasan, Sandhya
Victims or Perpetratars? (R)
Profitable and Now Legal (E)
Srivastava, Rahul
Health, Dirt and Images of Organic Food
Swaminathan, Padmini and Millie Nihila
Growing Exports, Sick Workers
Swatija and Chayanika
Women’s Testimonies vs Medical Opinion (R)
Vadair, Asha and Sandeep Khavilkar
Status of Indian Women: Production and Reproduction (F)
Veeraraghavan, D and V R Muraleedharan
Disease, Death and Local Administrtion: Madras City
in Early 1900s
Venkatachalapathy, A R
Plague: The Subaltern Experience (C)
^21
322
1995
RJH (New Series)
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150
116
302
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66
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J24
21
162
Muraleedharan, V R
Managing Resources (E)
Muraleedharan V R and D Vceraraghavan
Disease, Death and Local Administration: Madras City
in Early 1900s
Nihila, Millie and Padmini Swaminathan
Growing Exports, Sick Workers
Prakash, Padma
Through a Bhopal Prism (E)
‘If You Can’t Have Bread’ (E)
Symptoms of Distress (E)
Purohit, Brijesh C
Government Expenditure on Health Care (R)
Ramanna, Mridula
Indian Practioners of Western Medicine:
Grant Medical College, 1845-1885
Ramasundaram S
Interpreting Demographic Data
Rane, Wishwas
Making Way for Price Rise: New Drug Policy (C)
Rao, Sujata
Economic Aspects of TB Control in India
Sadgopal, Mira et al
Women, Health and Development
Sarangi, Satinath
Injured Psyches: Survivors of Bhopal
Disaster (C)
Sodani, P R
Utilisation of Maternal Health Services:
Report from. Rajasthan (C)
Srinivasan, Ravi
Market, Health and Ideology (C)
Srinivasan, Sandhya
Victims or Perpetratars? (R)
Profitable and Now Legal (E)
Srivastava, Rahul
Health, Dirt and Images of Organic Food
Swaminathan, Padmini and Millie Nihila
Growing Exports, Sick Workers
Swatija and Chayanika
Women’s Testimonies vs Medical Opinion (R)
Vadair, Asha and Sandeep Khavilkar
Status of Indian Women: Production and Reproduction (F)
Veeraraghavan, D and V R Muraleedharan
Disease, Death and Local Administrtion: Madras City
in Early 1900s
Venkatachalapathy, A R
Plague: The Subaltern Experience (C)
322
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116
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