Radical Journal of Health 1996 Vol. 2, No. 1, Jan. – March
Item
- Title
- Radical Journal of Health 1996 Vol. 2, No. 1, Jan. – March
- Date
- March 1996
- Description
-
Investment in medical equipment: study of private hospitals in Madras
Famine and epidemics: Insights from major famines
Toxic legacy of union Carbide in Bhopal
Women and reproductive health: Review of literature
National disease control programmes: selected data - extracted text
-
JOURNAL OF HEALTH
■
A SOCIApST HEALTH REVIEW TRUST: FUSU CATION
New Series VOLUME II
INVESTMENT IN MEDICAL
EQUIPMENT: STUDY OF PRIVATE
HOSPITALS IN MADRAS
FAMINE AND EPIDEMICS: INSIGHTS
FROM MAJOR FAMINES
JL
TOXIC LEGACY OF UNION CARBIDE
IN BHOPAL
WOMEN AND REPRODUCTIVE HEALTH:
REVIEW OF LITERATURE
NATIONAL DISEASE CONTROL
PROGRAMMES: SELECTED DATA
Rs 25
Consulting Editors'.
Amar Jesani,
CEHAT, Bombay
Binayak Sen, Raipur, MP
Dhruv Mankad,
VACHAN, Nasik
K Ekbal,
Medical College, Kottayam
Francois Sironi, Paris
Imrana Quadeer,
JNU, New Delhi
Leena Sevak,
London School of Hygiene and
Tropical Medicine, London
The Radical Journal 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.
Manisha Gupte,
Editor. Padma Prakash
CEHAT, Pune
Editorial Group: Aditi lyer, Asha
V R Muraleedharan,
Padmini Swaminathan,
Vadair, Ravi Duggal, Sandeep
Khanvilkar, Sushma Jhaveri,
Sunil Nandraj, Usha Sethuraman.
Madras Institute of
Development Studies, Madras
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Indian Institute of
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Volume II
Number 1
New Series
January-March 1996
Letter to Editor
2
Editorials: Moving Forward, World Bank Style Ravi Duggal
A Sports ‘High’
3
Padma Prakash'
Investment in Medical Equipment:
Study of Private Hospitals in Madras City
S Sukanya
9
Famine and Epidemics: Insights from Major Famines
in Late 19th and Early 20th Century
Arup Maharatna
26
Reproductive Health and Women: A Review of Literature
Malini Karkal
54
Communications
Toxic Legacy of Union Carbide in Bhopal
Satinath Sarangi
Rationalising Expenditure in Health Care Sector
Brijesh C Purohit
68
71
Reviews
Historiography of Colonial Medicine
Leena Abraham
Towards a New Perception of Women’s Health
Roopashri
75
81
Facts and Figures
National Disease Control Programmes
Ravi Duggal
Sunil Nandraj
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Letter to Editor
Don’t Burn Waste
BUILDING incinerators for hazardous municipal and medical waste will in
crease health risks from the formation of organochlorine by-products during
burning. In addition, the huge amounts of money invested in such expensive
technologies will act as a disincentive for industry to develop and market clean
alternative products to reduce the toxicity and volume of wastes. Hazardous
waste incinerators will be used to hide the sludges of chlorinated solvent
processes and the highly toxic wastes rising from the production of ethylene
dichloride (EDC), and vinyl chloride monomer (VCM), the raw materials of
PVC. As the consumer classes increasingly copy the environmentally unsustainable
‘throwaway’ consumption habits of northern societies, the waste stream of
municipal incinerators will increasingly mix PVC packaging wastes, commodity
plastics used in TVs, cars and white goods such as washing machines and
refrigerators, toys and PVC building materials such as cables, piping and floor
coverings. Medical incinerator waste streams contain PVC products such as
blood bags, syringes, surgical gloves and catheters.
We need to learn from the industrialised societies in the world which have
realised the dangers of chlorine and are now taking action against it. And we must
ensure that as northern countries become increasingly critical of both chlorine
industries and incineration, these dirty technologies are not shifted to Asia. We
must decrease our toxic body burden by banning chlorine compounds, phasingout the majority of chlorinated solvents like Sweden has done, or ban the use of
PVC in packaging and use in public buildings, like many municipalities in
Germany and Austria have done. Alternatives are now available for all major uses
of chlorine. Let’s look upstream to build a future through clean sustainable
industries and not downstream at expensive end-of-pipe waste disposal solutions
that simply hide and compound the problem.
Malini
Greenpeace International Toxics Compaign,
Amsterdam.
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Moving Forward, World Bank Style
The health care programme needs to be remodelled in the Ninth
Plan which is in the process of being formulated, but with clear
people-oriented priorities and not in step with World Bank
recomendations.
The process for formulating the Ninth Five Year Plan (1997-2002) has
begun and various groups and subgroups have been initiated to contribute
towards its formulation. There are a number of Working Groups formed
for the health sector and one of the crucial ones is the Working Group
on Health Management and Financing. Its terms of reference include
making suggestions for improving quality and efficiency of the existing
health care system and reduction of cost of health care services, iden
tifying strategies for total quality management, assessing the disease
burden and cost of ill health, estimating costs of public and private health
care and identifying alternate sources and strategies for financing the
rising costs during the Ninth Plan period. A number of subgroups have
been constituted to help this working group to work out strategy papers
to feed into the Ninth Plan.
From the terms of reference it is amply evident that the World Bank’s
recommendations from its report ‘Investing In Health’ is being taken
seriously. In the name of health sector reform soft loans have been
provided by World Bank on specific programmes like tuberculosis,
reproductive and child health, blindness and corporatisation of public
health services in selected states. These large investments from borrowed
capital are taking the health sector in the direction desired by the various
recent World Bank health sector reports which emphasise selective health
care to a targetted population by the state. This means that the commit
ment for primary health care for all is being abandoned in favour of
strategies being determined by the World Bank and other international
agencies like USAID. It is obvious that the Ninth Plan is working within
the framework of this design and it must be weaned away instead to accept
the principles of universal health care and formulate a strategy for
realising this through a plan which sets in a process for restructuring
healthcare services in India in acomprehensive manner creating a public
private mix which is accessible to all equitably.
Thus during the Ninth Plan a lot of rethinking needs to be done. Yes,
we do need a new strategy but this should focus both on strengthening the
state-sector and at the same time also plan for a regulated growth and
involvement of the private health sector. There is a need to recognise that
the private health sector is huge and has cast its nets, irrespective of
quality far wider than the state-sector health services. Through regulation
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and involvement of the private health sector an organised public-private
mix could be set up which can provide universal and comprehensive
health services to all. What we are trying to say is that the need of the hour
is to look at the entire health health care system in unison and evolve some
sort of a national system wherein public and private health care providers
are organised under a common umbrella to serve one and all. A frame
work for basic minimum level of care needs to be spelt out in clear terms
and this should be accessible to all without direct cost to the patients at the
time of receiving care.
Therefore the Ninth Plan should adopt a strategy of firstly, setting in
a process of reorganising the public and private health sectors into a single
regulated system which functions in the context of a universalised system
to provide equitable and basic care to all, irrespective of the capacity to
pay. And secondly, it must undertake defiitive action towards changes in
the existing system which can improve both efficiency and cost effective
ness.
While reorganising of the health sector into a universal public-private
mix will take time, certain positive changes are possible immediately
through macro policy initiatives :
-the medical councils should be directed to put their house in order by being
strict and vigilant about assuring that only those qualified and registered
should practice medicine and continuing medical education (CME) should be
compulsory for periodic renewal of registeration
-medical graduates passing out of public medical schools on whom the state
spends Rs.800,000 each at current prices must put in compulsory public
service for atleast five years of which three years must be in PHCs and rural
hospitals; this should be assured not through bonds or payments but by
providing only a provisional license to do supervised practice in state health
care institutions, and also by giving the right to pursue post-graduate studies
only to those who have completed their three years of rural medical service;
such a measure will itself create a resource of about 14,000 medical graduates
(not counting other systems) every year for public health services
-regulating the spread of private clinic and hospitals through a strict locational
policy whereby the local authorities should be given the right to determine how
many doctors or how many hospital beds they need in the area; norms for
family practice, practitionenpopulation and bed:population ratios, fiscal in
centives for remote and underserved areas and strong disincentives and higher
taxes for urban and overserved areas etc., can be used
-regulating the quality of care provided by hospitals and practitioners by
setting up minimum standards to be followed
-putting in place compulsory health insurance for the organised sector by
restructuring the existing ESIS to cover all employees, irrespective of their
class, and obtain contributions proportinate to their earnings; for instance if
such employees contribute 2 per cent of their salaries and employers add 3 per
cent then this itself would raise resources of about Rs 100 billion which is more
than what the ministries of health spend on health care presently; of course
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similar insurance or funds for other categories of persons like traders, midlle
and rich farners, businessmen, professionals, etc who have the capacity to pay
must also be created;
-special taxes and cesses for health can be charged to generate additional
resources - alcohol, cigarettes, property owners, vehicle owners, etc., are well
known targets and one can add paan masalas, non-essential drugs, etc to the list
and just a one percent tax on turnover could bring in billions
-allocation of existing resources can be rationalised better through preserving
acceptable ratios of salary: non-salary spending so that critical inputs for
efficient and effective provision of care are maintained;
-setting up a referral system for secondary and tertiary care
-evolving a national formulary for drug production and use and regulating its
distribution, pricing etc., on the basis of such a formulary;
These are a few suggestions which the Planning Commission and the
ministries of health should consider in evolving their strategy for the
Ninth Plan period. Only such processes and actions can take the health
sector closer to realising the objective of providing comprehensive health
care to all. The existing allocations are definitely too meagre to realise
such an objective and hence much larger allocations will be necessary and
alternate sources of financing as suggested above will of necessity have
to be tapped. Analysis of data shows that for providing reasonable quality
basic health care for all during the Ninth Plan period we will need an
average of Rs 350 billion per year at today ’ s prices (Rs 350 per capita) and
this would mean a plan size three to four times larger in real terms than
its.preceding one.
-Ravi Duggal
A Sports ‘High’
The ethos which has promoted the growing interest in sports
is also making access to sporting facilities, and to achieving physical
fitness more remote for the masses.
THIS year brings a feast of sports—at least that is how those who enjoy
it will see it. Not only will we have cricket and tennis but also the Euro
96 and of course the Olympics at Atlanata. All this surfeit of sports on
the air waves and in the neighbourhood raises many issues impinging
on a range of social science fields including certainly, health and
medicine.
Undoubtedly, there has been an apparent expansion of sporting inter
est: some of this has merely been in terms of spectatorship—a fact not
missed by the increased corporate sponsorship of sporting events—but it
has inevitably led to a slow but growing legitimacy for sports participa-
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(ion, especially in the upwardly mobile middle class. Gone are the days
when youngsters had to sneak out to play a game of street cricket, or
football or for that matter, even to watch a local match. But then again this
very phenomenon of according legitimacy to sports has emerged out of
the fact that sports has, in a big way entered the market place. Sporting
abilities, even spectator interest, have become ‘qualifications’, just like a
diploma in computer programming, in the pursuit of careers in the
corporate sector.
Globally, too, especially after the second world war, the sporting ethic
complements the capitalist ethic—the credo of competition, of success at
all costs, of the debilitating relationship between the victor and the
vanquished. In the words of India’s premier chess player, V Anand, “ be
aggressive, ruthless and show no pity” lie the essence of today’s sports,
and of life in the 21st century.
What has all this done to the quintessential meaning of sports, as the
product of physical fitness and a contributor to it? How does all this
interest in sports translate in terms of physical health? For instance, has
India’s spurt of interest in sports in the last 15 years resulted in better
health indices or anthropomorphic measurements even among middle
class children? It may be too early to reckon these answers. However,
there are some home truths which everyone, those who enjoy sports and
those who shun it for whatever reason, must face.
First,this new awareness of sports has not as yet ‘filtered’ down—to
give one example, while many new ‘elite’ schools are giving special
empahsis on sports, no such enthusiasm is evident in the department of
education which funds or runs district level schools. This especially tells
on the physical education of girls—while boys continue to monopolise
the streets and public fields for all sorts of games, girls have never done
so. Further, there is on paper a scheme to encourage sports at the district
and village levels by holding competitions annually. This has hardly
produced any new talent. Again, with the drop out rates in schools
remaining high (and some claim ever going higher), there is unlikely to
be a larger number of school children having access to sports competi
tions. Another factor to be kept sight of is that with the increasing
expansion of the market economy, among families with limited re
sources, it becomes increasingly more important for the children to
devote time to acquiring additional skills which help in the employment
market rather than indulge in leisure activities. As for those sections who
cannot afford to send thier children to school, with the intensifying
struggle for food, children have access to neither modern sporting
activities nor to perhaps traditional sports, with the disintegration of the
socio-cultural fabric of their lives. Interestingly, there is a process of
cooption under way of old traditional sports like ‘malkhamb’ and khokho into the modem realm, such that even as poorer sections, especially
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in the countryside are losing out on these arts/ski 1 Is, a new generation of
middle class children are accessing it. In other words the very ethos that
has expanded the realm of sports at one level is conributing to the denial
of opportunities for leisure at another.
In such a context it is hardly likely that the new and growing interest
is contributing to an overall improvement in health or physical and mental
fitness. Does that mean we jettison modern sports altogether? Or as some
have suggested somehow make competition and winning a less important
component of sports? Certainly, the fact that running the race is as
important as winning it is a truth that can only be driven home if sports
becomes a truly leisure activity, an activity indulged in for the joy of it,
and not for obtaining ‘participation certificates’. However, it is important
to remember that part of the ‘competition’ in sports is against oneself—
to excel is to compete with one’s own previous performance; to better
one’s timing is to compete against the clock. Equally important is it to
recognise that the essence of the spirit of sports lies in extending the limits
of the body in the physical sense as well as in the psychological; the
strength that may be gained in being able to achieve what has seemed
impossible.
This confidence in one’s strength, not just physical, but emotional and
mental, is as essential to fighting injustice and for a better order in life as
it is for climbing the corporate ladder. And while there may be and are
any number of medical explanations about the ‘sports high’ athletes
experience, it is essentially, both the setting free and the capturing of the
.will to live that accounts for the exhilaration in breasting a tape, breaking
a record or scoring a goal. As Joan Benoit, the distance runner put it: “I
run because I love to run. ...If I can help people to realise their potential
that there’s something worth living for in life, that’s marvellous. But I’m
not trying to make a statement with my running.”
—Padma Prakash
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Investment in Medical Equipment
Study of Private Hospitals in Madras City
S Sukanya
Increasing privatisation and corporatisation has had a significant
impact in the investment patterns in medical equipment. This study
analyses the pattern of investment in medical equipment in 50 private
hospitals in Madras city.
IN the last two decades, there have been major changes in the pattern of
demand for health care. The changes in the perception of people on health
care and the development of medical technologies have considerably
increased the demand for numerous medical services. On the suppliers’
side, hospitals invest huge amount of capital to meet the growing demand
for hospital services. Many hospitals have become complex organisations
with specialty and super-specialty medical departments. Medical depart
ments specialising in different fields operate with costly and sophisticated
medical equipment.
Although sophisticated medical equipment involve a heavy capital
investment, it also leads to improvement in providing medical care. In
many developing countries, hospitals with inadequate medical equipment
co-exist super-specialty hospitals operating with state-of-art equipment.
This results in a wide variation in the types of medical equipment owned
by different hospitals. A well-planned health care system presupposes the
proper distribution of medical equipment among the hospitals according
to the health care needs of the people.
The aim of this paper is to analyse the pattern of investment in medical
equipment in private hospitals in a metropolitan city in India. It relies on
a survey of 50 private hospitals in Madras city. This paper is divided into
three parts. Part I deals with the changes in the structure of health care
industry in India during the last 15 years. It also discusses the need for the
studies on investment pattern of private hospitals in India. Part II deals with
the methodology of this study. The results of the survey are presented in
Part III.
I
Changes in the Health Care Industry
The health care industry in India has undergone changes in its structure
with (i) the increased role of private sector, (ii) the emergence of corporate
hospitals and (iii) the diffusion of modem health care technology. Income
growth, increased demand for hospital-based health care and scarcity of
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governmental resources have encouraged the expansion of private sector
in the health care industry. Many empirical studies have observed the
significant contribution of private sector in the health care utilised in
India [Duggal and Amin 1989; Yesudian 1988; Jesani and Anantharaman
1993: 3; Bhat 1993:43].
The dominance of private hospitals, high competition among them and
the emerging philosophy of viewing hospital enterprises as a commercial
proposition have made a large number of medical practitioners move into
group practice. The concept of corporatisation of health care services has
been developed in India in the early 80s [Anantharaman 1990:4]. Apollo
Hospitals Enterprises was the first company to introduce this concept. It
started its hospital in Madras, a metropolitan city in India. At present there
are five public limited corporate hospitals in Madras. The total number of
corporate hospitals (both private and public limited companies) has
increased from five in 1985 to more than 50 in 1993.1
Corporate hospitals are in an advantageous position for mobilising
capital resources. As a result, they are able to invest in costly and
sophisticated medical equipment. Anatharaman (1990: 4) observed that
after the introduction of corporatisation, the investment in medical equip
ment had increased in India; it was evident with the starting of many
diagnostic centres - numbering more than 60 - with high-tech equipment
involving an investment of Rs 200 crore in a short period of two years in
the early 80s in India. Non-resident Indians have started investing heavy
amounts in super-specialty corporate hospitals. In this decade, many
super-specialty hospitals have been importing medical equipment with the
latest technologies. The liberal eco
nomic policy of the Indian govern
Table 1: Import of Medical
ment has also contributed to the
Equipment
diffusion of imported medical
(Rs in lakhs)
technology in India. Table 1 pre
Import of Medical
Years
sents the value of the imported medi
Equipment
cal equipment for the period from
1977-78 to 1987-88.
1977-78
941.20
It can be observed from Table I
1253.90
1978-79
that the import of medical equip
1979-80
1547.70
ment has increased by more than
1980-81
1972.10
2399.00
1981-82
Rs 5000 lakh in a period of 10 years.
2869.00
1982-83
There is an increasing trend in the
3268.04
1983-84
import of medical equipment. Thus
2894.57
1984-85
the liberal economic policy of the
5857.26
1985-86
government and the corporatisation
6500.00
1986-87
of health care industry have con
tributed to the diffusion of modem
Source; CEI, Handbook of Statistics,
1988.
medical technology. The develop10
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ment of sophisticated technology has the effect of increasing the
demand for hospital services. It is claimed that the most of the modem
technologies are characterised by investment in resource-intensive capital
equipment.
The hospital industry in India has thus become capital-intensive lead
ing to the above-mentioned changes. Judicious use of the capital resources
among various assets assumes importance. Any misapplication of the
resources may entail adverse effects on the cost of health services to
consumers [Whitted 1981:45;Johansen 1989: 169; Bronzino etal 1991:35;
Newhouse 1992:8] and the return on investment (ROI) to health care
providers. Besides, investment in medical equipment not related to the‘
needs of people may prompt inappropriate and indiscrete use of medical
technology to recover the outlay sunk in those equipment [Szczepura and
Stilwell 1988:715; Hindu 1994:3; Antia 1988:2; Jesani and Anantharaman
1993: 50; Menon 1994: 4]. An efficient resource allocation requires an
understanding of the pattern and management of investment in capital
equipment.
But there is a dearth of literature in the investment management of
hospitals in India. The Indian Council of Medical Research and Indian
Council of Social Science Research [ICMR-ICSSR 1980: 140] in their
joint report on healthcare expenditures in India observed qs follows: “It is
a pity that problem of economics of health and financing of health services
have received little attention in our country. Very little data is available in
this area. A fairly large scale and intensive research on this subject needs to
be developed on a priority basis.’’ It will not be an exaggeration to say that
such a comment would largely hold good even today.
In this connection, a study on the investment behaviour of private
hospitals in India will throw light on the investment management of
hospitals in India substantially, if not fully, as the market share of private
hospitals is dominant. The expenditure incurred by private hospitals,
dispensaries, and voluntary organisations on health is substantial. There
are more than 7,200 private and voluntary hospitals and clinics in India.
[Reddy 1991: 30]. Secondary and tertiary hospitals in private sector
expand in response to the increasing demand for health care [Satia and
Deodhar 1993: 227]. This being the case, studies on health care services
by private sector will help policy-makers to regulate the development of
private sector and to channelise the investment in accordance with the
national objectives [Bhat 1993: 43]. Information on the amount of invest
ment by private hospitals is rarely published and much less analysed. Baru
(1992) in her study on the private sector and its relationship with public
sector in medical care outlines clearly the difficulties in collecting data on
private hospitals in India. The existing studies on the health expenditure
are based on household surveys, based on consumers’ expenditure pattern
[Duggal and Amin 1989; Yesudian 1988]. These studies do not indicate
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the allocation of the resources mobilised among capital and revenue
expenditure. There is no study on the resource management of private
hospitals in India based on a hospital survey.
The present study, a hospital-based survey, attempts to fill this gap. The
methodology and the results of the study are discussed in the following
sections.
II
Methodology
The survey population for this study constituted all the ‘for-profit’
private hospitals in Madras city (a metropolitan city in India) offering
general and multi-specialty sendees in allopathic medicine to both in
patients and out-patients. Thus the survey excluded voluntary hospitals,
government hospitals, institutions offering services to in-patients or out
patients alone and nursing homes specialising in a single service alone.
There is a dearth of secondary sources of data on private hospitals in
India. Though the doctors have to register themselves with the directorate
of medical services while setting up the practice, there is no provision
under the present regulation in Tamil Nadu requiring the registration of
private hospitals/nursing homes at the time of incorporation with any
statutory medical body. Hence there is no authentic record readily avail
able even on the number of the private hospitals operating in Tamil Nadu.
As the information on private hospitals was not adequate, it was decided
to adopt two-phase sampling technique. In the first-phase of data collec
tion, a list2 of 130 hospitals was prepared and the questionnaires were
Table 2: Apollo Hospital: Investment in Various Fixed Assets
(Gross Amount as on 31.3.92)
Fixed Assets
Land
Building
Medical equipment
Electrical Installation and generator
Air conditioning plant and air conditioner
Office equipment
Furniture, fixtures, and projectors
Fire fighting equipment
Boilers
Kitchen equipment
Refrigerators
Vehicles
Work-in-progress
Total
Rs
Per Cent
5,25,45,000
6,37,80,465
13,80,91,243
1,25,81,849
1,15,79,835
70,85,025
71,14,319
4,75,314
6,87,952
9,42,605
3,77,596
9,95,289
79,37,597
30,41,94,089
17.27
20.96
45.39
4.13
3.81
2.33
2.34
0.16
0.23
0.31
0.12
0.33
2.62
100.00
Source: Apollo Hospitals, Annual Report, 1992.
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mailed to them seeking information on the following: (1) nature of hospital
(services of facilities offered); (2) size of the hospitals (such as number of
medical and service departments, total manpower and bed capacity);
(3) form of hospital (sole proprietary, partnership, corporate, registered
society and trust). Based on this information, it had been planned to
prepare a sampling frame for the second-phase of data collection.
The response rate for the first-phase data collection was only 10 per cent
and hence the method of sampling was changed from two-phase sampling
to purposive sampling. A questionnaire was designed to collect data on the
investment decisions of private hospitals. The questionnaires were distri
buted to all the corporate hospitals whose names appeared in the list
prepared for the first-phase of data collection and 15 corporate hospitals
responded. In addition to this, the questionnaires were distributed at
random to non-corporate hospitals and 35 responses were taken for
analysis, making the sample size to 50. Data were collected during the
period 1992-93. The market value of medical equipment in 1992 were
taken for analysis. The investment pattern of the hospitals was studied with
respect to 50 hospitals (1) at aggregate level ie without any segmentation;
(2) segment-wise based on ownership pattern; (3) segment-wise based on
bed capacity.
The study was restricted to examining the investment pattern of
medical equipment among various capital assets.'
Ill
Analysis of Investment Patterns
The analysis on investment pattern was carried out in the following
manner: First, the investment pattern was studied by considering the
medical equipment as a component in the total capital assets. In other
words, the amount allocated to medical equipment in the total amount
invested in capital assets was found out. Secondly, the types of medical
equipment and the amount in vested in them by the hospitals were analysed.
Table 3: Devaki Hospital: Investment in Various Fixed Assets
(Gross Amount as on 31.3.92)
Fixed Assets
Building
Medical equipment
Furniture
Electrical fittings
Office equipment
Capital work-in-progress
Total
Rs
Per Cent
21,28,141
1,36,36,200
5,63,541
9,79,294
39,347
51,52,535
2,24,99,058
9.46
60.60
2.50
4.36
0.18
22.90
100.00
Source: Devaki Hospital, Annual Report, 1992.
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(1) The amount invested in medical equipment loomed large in the asset
structure of many hospitals. The figures in Tables 2 to 5 give the
investment in various assets by each of the four’ public limited corporate
hospitals in the study area based on their published annual report.
Tables 2 to 5 reveal that the investment in medical equipment was the
highest among various fixed assets. It ranged from 50 per cent to 60 per
cent of the total investment in capital assets. In respect of other hospitals,
Table 4: Malar Hospital: Investment in Various Fixed Assets
(Gross Amount as on 31.3.92)*
Fixed Assets
Land and development
Building
Electrical installation
Air conditioner
Medical equipment
Computers
Vehicles
Furniture and fittings
Miscellaneous fixed assets
Total
Rs
Pcr Cent
2,28,19,716
5,57,24,022
59,55,150
1,06,31,477
10,38,66,568
35,15,643
2,57,37,772
10,48,929
77,42,312
23,70,41,589
9.63
23.51
2.51
4.49
43.82
1.48
10.86
0.44
3.26
.100.00
The above figures are extracted from the first annual report of Malar
Hospital for the period starting from its commercial operations in mid
1992 and ending on March 31, 1993.
Source: Malar Hospital, Annual Report, 1992.
Note:
Table 5: Tamilnad Hospital: Investment in Various Fixed Assets
(Gross Amount as on 31.3.92)
Fixed Assets
Per Cent
Rs
Land
Building
Medical equipment and surgical instruments
Electrical installation and generator
Office equipment
Computer
Furniture and fittings
Kitchen equipment
Vehicles
Capital work-in-progress
Total
36,25,491.86
9,03,62,912.98
13,64,23,738.92
2,18,33,763.29
25,68,172.16
28,97,364.61
36,50,615.50
4,57,819.39
23,57,922.69
35,45,006.00
26,77,22,807.40
1.35
33.75
50.96
8.16
0.96
1.08
1.36
0.17
0.88
1.33
100.00
The above figures are extracted from the first annual report of Tamilnad
Hospital starting from its commercial operations in mid 1992 and ending
on March 31, 1993.
Source: Tamilnad Hospitals, Annual Report, 1992.
Note:
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similar authentic records on fixed-asset investment were not available.
However, the hospital authorities covered under this study were contacted
and it was ascertained that the investment in medical equipment formed a
significant portion of their investment in total capital assets.
Thus there was an uniformity among all the hospitals in the sense that
they allocated a major portion of their resources to medical equipment. But
there may be differences in the distribution of the resources to various
types of medical equipment. Investment in different types of medical
equipment may be influenced by various factors like the nature, size and
competitive strength of the hospitals. Hence the investment pattern in
medical equipment was further analysed.
(2) Here the question arises on how to analyse the investment in various
types of medical equipment. The possible methods to analyse the invest
ment pattern in medical equipment are given below:
(i) Individual-item analysis: One way of analysing the investment
pattern is to study how the amount is distributed among various medical
equipment. But collecting data on the individual items would be tedious
and time consuming as hospitals invest in a wide variety of medical
equipment. It is also difficult to draw meaningful conclusions based on
the individual-item analysis.
(ii) Department-wise analysis: Analysis can also be made by identify
ing medical departments and analysing the amount invested in medical
departments and in medical equipment by those departments. Hence
information on medical services offered by the hospitals were collected.
(a) At aggregate level: In the sample, almost all the hospitals
invested the resources in maternity and radiology departments. Only few
hospitals offered cardiothoracic medical services. The departments
namely orthopaedics, obsterics, gynaecology, maternity and radiology were
common to many hospitals. These departments were operated even among
the hospitals in the same locality in spite of possible competition.
(b) Ownership pattern: More than 80 per cent of the corporate hospitals
invested in specialities like cardiology, urology and neurology. Only 4 per
cent of the sole proprietary hospitals invested in cardiology, oncology,
cardiothoracic and rheumatology. Similar is the case with the partnership
hospitals, (c) Bed Capacity: Out of the 15 small hospitals (with bed
capacity 1-10), none had medical services in cardiothoracic, obesity,
diabetology and cosmetic surgery, allergy and traumatology. All the
hospitals with bed capacity above 99 invested in cardiology, radiology,
and neurology departments.
During the pilot survey it was observed that costly medical equipment
were bought in medical departments, namely (1) cardiology, (2) urology
(3) neurology (4) and radiology. In this study, it was observed that the
corporate hospitals and big hospitals (hospitals with bed capacity above
99) invested in those medical departments. Thus we can infer that the
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hospitals with adequate capital base would invest heavy amounts in
complex medical services.
There are difficulties in making further analysis on the department
wise investment pattern. They are: some of the specialty departments may
have a separate set of medical equipment, exclusively for their use. Other
departments may not have a separate set of medical equipment. Besides a
set of medical equipment may be used by more than one medical depart
ment, including specialty departments. For example, medical equipment
in radiology will be used by almost all medical departments. Hospitals
maintained neither a record of the investment in medical equipment
categorised by medical department, nor the rate of utilisation of medical
equipment by each medical department. In view of these difficulties, the
pattern of investment had been analysed by classifying medical equipment
into four distinct groups.
(iii) Category-wise analysis-. Medical equipment were categorised into
following groups. They are: (a) Imaging equipment (eg. X-ray equipment,
Table 6: Frequencies of Hospitals Owning Each Category of Medical
Equipment - Aggregate Level (Madras, 1993)
Imaging
Surgical
39 (78)
50(100)
~
ICU and Therapy
Laboratory
24(48)’
39 (78) -
.
Note'. Percentages are given in the parantheses.
Table 7: Frequencies of Hospitals Investing in Each Category of Medical
Equipment (Ownership-wise) (Madras, 1993)
Ownership
Pattern
Imaging
Surgical
ICU and
Therapy
Laboratory
Sole proprietary
Partnership
Corporate
Total
14(56)
10(100)
15(100)
39 (78)
25(100)
10(100)
15(100)
50(100)
3(12)
6(60)
15 (100)
24 (48)
16(64)
8(80)
15(100)
39 (78)
Note: Percentages are given in the parantheses.
Table 8: Frequencies of Hospitals Investing in Each Category of Medical
Equipment (Bed-capacity-wise) (Madras, 1993)
Bed Capacity
Imaging
Surgical
1-10
11-30
31-99
Above 99
Total
8(53)
15(79)
11(100)
5(100)
39 (78)
15(100)
19(100)
11 (100)
5 (100)
50(100)
ICU and Therapy Laboratory
3(20)
6(32)
10(91)
5(100)
24 (48)
10(67)
14(74)
10(91)
5 (100)
39 (78)
Note: Percentages are given in the parantheses.
16
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ultrasound equipment, CT scanner and magnetic resonance imaging
equipment), (b) Surgical equipment (eg operation table, operation lamp,
suction apparatus boyle apparatus and diatheramy). (c) intensive care and
therapy equipment (eg, cardiac monitor, artificial ventilator, and therapy
equipment), (d) laboratory equipment (eg, autoanalyser, centrifuge and
microscope). The investment pattern in the four categories of medical
equipment was analysed by examining (A) the number of hospitals
investing in each category of medical equipment and (B) the amount of
investment in each category of medical equipment.
Both (A) and (B) are presented (a) at aggregate level (b) with respect
to ownership pattern and (c) with respect to bed capacity.
(A) Number of hospitals investing in each category: (a) At aggregate
level: In the sample, all the hospitals had surgical equipment. Next to
surgical equipment, many hospitals (78 per cent of hospitals) invested in
laboratory or imaging equipment. The number of hospitals investing in
intensive care and therapy equipment was the lowest (refer Table 6).
(b) Ownership pattern: AU the corporate hospitals invested in all the
four categories of medical equipment. In the group of non-corporate
hospitals, the number of hospitals investing in intensive care and therapy
equipment was the lowest. Next to the surgical equipment imaging
equipment ranked second for the partnership hospitals; whereas labora
tory equipment ranked second for the sole proprietary hospitals based on
the frequencies of hospitals investing in each category of medical equip
ment (refer Table 7).
(c) Bed capacity: Table 8 reveals that the percentage of hospitals
investing in each category of medical equipment increases as there is an
increase in the bed capacity of the hospitals. The hospitals with bed
capacity above 99 invested in all the four categories of medical equipment.
Almost all the hospitals with bed capacity 31 -99 (99 per cent) invested in
all the fourcategories of medical equipment. Among the hospitals with bed
capacity upto 30, the number of hospitals investing in intensive care and
therapy equipment was the lowest.
During the interview with the hospitals authorities, it was learnt that all
non-corporate hospitals started their medical services with investing in
surgical equipment. As they grew they began to invest in laboratory or
imaging equipment and later they invested in intensive care and therapy
equipment. Hospitals should have an adequate number of physicians and
their support round the clock for having an intensive care unit. The
requirement of heavy investment and the need for doctors’ support
throughout the day may explain the reason why there are only a few smaller
(sole proprietary hospitals or hospitals with bed capacity 1-10) with
intensive care and therapy equipment.
(B) Amount of Investment: Amount of investment was studied by
examining range of investment, total and average investment in medical
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Figure 1: Total Investment in Medical Equipment
Imaging
Surgical
Note'. Amount in lakhs of rupees.
18
IC and Therapy
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equipment. Figures 1-3 reveal the total investment and Figure 4 reveals
the average investment in medical equipment by sample hospital. The
range of investment gives the minimum and maximum investment in
each of the four categories of medical equipment. The average investment
was obtained by dividing the total investment by the respective frequen
cies of the hospitals investing in each of the four categories of medical
equipment.
(a) At aggregate level: The minimum investment in surgical, intensive
care and therapy and laboratory equipment was Rs 50,000 and the
maximum investment was Rs 2,00,000. In the case of imaging equipment,
the investment by a hospital ranged between Rs 2,60,000 and Rs 7,20,00,000.
One of the public limited corporate hospital has invested in magnetic
resonance imaging (MRI) equipment. This one instrument itself costs
Rs 6,00,000 and hence the maximum investment was high for imaging
equipment.
The investment in imaging equipment was the highest and the invest
ment in laboratory equipment was the lowest based on the total and average
investment. The average investment in imaging equipment accounted for
almost 50 per cent of the investment and the rest was shared by surgical
equipment, intensive care and therapy equipment, and the laboratory equip
ment in the same order (Figure 4). The average investment with respect to
surgical and intensive care and therapy equipment did not reveal the same
picture as that of total investment. The investment in intensive care and
therapy equipment ranked third based on total investment and it ranked
second based on average investment. The reason for this is that the investment
required for an intensive care unit is higher than that required for an operation
theatre. But the number of hospitals having intensive care unit was less than
the number of hospitals with surgical equipment.
(b) Ownership pattern: The range of investment was almost the same
in the hospitals categorised by ownership pattern. It was also observed that
a corporate hospital invested lesser amount in ICU and therapy equipment
than that of a sole proprietary hospital. Hence it can be inferred that besides
ownership pattern, organisation’s culture, ability of the board of manage
ment and various other factors peculiar only to individual hospitals may
also influence the investment decisions. Further studies can be undertaken
to identify those factors.
The investment in imaging equipment was the highest based on total
investment and average investment. The total investment in laboratory
equipment was the lowest for partnership and corporate hospitals, while
for sole proprietary hospitals the total investment in intensive care and
therapy equipment was the lowest. The average investment in laboratory
equipment was the lowest for all the categories of hospitals.
The investment by corporate hospitals in medical equipment was the
highest among that of the three categories of hospitals. The average
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Figure 2: Total Investment in Medical Equipment based on
Ownership Pattern
1,600
M Investment
Partnership
IC and Therapy
Imaging
Surgical
Note: Amount in lakhs of rupees.
20
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investment by them is 15 to 22 times (19.84, 18.5, 15.79, and 22.2
respectively in each category of medical equipment) as that of a sole
proprietary hospital and four to nine times (7,4.29,4.45,9.34 respectively
in each category of medical equipment) as that of a partnership hospital.
(c) Bed capacity: The range of investment varied with the bed capacity
of the hospitals. There was an increase in the maximum investment by
hospitals with the increase in the bed capacity. It was observed that the
minimum investment by the hospitals with bed capacity above 99 was
higher than the maximum investment in the three categories of equipment
excluding surgical equipment.
The investment in imaging equipment was the highest based on total
and average investment for all the categories of hospitals based on bed
capacity. The total investment in intensive care and therapy equipment
was the lowest for the hospitals with bed capacity upto 30 and the total
investment in laboratory equipment was the lowest for the hospitals with
bed capacity above 30.
The average investment in laboratory equipment was the lowest for all
the categories of hospitals except the category with bed capacity 11-30.
Average investment in intensive care and therapy equipment was the
lowest for the category of hospitals with bed capacity 11-30. It was also
observed that the average investment in surgical equipment was ranked
second for the hospitals with bed capacity below 100, while the average
investment in surgical equipment was ranked second for the hospitals with
bed capacity below 100, while the average investment in intensive care and
therapy equipment ranked second (next to imaging equipment) for the
category of hospitals with bed capacity above 99. So it can be inferred that
with the increase in bed capacity, hospitals invested more in intensive care
and therapy equipment than in surgical equipment.
The hospitals with bed capacity above 99 and corporate hospitals
invested more in intensive care and therapy equipment and less in
laboratory equipment comparatively, while reverse was done in smaller
hospitals (sole proprietary and hospitals with bed capacity 1-10).
Thus this study observed that the investment pattern of the hospitals
differed with the ownership pattern and size of the hospitals. But irrespec
tive of this categorisation all hospitals invested in surgical equipment; and
in terms of amount of investment, the total investment in imaging equip
ment was the highest.
Quantification of the investment pattern of the different types of
hospitals with respect to specified categories of medical equipment will
help any hospital to know its strategic position in the market in terms of its
investment. The affordability of corporate hospitals in investing in the
state-of-art medical equipment is observed and is quantified in relation to
hospitals with different ownership pattern. Besides, the quantification of
the investment pattern of hospitals will help medical instrumentation
21
Figure 3: Total Investment in Medical Equipment based on
Bed Capacity
industry to assess the demand position for different categories of medical
equipment.
Hospitals invest in a wide variety of medical equipment. A study on
investment decision in medical equipment may require categorisation of
all medical equipment into specified classes. This study has categorised
medical equipment into four distinct classes. Big corporate hospitals may
invest in costly medical equipment that are not related to the health care
needs of the people. Introduction of compulsory medical audit/technology
22
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Figure 4: Average Investment in Medical Equipment
Note. Amount in lakhs
assessment may require information on the commitment of resources to
capital equipment. For example, this study observed that the investment in
imaging equipment was the highest among the different categories of
medical equipment indicating the need for close monitoring of investment
in imaging equipment.
Concluding Remarks
The sample should cover more geographical regions - including rural
and urban for a better understanding of the health care industry in India.
The study highlights the impact of corporatisation on the investment
pattern of hospitals. On an average a corporate hospital invests almost 20
times more than a sole proprietary hospital. As huge resources are
committed in medical equipment, studies on resource management as
sume relevance. The present study makes a beginning for further studies
in the direction of efficient resource management of the hospitals in
India. Further studies on comparison of private and public sector hospitals
regarding investment pattern, rate of utilisation of medical equipment and
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23
the price charged by them can be undertaken. Understanding the invest
ment behaviour and resource management of private hospitals will help
policy-makers in (i) efficiently allocating the scarce resources to various
health services (ii) regulating the investment pattern of private hospitals
for providing health care suited to the needs of the people.
Notes
[I sincerely thank V R Muraleedharan and D Malathi for their encouragement and
guidance.]
Based on the list of companies in 1993 in the Office of the Registrar of
Companies, Madras. For the distinction between private and public limited
company, refer Indian Companies Act, 1956.
2 The list was based on the yellow pages of Telephone Directory (1992), Tamil
Nadu Medical Directory (1990), and the list of member-hospitals in the private
hospitals’ associations formed by Devaki Hospital, and Apollo Hospital.
3 At the time of survey, the total number of public limited corporate hospitals
was four.
1
References
Anantharaman S (1990): ‘Corporatisation of Health Care in India’, FRCHNewsletter, 4,4: 4-6.
Antia N H (1988): ‘High Technology in Medicine’, FRCH-Newsletter, 2, 5: 1-2.
Apollo Hospitals, (1992): Annual Report 1991-92, Madras.
Baru R V (1992): ‘Some Aspects of the Private Sector in Medical Care and its
Relationship with the Public Sector: A Study of Hyderabad - Secunderabad.’
Unpublished doctoral dissertation of Jawaharlal Nehru University, New Delhi.
Bhat R (1993): ‘The Pri vate/Public Mix in Health Care in India’, Health Policy and
Planning, 8, 1: 43-56.
Bronzino J D, Smith V H, Wade M L (1991): Medical Technology and Society: An
Interdisciplinary Approach, Cambridge: MIT.
CET, (1988): Handbook of Statistics, CET, Delhi.
Devaki Hospital, Annual Report 1991-92, Madras.
Duggal R, and S Amin (1989): Cost of Health Care, A Household Survey in an
Indian District, Bombay: FRCH.
Health Care India, (1990): Tamil Nadu Medical Directory, Hindu, Madras,
February 8, 1994.
ICMR-ICSSR (1980): Health for All: An Alternative Strategy, New Delhi.
Jesani A and S Anantharaman (1993): ‘Private Sector and Privatisation in the
Health Care Services: A Review Paper for ICSSR-ICMR Joint Panel on
Health’, FRCH, Bombay.
Johansen K S (1989): “Health Care Technology and Quality Around the World'
(169-174) in ISHA, (ed), Modem Technology for Health and Health Care,
ISHA, Bangalore.
Malar Hospitals (1993): Annual Report 1992-93, Madras.
Menon V (1994): ‘Medical Diagnosis - A User’s Eye View’, Business Line,
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February 1: 4.
Newhouse J P (1992): ‘Medical Care Cost: How Much Welfare Loss’, Journal of
Economic Perspectives, 6, 3: 3-21.
Reddy K N (1991): Health Expenditures in India, Institute of Public Finance and
Policy, New Delhi.
Satia J K, and N S Deodhar (1993): ‘Hospital Cost and Financing in Maharashtra’
(227-260) in Berman P and M E Khan (ed), Paying for India's Health Care,
Sage Publications, New Delhi.
Szczepura A K, and J A Stilwell (19b8): ‘Information for Decision-Makers at
Hospital Laboratory Level: An Example of a Graphical Method of Represent
ing Costs and Effects for a Replacement of Automated Technology in a
Haematology Laboratory’, Social Science and Medicine, 26, 7: 715-25.
Tamilnad Hospitals (1993): Annual Report 1992-93, Madras.
Whitted G S (1981): ‘Medical Technology Diffusion and its Effect on Modem
Hospitals’. Health Care Management Review, 6, 1:45-54.
Yesudian C A K (1988): Health Service Utilisation in Urban India, Mittal
Publications, New Delhi.
SSukanya
IIT, Adyar
Madras
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RJH
(New Series)
VolII: 1
1996
25
Famine and Epidemics
Insights from Major Famines in Late
19th and Early 20th Century
Arup Maharatna
Based on Indian historical famine experiences this paper seeks to
explain why and howfamines lead to epidemics and a mortality crisis.
It concludes that while a general course of rising mortality seems to
have often been shared by most diseases especially during the year
following drought, reflecting broadly the somewhat lagged effects of
nuritional deprivation on human health and survival, the exact timing
ofpeak mortalityfrom specific epidemic was probably partly shaped by
environmental factors (monsoon in the case of malaria, heat and lack
drinking water in the case of cholera) and partly by other influences
(eg, period of maximum congregations at relief camps causing maxi
mum spread of cholera and dysentery/diarrhoea).
I
Introduction
WHILE both famines and epidemics abound in the history of human
societies, much haziness prevails over hie question of a precise relation
ship between these two phenomena. This is perhaps partly because both
are the things of past for much of the globe today, and partly because both
connote a very complex social crisis. While a famine is generally believed
to bring in its wake epidemics and excess mortality, an independent
outbreak of epidemics — uninitiated by a famine — can presumably lead
to famine conditions.1 In this context the present paper, based on Indian
historical famine experiences, seeks to explore the former question of why
and how famines lead to epidemics and a mortality crisis.
In fact this question of famine-epidemic relationship is quite an old one,
argued (either implicitly or explicitly) that, since famine generally repre
sents an acute food shortage and mass starvation and undernutrition, a
mortality crisis that may develop, in its wake, out of various epidemics and
diseases (rather than due to direct starvation deaths) should deserve a
separate treatment on its own right. In particular, as the argument goes,
excess mortality due to outbreak of epidemics of various diseases should
not be branded as ‘famine mortality’.2 In this connection the issue relating
to the role of undemutrition in infectious disease and mortality has
understandably has been accorded much prominence in the literature.
While the role of undernutrition in lowering human resistance against
26
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infectious disease, and thus enhancing vulnerability to death, is tradition
ally held, the existence of such simple nutrition-epidemic relationship has
been questioned recently. First, in the medical literature the relationship
between under/malnutrition and infectious disease is well established as
synergistic [sec Scrimashaw et al, 1968; and Taylor-1985]. Since famine
causes a considerable decline in food consumption, undemutrition pre
sumably initiates the synergy leading increased mortality.3
However, famine represents not only acute nutritional crisis, but it also
entails severe social dislocation (eg, population movements, overcrowd
ing in relief camps, breakdown of sanitary standards). Indeed, evidence on
the subsistence crises of 18th century Europe suggests that the breakdown
of social relations — and the resulting migration, vagrancy and over
crowding in insanitary conditions, without the benefit of adequate welfare
provisions — was a major cause of mortality elevation even from diseases
(like smallpox) which are not normally identified synergistically with
malnutrition [see Post 1990]. If a higher mortality is found for the more
undernourished classes, this may, as the argument runs, result from poor
living conditions (eg, crowded shelter) and higher risk of exposure to
diseases ralher than undemutrition per se [Walter and Schofield 1989]. In
fact the nutritional status of a population depends not only on availability
of food but also on other non-food inputs including health care, basic
education, quality of drinking water and sanitary conditions [Dreze and
Sen 1989: 44]. Thus, increase in mortality during famine can occur either
through an increase in susceptibility to potentially fatal diseases or through
an increase in exposure to them or a combination of the two. Thus, while
undemutrition and associated debilitation appear to play some role in
raising susceptibility to fatal infections, increased exposure during famine
— through various social dislocations — seems to contribute to spreading
epidemic diseases. Indeed there is a continuing debate on th enature and
significance of the famine-nutrition-disease-epidemics-mortality rela
tionship.
Several of above issues relating to famine-epidemics relationship have
been raised recently in the context of Indian famines during late 19th and
early 20th centuries [eg, Lardinois 1985; Dyson 1991a; Arnold 1991;
Whitcombe 1993; Maharatna, 1994; and Maharatna, 1995]. Indeed India
with a fairly old census and registration system (which started around
1870s) offers a good opportunity for examining these issues.4 The wide
areas of the present-day Indian subcontinent experienced major famines in
1876-78, 1896-97, 1899-1900 and 1907-08 — each involving several
millions of excess deaths.5 They were all precipitated by severe droughts.6
Fairly heavy rains during the three monsoon months of July, August
and September, and some further rains in December and January, are
generally considered to be necessary for good harvests in most parts of
India. The former rains, resulting from the southeast monsoon, give what
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1996
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is known as the kharif cropping season; the latter rains result from the
northeast monsoon, and give the rabi season. Given the weather-depen
dence of south Asia’s agriculture, the failure of monsoon can mean the
threat of famine conditions an associated distress.
Using mostly registration data, Dyson analyses three major nineteenth
century famines in particular locations: the famine of 1876-78 in the
Madras Presidency, and the famines of 1896-97 and 1899-1900 in both
Central Provinces and Bombay Presidency [Dyson 1991a]. In these
famines the main mortality peak not only occurred late, but it also lasted
for a short span. “In each case it happened in or around August [of the year
following the drought] and was almost certainly related to the resumption
Table 1: Annual Rainfall in the Pre-famine Period and Famine Years,
Three Historical Famine Locations in India
Province/Period
Rainfall
(inches)
Province/Period
Bombay
Pre-famine
1872-75
1875
Famine years:
1876
1877
1878
Berar
Pre-famine:
1885-95
1895
Famine years:
1896
1897
Pre-famine:
1898
Famine years
1899
1900
58.49
60.12
Rainfall
(inches)
United Provinces
Pre-famine:
Average normal
1906
41.84
42.09
Famine years:
1907
1908
27.03
33.23
•
36.06
38.57
71.76
40.57
27.31
26.62
31.34
28.09
12.92
33.07
The number of years involved in calculating the normal average is not
always clearly specified in the official sources. However, sometimes the
averages are based on the 25 normal years. We have used the normal pre
famine averages given in the Gazettes for the United provinces.
Sources: The United Provinces Government Gazettes, Part II, Allahabad, various
years; The Bombay Government Gazettes, Part II, Bombay, various
years; Report on the Sanitary Administration ofthe Hyderabad Assigned
Districts, Hyderabad, various years.
Note:
28
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of monsoon rains” [ibid: 22]. Thus, the peak of famine mortality appears
to have matched the normal seasonal mortality pattern — occurring during
and just after the rains.
Apropos causes of famine mortality, the importance of ‘cholera’ and
‘fever’ mortality was apparent. ‘Dysentery and diarrhoea’ also seemed
significant in some cases. The famine mortality due to cholera (and
dysentery and diarrhoea) usually peaked somewhat earlier, broadly corre
sponding to the phase of maximum starvation and social disruption (eg,
wandering and crowding). However, as Dyson observes, ‘‘Malaria was
probably the most important single component of the main death rate
peaks which accompanied the return of the rains... when field activities
were resuming, employment prospects were improving, relief works were
being run down and people were returning home” (ibid:22). He however
adds that the occurrence of such a peak in famine mortality in a year
following drought did not depend entirely upon the resumption of rains —
since mosquitoes breeding and disease transmission depended also on the
“particular conditions of precipitation, temperature, atmospheric humid
ity etc”. Another possible mechanism for outbreaks of epidemic malaria,
particularly after the resumption of both rains and normal farm activities
(which in turn are supposed to improve the nutritional tatus of the
population), has been proposed to be ‘ipalaria refeeding’. According to
this hypothesis severe undernutrition may obstruct the multiplication of
malaria parasites in the human body and brake both the development and
transmission of the disease; conversely improvements in nutritional status
induces parasite multiplication, and hence contributes to major outbreaks
of malaria [ibid: 24, and also references cited therein].
Analysing the course of mortality during Madras famine of 1876-77
and Punjab famines of 1896-97 and 1899-1900 Whitcombe views ‘famine
mortality’ as resulting primarily from an outbreak of malaria epidemic the
scale of which, according to her argument, was largely determined by the
‘cruel’ whims of climate (eg, drought followed by excessive rains as in
Madras in 1877 and in Punjab in 1900) and consequent quantity of surface
water (including irrigation canals) and humidity and the resultant scale of
mosquito-breeding [Whitcombe 1993]. Even the excessive cattle mortal
ity during droughts has also been held partly responsible for outbreaks of
malaria epidemic, as anophelines, deprived of cattle — the most important
host population, ‘fed almost exclusively on humans’ [Ibid: 1178]. Indeed
Whitcombe concludes that “[a] crucial part of the explanation [for the
malaria epidemics] lies not in ‘famine’ as such, but rather in the peculiar
climatic character of the famine years...” [Ibid: 1177].
The present paper seeks to examine, in statistically more systematic
ways, several of these issues relating to famine-epidemics relationship in
the context of various Indian locations, which have hitherto remained
unanalysed. In particular we would include for our present study the
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famine of 1876-78 in Bombay Presidency, famines of 1896-97 and 18991900 in Berar, and the famine of 1907-08 in United Provinces of Agra and
Oudh (hereafter United Provinces).7 Table 1. which summarises rainfall
data for both prefamine and famine years, clearly indicates a considerable
shortfall in monsoon rains as being the proximate trigger behind each of
these famines. That there was a substantial excess deaths in all of these
locations can be guaged in terms of the difference between prefamine and
prime famine year death rates as shown in the last row of Table 2.
We shall, however, chiefly focus on the time path of mortality (includ
ing various causes) in course of the development of famine distress. The
sole economic index used here to reflect the build-up of famine is the
Table 2: Cause-specific Death Rates in the Pro-Famine Baseline and
Famine Years, Four Major Historical Famine Locations
Cause of Death
Bombay
1871-75 1877*
Berar
1891-95 1897*
Cholera
0.35
(1.79)
0.80
(4.12)
11.92
(61.40)
1.85
(9.52)
3.53
(16.51)
1.69
(4.62)
20.76
(45.90)
3.71
(9.66)
1.83
(4.81)
0.13
(0.34)
18.66
(48.96)
6.02
(15.81)
0.38
(1.97)
4.12
(21.21)
19.42
(100)
0.46
(0.42)
8.53
(22.90)
38.68
(100)
0.38
(1-00)
11.07
(29.06)
38.11
(100)
Smallpox
Fever
Dysentery/Dia
Plague
Injuries/accidents
All other
All causes
United Provinces
1901-04 1908*
3.49
(12.08)
0.21
(0.58)
22.64
(28.97)
10.20
(30.42)
0.91
(2.66)
0.15
(0.44)
24.55
(71.57)
0.63
(1.84)
2.16
(6.30)
0.46 ’
0.50
(0.58)
(1.40)
14.84'
5.40
(27.44) (15.74)
34.30
51.85
(100)
(100)
1.75
(4.56)
1.26
(6.02)
41.31
(90.94) •
0.41
(-1.19)
0.48
(-9.12)
0.57
(0.37)
6.95
(8.41)
52.73
(100)
1) The years marked (*) are the prime famine years. 2) All these rates are
based on constant denominators being the respective enumerated popu
lation under vital registration according to the last census prior to famine.
3) For all baseline periods, the figures in parentheses are the respective
percentage shares to total average deaths while for all the famine years
they are the respective shares to the total excess deaths. Total excess
deaths for each cause of death in a famine year have been calculated over
the respective average number of death during baseline period. 4) In
United Provinces plague began to be included as separate cause of death
only from 1902; so, baseline period average for plague is based on three
years, 1902-04. Respiratory diseases were included as a separate cause of
deaths only from 1905. Its percentage share to total excess deaths in 1908
w'as below 1 per cent.
Sources: Maharatna 1995.
Notes'.
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monthly movement of average provincial price of a staple foodgrain,
namely, jower (large millet). Although rise in foodgrain prices is not a
necessary condition for the existence of famine,8 dramatic price rises
appear to have been a common feature of these historical famines [see
Dreze 1990: 16-17; also Bhatia 1967]. And, rises in the prices of staple
food have widely been used as proxies for the timing and severity of
famines. Weekly prices of different food-grains for the districts of these
provinces are available in the respective provincial Gazettes (except for
Berar).9 Accordingly averages of these district-level prices for the weeks
ending in the middle of each month have been calculated, and they are
taken here as the monthly provincial foodgrain prices.
As for mortality data we too will use demographic information pro
vided by India’s vital registration system. Since the inception of the
registration system the Sanitary Commissioner of each province was
responsible for producing an annual report containing quite detailed
registration data. The information on vital events was collected by village
watchmen (‘chaukidars), each being responsible for a particular jurisdic
tion. Although under-registration of vital events was one major deficiency
of registration data, this should not seriously affect our present analysis of
temporal (ie monthly) pattern of mortality.
When analysing short-term mortality response to famine it is important
to recognise seasonality in the ‘normal’ annual distribution of registered
deaths. The monthly data show a distinct seasonal variation in the
registered numbers of deaths during the pre-faming baseline period (see
Maharalna, 1995 Appendix A). To discount for such seasonal influences
on the monthly mortality effects during the famine we have constructed
monthly mortality indices (MI). These are the monthly ratios of numbers
of deaths to the respective pre-famine baseline average figures (the base
being taken as 100). Consequently our indices reflect proportional (rather
than absolute) changes in deaths from the respective baseline monthly
numbers.
Registered deaths were usually classified under five major causes:
cholera, dysentery/diarrhoea, smallpox, fevers, injuries and all others.
Subsequently plague and respiratory diseases were also included. Distri
bution of registered deaths from each specified cause — both by district
and by month — is available. There is no doubt that cause of death data are
not accurate especially because village officials can hardly be assumed to
have had much skill in assigning deaths to appropriate categories. How
ever, statistics for categories such as cholera, smallpox, plague are gener
ally thought to have been relatively reliable because of their very distinc
tive symptoms. Fevers — under which normally most deaths are classified
— seem to have been a catch-all category in the sense that several diseases
which cause temperature are likely to have been included under this
heading. On that count, a certain degree of misclassification of deaths
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> /
between fever and dysentery/diarrhoea seems possible. Some serious past
investigations of malaria have also shown that malaria often predisposes
to respiratory diseases and dysentery/diarrhoea [Census of India 1911, vol
XV, Part I, p 45]. As the official report on the United Provinces famine of
1896-97 also noted, “[t]his heading [fever] is very general and probably
includes most cases of pneumonic and lung diseases, so fatal to people of
reduced stamina (especially the young and very old) employed on relief
works and elsewhere” [Government of North-Western Provinces and
‘Oudh 1897: 135]. However, malaria is generally taken to have been the
most important component of the fevers category. A usual surge in fever
mortality during the monsoon and post-monsoon months has often been
attributed to the increased incidence of malaria following the rains.
II
Bombay Famine of 1876-78
The Bombay famine of 1876-78 began with the failure of both the
summer and autumn monsoon rains during 1876. The summer monsoon
of 1877 also failed. Drought in two consecutive years resulted in a severe
and prolonged famine in much of the Presidency. Figure 1 traces the
Table 3: Estimates of Cross-correlations with the Monthly Time-series(differenced) Data on Food Price and Mortality Indices: Ten Major
Historical Famine Locations
Famine Locations
The Highest Cross-correlation Coefficient
between Monthly Variations in Food
Prices and Mortality Indices with the
Corresponding Lags (in months)
r
lag
1 Madras famine, 1876-78, n=36
2 Bombay famine, 1876-78, n=36
3 Berar famine, 1896-1897, n= 16
4 Bombay famine, 1896-1897, n=24
5 Central Provinces, 1896-1897, n=24
6 Berar famine, 1899-1900, n=24
7 Bombay famine, 1899-1900, n=24
8 Central Provinces, 1899-1900, n=24
9 Punjab famine, 1899-1900, n=29
10 United Provinces, 1907-08, n=30
0.39*
0.24
0.28
0.32
0.42
0.28
0.38
0.42
0.33
0.26
2
0
6
2
0
4
6
0
3
3
Note'. 1)* significant at less than five per cent level.
2) The cross-correlation coefficients with the expected directions in lags are
considered here.
3) n = number of observations.
Source'. See Maharatna, 1995, Table 2.7.
32
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monthly evolution of the average price of an important staple food, jower
(large millet) and the mortality inices (M1). Because the prices of foodgrains
were expressed in terms of quantities (seers) per one rupee, we have
reversed the direction on the Y-axis when plotting these prices.
It appears from Figure 1 that the average price ofjower was already high
by the beginning of 1876 compared with the same period of 1875. It then
rose steadily to reach a peak in September of 1877 and stayed very high
until the end of 1879. It then fell rather sharply during 1877 along with a
similar rising trend in mortality. It is noteworthy that both the highest food
price and MI coincided in the month of September 1877. Although the
closing months of 1877 and the first three months of 1878 witnessed a
reduction in MI (from its peak), the MI moved ina sharply adverse
direction again during June-September of 1878.
Relief operations in this famine started only around November of 1876.
Given the employment losses and high prices from the beginning of the
kharif season (June), the very scant start of relief in November may well
be considered as late [see Maharatna, forthcoming, ch 2).
Table 2 presents the changes in the cause-specific death rates and their
relative importance. It shows that deaths from cholera were proportionate
ly more important in the excess mortality of both 1877 and 1878 than in
the baseline.period. But. fever deaths constituted the largest share of
mortality in both normal and famine years — especially 1878. Figure 2
plots the monthly numbers of deaths from cholera, fever and bowel
complaints. It shows that deaths from these causes were all rising from
about August; deaths from bowel-complaints peaked in September; and
the fever deaths two months later in December of 1877. Thus, while
cholera mortality mostly occurred during the pre-monsoon and early
monsoon months, mortality from bowel-complaints and fever (presum
ably in part malarial) tended to peak during and after the monsoon. This
said, it also seems significant that all major causes of death show a similar
rising pattern from the beginning of 1877. Although the fever mortality
peak in November of 1877 may be related to the unusually heavy rains of
‘October (see Figure 3), its sharp rising trend throughout the year is
noteworthy. Misclassification of deaths is likely, especially at this time
when the registration system was still in its infancy. It seems probable that
some deaths from cholera, dysentery/diarrhoea were recorded under
fevers category. However, as the Sanitary Commissioner of Bombay
Presidency in his annual report for 1877 writes, “... [it] is impossible
therefore to say how many of these [fever] deaths were due to malarial
fevers, though I think there is but little doubt that the mortality recorded
under this heading in the famine districts, was at all events during the latter
half of the year, principally due to remittent fever” [Government of
Bombay 1878: 176]. By ‘remittent fever’ he seems to have had malaria in
mind.
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Thus, excess mortality from fevers (which has sometimes been expected
to occur after the resumption of rains following a drought year) can happen
even in a second successive year of drought. As Figure 3 shows, in terms of
rainfall 1877 was little better than 1876. Assuming that fever mortality
represented much of the malarial deaths, this implies that the malaria
epidemic in 1877 was largely related to famine and undemutrition. In 1878,
the MI initially peaked in May — though it rose slightly higher still during
the period up to September (see Figure 1). In 1878, the cholera deaths peak
in June was followed by bowel-complaints deaths peak in August, which was
followed by fever deaths peak in November (see Figure 2). The delayed
fever-mortality peak in 1878 was probably related to te above-normal rainfal 1
especially in August and September (see Figure 3). Figure 2 thus suggests that
in both 1877 and 1878 cholera deaths tended to peak around the beginning
of monsoon; bowel-complaint deaths peaked in the mid-monsoon period;
and fever deaths peaked after the end of the monsoon.
Ill
Berar Famines of 1896-97 and 1899-1900
The Famine Commission of 1880 described Berar as “one of the parts
of India particularly free from apprehension of calamity of drought”
[quoted in Census of India 1901, Volume VIII, Part 1: 30]. However, in
1896-97, the province fell under the grip of a serious famine. Berar
experienced a considerable shortfall of rain in 1895; and the successive
drought and consequent crop failure in 1896 brought famine conditions.
Unfortunately, Berar experienced another and more severe drought in
1899 when annual rainfall amounted to less than one-third of its normal
level. The crop output during 1899-1900 was estimated to be only 2.5 per
cent of the average outturn during the preceding ten years (excluding
1896-97) (Ibid:31). The famine of 1896-97 was described as a “famine of
high prices rather than of scarcity of food” [Crawford 1901, Volume 1:2].
However, the 1899-1900 famine was both much more severe and wide
spread throughout the province.
Figure 4 presents the monthly series of the MI and the average price of
jower during 1895-1901 could not be found. The Mis in 1895 show some
excess over the baseline level.Again, the beginning of 1896 witnessed a
sharp rise in mortality which peaked around May and then fell fairly fast.
However, mortality during the closing months of 1896 and the first three
months of 1897 was below its pre-famine baseline level — although food
prices were rising dramatically (see Figure 4). The MI peaked rather
sharply during the monsoon period of 1897, and reached a maximum in
September when food prices also peaked. Peak famine mortality, thus,
seems to have lasted for only a short duration, mainly, the latter half of
1897. Among the specified cause of death, cholera, dysentery/diarrhoea,
34
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and fever were the major killers during he baseline period (see Table 2).
However, comparing relative shares of different causes indicates an
increased importance of cholera, smallpox and dysentery/diarrhoea in
total excess deaths in 1897 and also a fall in the relative importance of fever
deaths. Figure 5 shows monthly movements in the number of deaths from
these three major causes. It suggests a quite similar time patternof deaths
from all these diseases in the main mortality year. While deaths from
dysentery/diarrhoea, and from fever, peaked in September of 1897, the
cholera peak occurred just one month before in August. As Berar’s
Sanitary Commissioner in his report for 1897 writes, “[i]t was the experi
ence at all our relief centres that after the rains set in sickness greatly
increased, especially fevers and bowel-complaints. Indeed, the most
common termination of life in those debilitated by famine was diarrhoea
or dysentery, aggravated by damp and exposure after the setting in of the
South-West monsoon. Cold and damp had a most detrimental effect upon
the starving poor, and those in a physically reduced condition from chronic
insufficiency of food” [see Government of Hyderabad Assigned Districts
1898:7]. The Report also noted that ‘‘the number of deaths from starvation
returned by village registrars numbered 377. These take no account of the
deaths at poor-houses due to diarrhoea, dysentery etc, primarily the cause
of chronic deprivation of food” [Ibid: 32]. In this connection it would be
useful to quote the Sanitary Commissioner’s criticism of the official view
on starvation deaths:
the official definition of death from starvation signifies that so long as a person has
food before him, or the means of procuring it, he cannot die from starvation. This
is a mistake, for physiologically the human body may be starved of every essential
to its vitality in spie of the most nutritious food if digestion has been so impaired
by the effects of chronic starvation that nutrient cannot be assimilated and this
form of starvation caused directly or indirectly many deaths throughout the
province and explains the excess mortality under ‘other causes’ [Ibid: 32-33].
It is also notable that in 1897 — a year of huge fever-mortality — there
was a marked decline in admissions from fever in several medical
institutions of the province. According to the Sanitary Commissioner for
Berar, this largely reflected the fact that most of the excess fever mortality
in that year occurred ‘‘amongst the famine-stricken poor, with whom the
question of medical relief was secondary to that of food...” [Ibid: 16]. All
these considerations suggest that the general course of mortality rise
during the famine was largely determined by the general course of famine
distress and its lagged effects on human survival, being, of course, partly
mediated by both environmental factors (eg, post-monsoon surface water,
humidity) and social disruptions (eg congregation at relief camps, popu
lation movements).
The mortality was below its baseline level throughout the post-famine
year of 1898. While mortality was somewhat higher than its normal level
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Figure 1: Price of Jower and Mortality Index (MI) by month,
Bombay, 1875-80
Ranges of variation: MI, 94 (October 1880) to 261 (September 1877); Jower price,
26.12 (January 1875) to 8.3 seers per rupee (September 1877).
Sources: see text.
during the early months of 1899, interestingly, it was below its baseline
level in late 1899 — when the food price had risen dramatically (see Figure
4). As in 1896, this mortality improvement during the initial phase of
famine may, as suggested by the Sanitary Commissioner in his report for
1900, have been due to the drayness of the weather and the consequent
lower incidence of fever [see Government of Hyderabad Assigned Dis
tricts 1901: 10]. Moreover, there may well be a time lag between the onset
of famine and it excess mortality outcome. Note that the price of food
remained extremely high throughout 1900.
36
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Figure 2: Monthly Distribution of Deaths by Cause Bombay 1876-78
Sources: see Table 2.
Figure 3: Monthly Distribution of Rainfall in Normal and
Famine Years, Bombay 1876-78
Rainfall (inches)
1876
1877
— Average 1872-75 actual
1878
•
Sources: see Table 1.
From the beginning of 1900 the MI rose drastically to reach a huge
climax within a few months — peaking in July (see Figure 4). It then
declined with similar rapidity and by the end of 1900 mortality came
down to its baseline level — remaining below this level throughout 1901.
The relief provision reached a maximum in June of 1900, after which it
fell sharply — probably due the resumption of rains and normal farm
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Figure 4: Price of Jower and Mortality Index (MI) by month,
Berar, 1895-1901
—------- 1_________I_________ I_________ I_________ I_________ I_________ L_
1895
1896
1897
1898
1899
1890
1901
Ranges of variation: MI, 43.9 (August 1898) to 423.5 (July 1900); Jower price,
33 (April 1899) to 7 seers per rupee (July 1897).
Sources: see text.
activities. In contrast to the famine of 1896-97, in this second famine the
rise in the number of persons on relief better corresponds to the rise in the
MI [for details see Maharatna, forthcoming: ch 2].
As Table 2 suggests, there has been, like the former famine, an
increased importance of cholera, dysentery/diarrhoea, and a reduced role
38
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Figure 5: Monthly Distribution of Deaths by Causes Berar 1896-1900
— Cholera • • -Fever - Dys/Dia
Sources: see Table 2.
Figure 6: Monthly Distribution of Rainfall in Normal and
Sources: see Table 1.
of fever mortality in accounting for overall excess deaths in 1900. Indeed,
as Figure 5 shows, deaths from cholera, dysentery/diarrhoea and fevers all
tended to rise steadily from the closing months of 1899. According to the
Sanitary Commissioner for Berar many cholera deaths (about 10,000 by
his estimate) were registered under other heads [Ibid: 8]. While cholera
deaths peaked in July of 1900 — coinciding exactly with the highest MI
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— the other two causes reached a maximum just one month later in August,
when deaths from dysentery/diarrhoea actually exceeded the number of
fever deaths. Therefore, the indications are that the huge elevation in
mortality which lasted throughout 1900 did not result mainly from an
outbreak of malaria following the resumption of rains. In an extract from
the Proceedings of the Resident at Hyderabad No 2936 dated August 12,
1901, much of the faminemortality was attributed to the prevalence of
cholera and bowel-complaints due to “excessive consumption of rank
vegetables and foul water after the first heavy rain of the monsoon”
[Quoted in Crawford 1901, Volume I: 2]. In fact, Mr J A Crawford, the
Commissioner of Berar in his Foreword to the Sanitary Commissioner’s
report for 1900 specifically stated that “[t]he death rate in Berar in 1900
was increased largely by the famine” [Government of Hyderabad As
signed Districts 1901: no page number].
The scanty rainfall and the related dryness of weather may have sup
pressed the expected post-monsoon peak in fever mortality in both 1896 and
1899. However, the occurrence of peak fever mortality during the pre
monsoon months in 1900 is of interest. This, as reported by the Sanitary
Commissioner of Berar, was due in large part to influenza and other simple
fevers. As he wrote in his report for 1900, “[a]s the year 1900 advanced,
‘influenza’ became prevalent, and deaths from it were registered under the
head ‘fevers’, and the number of cases of fevers also gradually commenced
to increase —- mostly of the type of simple continued...”. This, according to
him, was largely due to ‘unwholesome water and food’ consumed by people
who lost stamina and were exposed to heat and rains. But after the resumption
of rains, the malarial fever with hepatic complications and jaundice symp
toms increased till the end of the year [Ibid: 10-11]. Indeed there is more
evidence in the context of other locations that famine may cause deaths from
‘some fatal types of fever other than malarial fevers, aggravated by the
debilitating effects of want of food’ [see Guz 1989: 204]. Thus, like the
former famine, the monthly data on cause-specific deaths during the famine
of 1899-1900 also indicate the effects (presumably lagged) of the general
course of nutritional deprivation on the general course of mortality increase,
although environmental and other factors seem to have influenced the exact
timing of the peaks from specific causes. In this connection, note excess
rainfall in August of both 1897 and 1900 — a fact which may have
contributed to mortality peak in the following months.
IV
United Provinces Famine of 1907-08
The famine of 1907-08 in United Provinces was brought about by the
premature cessation of monsoon rainfall in August of 1907, following a
generally poor start to the monsoon. In large parts of the province the rains
40
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Figure 7: Figure 1 Price of Jower and Mortality Index
(MI) by month, United Provinces, 1906-1910
_____________ I____________ I____________ I____________ 1____________ L__
1906
1907
1908
1909
1910
Ranges of variation: MI, 84.5 (June 1909) to 244.5 (November 1908); Jower
price, 19.6 (April 1907) to 7 seers per rupee (December 1907).
Sources', see text.
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Figure 8: Monthly Distribution of Deaths by Causes
— Cholera---Fever -Dys/Dia
Sources-, see Table 2.
-Plague -Smallpox
lasted for only 5 to 8, instead of their usual 12 weeks. The failure of the
kharif season in 1907 against the backdrop of some partial weather failures
in the preceding two years ultimately produced famine conditions.10
Drought continued until January of 1908, and there was a very small rabi
crop in early 1908 as well. According to the official report on the famine
the kharif harvest was only 31 per cent of normal output and only about 60
per cent in the case of rabi production [Government of United Provinces
of Agra and ‘Oudh 1909a: 18]. The net loss in food crops in the Province
in 1907-08 was estimated to be seven million tons.
The prices of food grains, which were already high during the early
part of 1906 (owing to the partial drought and famine during 1905-06)
declined until early 1907, but then rose sharply to reach a peak around
December (see Figure 7). Due to the persistence of high prices during the
pre-famine period, people who were net purchasers of foodgrains,
probably were already distressed and thus less able to cope with this fresh
round of price rises in 1907. There was somewhat delay in the com
mencement of relief operations. This was probably because of the
official assumption that large advances given early in the autumn (for the
sowing and irrigation of the spring crops) and the ‘prompt and liberal’
suspensions and remissions of land revenue encouraged people to
continue the sowing of spring crops until a much later period than was
usual [Ibid: 28].
As Figure 7 shows, mortality was somewhat above the baseline normal
level during most of 1906. There was a considerable MI peak during the
first half of 1907 — largely due to the prevalence of plague.
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Figure 9: Monthly Distribution of Rainfall in the Normal and
Famine Years, United Provinces, 1907-08
Sources-, see Table 1.
It is clear both that the MI peak of this famine was of rather short
duration and that it was largely accounted for by a sharp rise in fever
mortality during the last months of 1908, ie, after the resumption of
monsoon rains (eg, see Figures 7, 8 and 9). As Table 2 also shows,
although there was an increase in the relative importance of cholera in
1908, about 91 per cent of the total excess deaths were recorded under the
fever category. Note too that there was no rise in the mortality from
dysentery/diarrhoea, and according to the Sanitary Commissioner for
United Provinces “this no doubt to some extent is due to the measures
adopted and to the judicious feeding of the people on the relief works
especially young children and suckling mothers” [Government of United
Provinces of Agra and Oudh 1909b: 14]. Cholera deaths peaked in
September, which usually marks the end of the monsoon; fever mortality
rose steeply in September and peaked in November (see Figure 8).
Although the cholera death peak thus preceded the fever mortality peak,
both seem to have followed the same broad time pattern and occurred
rather late, and note also that it occurred at a time when relief was nearly
over. The sharp and huge fever deaths peak, according to the official
reports, corresponds to a malaria epidemic [ibid: 11; see also Govern
ment of United Provinces of Agra and Oudh 1910a]. There has, indeed,
been an enormous rise in the attendance of malaria patients at hospitals
and dispensaries: it rose from an average annual figure of 625,885 during
1904-07 to 1,369,583 in 1908 [see the Sanitary Department Resolution
dated July 7, 1910 quoted in Government of United Provinces of Agra
and ‘Oudh 1910b: 1].
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V
Monthly Movements of Prices and Mortality
The previous diagrams generally suggest that the monthly Ml appears
to have had somewhat positive relationship with monthly movements of
food price. However, coming to a precise view about the appropriate lags
involved in this relationship is difficult on the basis of diagrams alone.”
Cross-correlation coefficients may help us to explore the precise nature of
lags in the various time-series data on food prices and the MI.
A cross-correlation function describes the extent of correlation be
tween two time series Xt and Yt, allowing for different lags in the series.
For each integer k (positive or negative), the cross-correlation measures
the correlation between Yt and the shifted series Xt k (or equivalently,
between Y(+k and Xt) (see Fornum and Stanton 1989). The calculation of
the cross-correlation function is as follows:
rxy (k) = sample cross-correlation coefficient of lag k
£t=1 (Xt-X) (Yuk-Y)
V E =1 (X - X)2, Sl=I (Yt - Y)2
k = ...-3, -2.-1,0, 1,2, 3..
T = series length
X = mean for Xt
Y = mean for Y
However, it is important to note that the cross-correlation function can
only be easily interpreted if both time-series are made stationary.12
Working with first differences is one way of making the series stationary
for this purpose. Moreover, the cross-correlation coefficient only de
scribes the linear association between the two series. However, the
estimated cross-correlations obtained with different lags help one to make
inferences about the direction of causality and, of course, the approximate
length of te appropriate lags.
It has become clear from all the famines examined so far that the lag in
the time-series of food price is only expected to produce correlations with
the MI series, and not the other way round. In other words, the direction
of causation is fairly clear. However, this relation does not seem to hold in
the context of non-famine period too. For example, we have noted some
occasions of considerable excess mortality in non-famine years which
were unaccompanied by price rises [eg, United Provinces in 1907, Bombay
in 1875, and Punjab in 1902. For furthr details on this see Maharatna,
forthcoming, Ch 2]. Consequently, we have restricted ourselves here to
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time series data mostly for the officially declared famine years when
calculating cross-correlations. We present estimates based on differenced
time series data for 10 major famine locations. And the main results are
summarised in Table 3.
Table 3 shows that the cross-correlation coefficients between food
prices and the MI are all in the expected directions. However, the
correlations are rather weak; also the results suggest that fairly long lags
(of at least several months) are sometimes involved. Indeed in some
famines this relationship appears to be very weak (eg, the United Provinces
famine of 1907-08 and Central Provinces famine of 1899-1900). This
weak association seems consistent with the fact (as seen above) that peak
famine mortality often occurred within a relatively short time span when
prices, though high, were not rising any further. Despite several issues
involved in the interpretation of the estimated cross-correlations, the
findings in Table 3 generally confirm the conclusions drawn on the basis
of the diagramatic presentations above.
The diagrams (not shown here) plotting the cross-correlation coeffi
cients (ie, ‘cross-correlograms’) involving lags of up to six months
suggests that the cross-correllogram for the famines of 1876-78 and 189697 generally has a quite consistent pattern, attaining their highest positive
values around lags of roughly 0 to two months. However, the famines of
1899-1900 and 1907-08 show relatively weak and longer lag effects of
food price movements on the mortality time path. This weakening in the
immediate response of mortality to price rises after the 1870s may be
thought of as consistent with an increasing growth and benevolence of
relief policy. Indeed, it has been argued by several authors that a temporal
moderation of excess famine deaths can at least partly be attributed to
increasing liberalisation and enhancement of relief policy through time
in India [see Klein 1984; McAlpin 1983, especially Chapter 6; and also
Dreze 1990].’3
Concluding Discussion
The major findings from our analysis of the monthly time-series data
— both diagrammatic and statistical — can now be reviewed. First, an
early indication of the development of famine has almost always been
reflected in soaring food prices. This period of rising prices represents
onset of the ‘starvation phase’ when people presumably pass through acute
economic distress, and various social disruptions ensue. In this connection
we may note the relatively weak positive link between the movements of
food prices and MI during famine. The reason seems to lie in the fact that
the main famine mortality peak usually occurred relatively late in the
process (with some lag after the beginning of distress), and it also occurred
within a relatively short span of time (ie, epidemic phase) when food prices
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45
were either stabilised at a high level or were only starting to decline.
Moreover, food prices often continued to remain quite high when mortal
ity went back to normal levels.
However, interestingly, we have discovered occasions when outbreaks
of epidemics resulted in an apparent mortality crisis, independent of any
immediate subsistence crisis. This does not seem to imply that the
outbreaks of epidemics that accompanied famine can be treated as inde
pendent of famine and the associated mass nutritional stress.14 Epidemics
of some diseases are rather easily recognised as famine-caused: for
example cholera and dysentery/diarrhoea [see eg, Arnold 1988, 1991;
Crawford 1991]. On the question of epidemic malaria, which seems to
have accounted for the bulk of excess mortality in most of the famines
considered here, three hypotheses (which are not mutually exclusive) may
be classified as follows:
(a) A relatively low incidence of malaria owing to dryness during the
drought year reduces the population’s immunity level; and this enhances
the chances of a malaria epidemic when the rains resume in the following
year [see eg, Dyson 1991a, and de Waal 1989b: 92].
(b) Since a fever mortality peak appears to have often occurred after the
resumption of rains when (along with the beginning of normal farm
activities) people presumably begin to experience an improvment in their
nutritional level, it may be an outcome of the ‘refeeding of malaria' [eg,
Dyson 1991a; Whitcombe 1993].15
(c) In view of a strong correlation found (historically) between food
scarcity and fever (or malaria) mortality in parts of the Indian sub
continent, the occurrence of malaria epidemics in wake of famines may be
primarily be attributed to acute nutritional stress and its debilitating effects
[eg, Christophers 1910; Zurbrigg 1988].
Several issues arise in assessing relevance of the above hypotheses.
First, the absence of malaria as a separate category of death in the reports
of the Sanitary Commissioners always leave some doubt as to whether the
fever mortality peak does indeed represent epidemic malaria. As already
indicated, several other diseases may have been misreported and included
in the fever category. For example, on the basis of very careful diagnostic
investigation of famine victims admitted to hospitals during the Madras
famine of 1876-78, Dr A Porter found that a considerable number of
registered fever deaths were actually due to pneumonia — which was not
a recognised cause of death in the registration system. Indeed, in the
postmortem room he found pneumonia (“in a more or less advanced
stage”) in more than 25 per cent of all cases [Porter 1889: 131].
In the Punjab famine of 1899-1900 too, there is a rather strong
indication that the registered mortality from fever in 1900 includes a large
number of cholera deaths. After an enquiry into high death rates in 1900
in Hissar — a very severely affected district in Punjab — the deputy
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commissioner writes on September 1, 1900:
...Rawalwas, Hissar Tahsil 12 deaths from cholera were reported, whereas
36 actually occurred, and that while 22 cases of fever were reported only 3
actually occurred... The total for the tahsil [Bhiwani] accordingly shows 187
actual cholera deaths to 82 reported, and 90 fever deaths against 194 reported.
The explanation seems to be that they [ie, choukidars] often dread the enquiry
and trouble necessary on reported outbreak of cholera and do all in their
power to minimise the matter or to avoid reporting it at all [Government of
Punjab 1901: 170-171].
Besides, in the case of the Berar famines, we have also seen that the
highest number of deaths recorded during the month of peak MI was under
the dysentery/diarrhoea category rather than that of fever. However, all
this said, it is difficult to ignore the fact that a large number of the registered
fever deaths very often represented malaria mortality, especially during
the post-monsoon months. Also, some malaria deaths may have been
entered under other headings as well.
The hypothesis (a) above can be subject to doubt in the light of our
evidence on at least two counts. First, the Bombay famine of 1876-78
shows that a fever mortality peak can certainly occur even in a year of
drought (eg, 1877) (see Figures 2 and 3). Second, the experience of the
Berar famines of 1896-97 and 1899-1900 shows that the time path of
mortality movements was similar for all major causes of death (Figure 5
above). This implies the existence of a more general time pattern of famine
mortality rather than the seasonality of malaria mortality per se. In fact, a
broad general time pattern of rising mortality in course of the prime famine
year seems to have often been shared by the major causes of deaths,
although the exact timing of peak mortality from specific diseases such as
cholera, dysentery/diarrhoea, and fever does not necessarily coincide.
There are also some difficulties regarding hypothesis (b). First, since
food prices almost always appear to have stayed very high during and even
beyond the monsoon months in the year following drought, and since
normal harvesting does not take place until lae of that year, it seems
uncertain whether a perceptible improvement in nutriional status of the
affected population occurred during the period of peak fever mortality.
Besides, the available evidence on the malaria refeeding hypothesis
suggests that even though the attack rate rises with refeeding (and the
consequent recovery in nutritional level) the actual mortality rate probably
depends considerably on the previous level of undemutrition. Reviewing
the relevant literature, Tomkins and Watson concluded that while a low
plasma nutrient level seems to inhibit the rate of (malaria) pathogen
multiplication, “in every situation this has to be balanced against the effect
of malnutrition on the immune host response’’ [Tomkins and Watson 1989:
24]. In fact there is no evidence that malnutrition is advantageous during
the recovery from infection.
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Indeed, there are indications that poor people were more vulnerable to
malaria mortality. For example, much greater malaria death rates were
reported by Chistophers for the poorer classes in the late nineteenth and
early twentieth century Punjab [Christophers 1910: 38-38]. The report of
an investigation of the epidemic of malarial fever in Assam during 1896
concluded that “the poor suffer in a disproportionate degree, and have less
chance of recover)', owing to their living in more crowded dwellings, and
o a deficiency of nourishing diet especially of a nitrogenous nature”
[Rogers 1897: 37]. In a recent study of young children admitted to
hospitals in the context of an African food crisis, undemutrition, though
seemingly protective against clinical malariaa, appeared to be associaed
with a higher overall risk of death [de Waal 1989b: 103]. Attention may
also be drawn to the finding of an early celebrated study with 100,000
English prisoners over four years — a study which is probably considered
to be an important event in the history of the ‘refeeding hypothesis’. This
study reported that while the sickness rate was found far higher for the
better-fed group, those receiving least food had four times higher mortality
than those consuming most food [see Murray and Murray 1977:472-473].
Although information about the class composition of mortality during
India’s past famines is particularly scant, relief records and contemporary
accounts indicate that the main rural victims were often the poor classes —
small cultivators, agricultural labourers and petty artisans [Currie 1991;
and also Ambirajan 1989].
All this, however, does not mean that the malaria epidemics that
accompanied several of these major Indian famines occurred solely due to
famine-caused food shortage and undemutrition — unrelated to rainfall,
temperature humidity and othr environmental, ecological and epidemio
logical conditions.16 The huge post-monsoon elevation of fever mortality
in several Indian famines — appearing often as a magnification of the
normal seasonal pattern — suggest a mediating role played by environ
mental factors. In many cases, low mortality in the drought year itself has
been attributed to a relative absence of mosquitoes and malaria [Dyson
1991a; Whitcombe 1993]. Furthermore, the fact that some famines appear
to have involved very small malaria epidemics is sometimes used to cast
doubt about the inevitability of a link as is proposed in (c) [see eg,
Whitcombe 1993].
However, resolving this question fully is probably impossible. And it
may indeed involve controlling for several factors such as the severity of
failures in both rains and crops, the nature of relief, and so on. Forexample,
in the Punjab famine of 1899-1900, although rainfall recovered in the yearof peak mortality (ie, 1900), the crop-output turned out to be even lower
than in the preceding year of drought.17 Christophers, while discussing the
major factors determining the recurrence of epidemic malaria in Punjab,
states that “[t]he facts certainly support the view that scarcity is a factor
48
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determiningto a large degree the situation, extent and intensity of epidem
ics” [Christophers 1910: 39]. He also recognised the role of rainfall in
creating favourable conditions for mosquito-breeding. The basic argu
ment is succinctly summarised by the following statement in the context
of ‘a most catastrophic malaria epidemic’ which followed the drought in
1934 in Sri Lanka: “Rainfall made the mosquitoes more abundant; famine
made the people more succeptible” [Harrison 1978: 202].
To conclude: while a general course of rising mortality seems to have
often been shared by most diseases especially during the year following
drought, reflecting broadly the somewhat lagged effects of nuritional
deprivation on human health and survival, the exact timing of peak
mortality from specific epidemic was probably partly shaped by environ
mental factors (monsoon in the case of malaria, heat and lack drinking
water in the case of cholera) and partly by other influences (eg, period of
maximum congregations at relief camps causing maximum spread of
cholera and dysentery/diarrhoea).
Notes
[This paper draws heavily on chapter 2 of the author’s forthcoming book, The
Demography of Famines: An Indian Historical Perspective, (New Delhi: Oxford
University Press). The author is grateful to Tim Dyson for his many useful
comments and suggestions on several sections of this paper. This paper was
presented at the 18th International Congess of Historical Sciences held at Montreal,
August 27 - September 3, 1995.]
As J Meuvret writes in the context of French demographic crises during 16th
to 18th centuries, “...[e]pidemic crises unaccompanied by famine did occur;
there is every reason to think however that conditions of shortage favoured the
spread of an epidemic. On the other hand there were few famine years which
did not lead into epidemic phases” [Meuvret 1965: 512].
2 In fact this seems to have been the view generally held by British administrators
who were entrusted with tackling famines in India. Interestingly as we see later
this view seems to have left a lasting influence among several present-day
researchers too.
3 It may be noted that among scholars, including medical scientists, there is a
continuing debate (and controversy) on the interrelationship between the level
of malnutrition and risk of infection and death [see eg, Chen et al, 1980;
Tomkins 1986; Martoell and Ho 1984].
4 The quality of these data was certainly not perfect. However, they can still be
used for examining some specific issues. For a useful discussion on this see
Maharatna (forthcoming), ch 1; Dyson 1991a.
5 For a useful background discussion and information about the severity and
regional spread of these famines see Bhatia 1967; Maharatna (forthcoming),
ch 1; Dyson 1991a.
6 The reasons behind the emergence of such large-scale famines have under
standably been the centre of a long-standing debate. Factors like colonial
1
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49
Indeed, there are indications that poor people were more vulnerable to
malaria mortality. For example, much greater malaria death rates were
reported by Chistophers for the poorer classes in the late nineteenth and
early twentieth century Punjab [Christophers 1910: 38-38]. The report of
an investigation of the epidemic of malarial fever in Assam during 1896
concluded that “the poor suffer in a disproportionate degree, and have less
chance of recover}’, owing to their living in more crowded dwellings, and
o a deficiency of nourishing diet especially of a nitrogenous nature”
[Rogers 1897: 37]. In a recent study of young children admitted to
hospitals in the context of an African food crisis, undemutrition, though
seemingly protective against clinical malariaa, appeared to be associaed
with a higher overall risk of death [de Waal 1989b: 103]. Attention may
also be drawn to the finding of an early celebrated study with 100,000
English prisoners over four years — a study which is probably considered
to be an important event in the history of the ‘refeeding hypothesis’. This
study reported that while the sickness rate was found far higher for the
better-fed group, those receiving least food had four times higher mortality
than those consuming most food [see Murray and Murray 1977:472-473].
Although information about the class composition of mortality during
India’s past famines is particularly scant, relief records and contemporary
accounts indicate that the main rural victims were often the poor classes —
small cultivators, agricultural labourers and petty artisans [Currie 1991;
and also Ambirajan 1989].
All this, however, does not mean that the malaria epidemics that
accompanied several of these major Indian famines occurred solely due to
famine-caused food shortage and undemutrition — unrelated to rainfall,
temperature humidity and othr environmental, ecological and epidemio
logical conditions.16 The huge post-monsoon elevation of fever mortality
in several Indian famines — appearing often as a magnification of the
normal seasonal pattern — suggest a mediating role played by environ
mental factors. In many cases, low mortality in the drought year itself has
been attributed to a relative absence of mosquitoes and malaria [Dyson
1991a; Whitcombe 1993]. Furthermore, the fact that some famines appear
to have involved very small malaria epidemics is sometimes used to cast
doubt about the inevitability of a link as is proposed in (c) [see eg,
Whitcombe 1993].
However, resolving this question fully is probably impossible. And it
may indeed involve controlling for several factors such as the severity of
failures in both rains and crops, the nature of relief, and so on. For example,
in the Punjab famine of 1899-1900, although rainfall recovered in the yearof peak mortality (ie, 1900), the crop-output turned out to be even lower
than in the preceding year of drought.17 Christophers, while discussing the
major factors determining the recurrence of epidemic malaria in Punjab,
states that “[tjhe facts certainly support the view that scarcity is a factor
48
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1996
determiningto a large degree the situation, extent and intensity of epidem
ics” [Christophers 1910: 39]. He also recognised the role of rainfall in
creating favourable conditions for mosquito-breeding. The basic argu
ment is succinctly summarised by the following statement in the context
of ‘a most catastrophic malaria epidemic/ which followed the drought in
1934 in Sri Lanka: “Rainfall made the mosquitoes more abundant; famine
made the people more succeptible” [Harrison 1978: 202].
To conclude: while a general course of rising mortality seems to have
often been shared by most diseases especially during the year following
drought, reflecting broadly the somewhat lagged effects of nuritional
deprivation on human health and survival, the exact timing of peak
mortality from specific epidemic was probably partly shaped by environ
mental factors (monsoon in the case of malaria, heat and lack drinking
water in the case of cholera) and partly by other influences (eg, period of
maximum congregations at relief camps causing maximum spread of
cholera and dysentery/diarrhoea).
Notes
[This paper draws heavily on chapter 2 of the author’s forthcoming book, The
Demography of Famines: An Indian Historical Perspective, (New Delhi: Oxford
University Press). The author is grateful to Tim Dyson for his many useful
comments and suggestions on several sections of this paper. This paper was
presented at the 18th International Congess of Historical Sciences held at Montreal,
August 27 - September 3, 1995.]
As J Meuvret writes in the context of French demographic crises during 16th
to 18th centuries, “...[e]pidemic crises unaccompanied by famine did occur;
there is every reason to think however that conditions of shortage favoured the
spread of an epidemic. On the other hand there were few famine years which
did not lead into epidemic phases” [Meuvret 1965: 512].
2 In fact this seems to have been the view generally held by British administrators
who were entrusted with tackling famines in India. Interestingly as we see later
this view seems to have left a lasting influence among several present-day
researchers too.
3 It may be noted that among scholars, including medical scientists, there is a
continuing debate (and controversy) on the interrelationship between the level
of malnutrition and risk of infection and death [see eg, Chen et al, 1980;
Tomkins 1986; Martoell and Ho 1984].
4 The quality of these data was certainly not perfect. However, they can still be
used for examining some specific issues. For a useful discussion on this see
Maharatna (forthcoming), ch 1; Dyson 1991a.
5 For a useful background discussion and information about the severity and
regional spread of these famines see Bhatia 1967; Maharatna (forthcoming),
ch 1; Dyson 1991a.
6 The reasons behind the emergence of such large-scale famines have under
standably been the centre of a long-standing debate. Factors like colonial
1
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exploitation, population pressure etc are sometimes held responsible for these
disasters. However, it is widely agreed that the failue of monsoon rains was the
single most important proximate factor in all of these famines in the Indian sub
continent.
7 It may be mentioned here that the selection of these locations was influenced
partly by the fact that they were relatively severely afflicted by the famines, and
partly because the quality of demographic data was relatively superior in these
provinces. For relevant evidence see Dyson 1989a, 1989b: Chapter 6; 1991a;
and also Maharatna (forthcoming), ch 1.
8 In fact there is substantial literature on the extent to w'hich rises in food prices
reflect famine distress; see eg, Sen (1981). especially chapters 1-5.
9 The sources of price data are as follows: Bombay Presidency: The Bombay
Presidency Gazette, Part III, Supplement: Bombay (various years); Punjab:
The Punjab Gazette, Supplement, Statistical, Part I: Lahore (various years);
United Provinces: The United Provinces Gazette. Part II: Allahabad (various
years). For Berar (for which we could not find any provincial Gazettes), see
Report onthe Sanitary Administration of the Hyderabad Assigned Districts:
Hydeabad (relevant years). It may be noted hat prices were expressed in terms
of seers (about two lbs weight) per rupee.
10 For details of the antecedents and partial weather failures before this famine,
see Government of United Provinces of Agra and Oudh 1909a: Chapter 1.
11 See Dyson (1991a) and Maharatna (forthcoming): ch 2 for diagrammatic
presentations for the famines which have not been shown above.
12 “Broadly speaking a time series is said to be stationary if there is no systematic
change in mean (no trend), if there is no systematic change in variance, and if
strictly periodic variations have been removed.” [Chatfield 1984: 14].
13 A clear weakening of the association between price and mortality over several
centuries has also been observed in the historical context of England (Lee 1981).
14 The question of how undemutrition enhances the risk of mortality seems to be
complex one. For a summary of the several issues involved, see Walter and
Schofield 1989:17-21. For possible mechanisms linking social disruptions and
outbreaks of diseases in the Indian historical context, see Arnold 1991.
15 For evidence in support of this hypothesis especially in the African context see
Murray et al, 1975, 1976, 1990; and also de Waal 1989b: 104-106.
16 For a useful discussion on the role of various factors (including the role
undemutrition) in the catastrophic malaria epidemic during the Bengal famine
of 1943-44 see Maharatna 1993, 1994; and also Dyson 1991b.
17 While in the drought year, 1899, the cropped area in the whole Punjab was
22.75 million acres, it declined even further to only 15 million acres in the
following year (ie, 1900), the year of peak famine mortality; see Census of India
1901, Volume 18, Part I: 42.
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z 'V
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Government of Bombay, 1894, Government Press, Bombay.
Government of Hyderabad Assigned Districts (1898), Report on the Sanitary
Administration ofthe HyderabadAssigned Districtsfor the year 1897, Govern
ment Press, Hyderabad.
— (1901): Report on the Sanitary Administration of the Hyderabad Assigned
Districts for 1900, Hyderabad.
Government of Norty-Westem Provinces and Oudh (1897): Resolution on the
Administration of Famine Relief in the North-Western Provinces and Oudh
during 1896 and 1897, Government Press, Allahabad.
Government of Punjab (1901): The Punjab famine of 1899-1900, Vol II, Lahore.
Government of United Province of Agra and Oudh (1909a): Resolution on the
Administration ofFamine Reliefin United Provinces ofAgra and Oudh During
the Years 1907 and 1908, Government Press, Allahabad.
— (1909b): Annual Report of the Sanitary' Commissioner of the United Provinces
of Agra and Oudh for 1908, Allahabad, 1909.
— (1910a): Report on the Administration of the United Provinces of Agra and
Oudh 1908-1909, Allahabad.
— (1910b): Annual Report of the Sanitary Commissioner ofthe United Provinces
ofAgra and Oudh for 1909, Allahabad.
Guz, D (1989): ‘Population Dynamics of Famine in Nineteenth Century Punjab,
1896-7 and 1899-1900’ in Dyson (1989b).
Harrison, G (1978): Mosquitoes, Malaria and Man: A History of the Hostilities
since 1880, John Murray, London.
Klein, I (1984): ‘When the rains failed: famine, relief, and mortality in British
India’, Indian Economic and Social History' Review, Vol 21, No 2: 185-214.
Lardinois, R (1985): ‘Famine, Epidemics and Mortality in South Asia: A Reap
praisal of the Demographic crisis of 1876-78’, Economic an d Political Weekly,
Vol 20, No 11:454-465.
Lee, R (1981): ‘Short-term Variation: Vital Rates, Prices and Weather’ in Wringley
and Schofield (1981).
Maharatna, A (forthcoming), The Demography of Famines: An Indian Historical
Perspective, Oxford University Press, New Delhi.
— (1993): ‘Malaria Ecology, Relief Provision and Regional Variation in Mortality
During the Bengal Famine of 1943-44’ in South Asia Research, Vol 13, No 1:
1-26.
— (1994): ‘The Regional Variation in the Demographic Consequences of Famines
in the Late Nineteenth Century and Early Twentieth Century India’, Economic
and Political Weekly, June 14.
Martorell, M and T J Ho (1984), ‘Malnutrition, morbidity and mortality’, Popula
tion and Development Review, Vol 10 (Supplement): 49-68.
McAlpin, M B (1983): Subject to Famine: Food Crises and Economic Change in
Western India, 1860-1920. Princeton University Press, Princeton.
Meuvrel. J (1965): ‘Demographic Crisis in France from the Sixteenth to Eighteenth
Century’, in Glass and Eversley, (1965).
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Murray, M J, A B Murray, C J Murray and M B Murray (1975): ‘Refeeding-malaria
and hyperferramia’ in The Lancet, 122, March: 653-654.
— (1976): ‘Somali Food Shelters in the Orgden and their impact on health’, in
Lancet, 123, 12 June: 1283-1285.
Murray, J and A Murray (1977): ‘Suppression of Infection by Famine And its
Activation by Refeeding — A Paradox?’, Perspectives in Biology and Medi
cine, Vol 20, No 4, Summer.
Murray, J, A B Murray, N J Murray and M B Murray (1990): ‘Susceptibility to
Infection During Severe Primary Undemutrilion and Subsequent Refeeding:
Paradoxical Findings’, (mimeo), Department of Medicine, University of Min
nesota.
Newman, L F (1990) (ed): Hunger in History: Food Shortage, Poverty and
Deprivation, Basil Blackwell, Oxford.
Porter, A (1889): The Diseases ofthe Madras Famine 7877-78, Government Press,
Madras.
Post, J D (1990); ‘Nutritional Status and Mortality in Eighteen-century Europe’ in
Newman (1990).
Rogers, L (1897): Report of an Investigation of the Epidemic ofMalarial Fever or
Kala-azarin Assam, Assam Secretarial Printing Office, Shillong.
Rotberg, R I and T K Rabb (eds) (1985): Hunger and History: The Impact of
Changing Food Production and Consumption Patterns on Society, Cambridge
University Press, Cambridge.
Scrimshaw, N S, C E Taylor and J E Gordon (1968): Interactions ofNutrition and
Infection, World Health Organisation, Geneva.
Singh, S N, M K Prcmi, P S Bhatia, A Bose (eds) (1989): Population Transition
in India, 2 Volumes, B R Publishing Corporation, Delhi.
Sen, A K (1981): Poverty and Famines: An Essay on Entitlement and Deprivation,
Clarendon Press, Oxford.
Taylor, C E (1985): ‘Synergy Among Mass Infections, Famines and Poverty’ in
Rotberg and Rabb (1985).
Tomkins, A M (1986): ‘Protein-energy Malnutrition and Risk of Infection’ in
Proceedings of the Nutrition Society, 45: 289-304.
Tomkins, A and F Watson (1989): Malnutrition and Infection: A Review, Clinical
Nutrition Unit, London School of Hygiene and Tropical Medicine, London.
Waller, J and R Schofield (1989): Famine, Disease and Social Order in Early
Modern Society, Cambridge University Press, Cambridge.
Whitcombe, E(1990): ‘Famine Mortality’, paper presented at the BASAS Annual
Conference, Edinburgh, April.
— (1993): ‘Famine Mortality’, Economic and Political Weekly, June 5,11691179.
Wrigley, E A and R Schofield (1981): Population History of England 1541-1871:
A Reconstruction, Edward Arnold, London.
Zurbrigg, S H (1988): ‘Hunger and Epidemic Malaria in Punjab’ (mimeo).
Arup Maharatna
Reader in Economics
Burdwan University
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Reproductive Health and Women
A Review of Literature
Malini Karkal
In the last decade or so the subject of reproductive health of women
has generated much literature. This review attempts to examine the
quality ofinformation in important contributions to thefield, providing
also a picture of women's reproductive health status, state interven
tions and their outcomes.
HISTORICALLY, the principal duty of women has been viewed as
bearing children, particularly sons, and serving as the foundation of
families. The cost to the women’s health of discharging this duty goes
unrecognised. In the discussion on the low status of women, their contri
bution to the unorganised sector and their invisibility in their productive
roles, is often discussed. The Government of India therefore appointed a
commission to enquire into the conditions of women working in the
unorganised sector, which brought out a detailed report describing the
conditions of the women [Government of India. 1975]. Several efforts are
also made to discuss women’s invisibility in data. However greatest
invisibility of women prevails in health issues. Health is the basic need of
a human being and therefore denying women their health needs has
affected seriously their productive and reproductive roles. Il has also to be
noted that the health and well being of the members of a family is far more
dependent on the productive capacities of the woman than that of any other
member of the family.
At the Alma Ata conference in USSR, in 1978, primary healthcare was
exclusively discussed by 134 countries and access to family planning,
maternal and child care and prevention of common diseases was accepted
as a basic human right [WHO 1978].
• Women play an enormous pan in maintaining the health care
system through their caring work at home, in the family, in the neigh
bourhood and in the health professions, as nurses, midwives, physicians,
etc. At present, more than ever, the health services depend on the
caring work of women,-and their skills and capacities. Yet the develop
ment is not matched by women’s participation in the health-care decision
making.
Generally there has been medicalisation of women’s normal life and
bodily functions, such as menstruation, menopause etc, or social issues are
seen as medical problems requiring medical solutions. This has resulted in
shifting the control from an individual to the medical profession. This
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means serious loss of control over and confidence in women’s own
capacities and in their own bodies [WHO 1985].
Reproductive health care strategies to meet women’s multiple needs
include education for responsible and healthy sexuality, safe and appropri
ate contraception and services for sexually transmitted diseases, preg
nancy, delivery and abortion. [Sai and Nassim 1989]. Such an approach
accepts that the reproductive health issues of women are inextricably
bound with their reproductive rights and freedom. However, even in
discussions on primary health care there is hardly any mention of the
reproductive health problems of women. In developing countries, cur
rently women are the main targets of the population control policies. This
is in keeping with the prevalence of patriarchal attitudes and social
structures. It is also in keeping with the interests of the population lobbists
who are more interested in reduction in numbers than protection of quality
of life of third world people. USAID’s office of population, speaks
publicly of integrating family planning.within a broader health care
framework. It argues privately that family planning should not be “held
hostage” to strict health requirements and that maximum access to contra
ceptives should override safety and ethical concerns.
Women’s rights and population control are.not inherently compatible.
The use of targets, incentives and experimental contraceptives in the context
of deepening poverty and patriarchy, makes family planning a tool for
women’s victimisation rather than liberation. Financial incentives offerd to
poor people to accept sterilisation, IUD insertions or hormonal contracep
tives, make enuine reproductive choice a fiction. There is no universal
meaning for reproductive rights. The meaning is always contingent upon
political and social context. The meaning of reproductive rights has to be
integrated with economics, race, gender and class.
In this context it is important to note the WHO definition of reproduc
tive health. Within the framework of WHO’s definition of health as a state
of complete physical, mental and social well-being and not merely the
absence of disease or infirmity, “reproductive health addresses reproduc
tive processes, functions and systems at all stages of life. Reproductive
health therefore implies that people are able to have responsible, satisfy
ing, an safe sex life and that they have capability to reproduce and the
freedom to decide if, when, and how often to do so. Implicit in this last
condition are the rights of men and women to be informed of and to have
access to safe, effective and affordable and acceptable methods of fertility
regulation of their choice, and the right of access to appropriate health care
services that will enable women to go safely through pregnancy and
childbirth and provide couples with the best chance of having a healthy
infant” [WHO 1978: 32].
The WHO further adds, “The basic elements of reproductive health are:
responsible reproductive/sexual behaviour, widely available family plan
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ning services, effective matemal care and safe motherhood, effective
control of reproductive tract infections (including sexually transmitted
diseases) prevention and management of infertility, elimination of unsafe
abortion, and treatment of malignancies of reproductive organs. Further
more, reproductive health affects, and is affected by other aspects of
health, most particularly HIV infection/acquired immunodeficiency syn
drome (AIDS), nutrition, infant and child health, adolescent health and
sexuality, lifestyle and environmental factors. Pervading and affecting all
aspects of reproductive health are various social and cultural factors, but
especially the status of women in society.”
Such a definition ignores the reproductive health of women who do not
wish to ‘accomplish reproduction’. It also makes fertility regulation
mandatory as a part of health. Major emphasis of the WHO discussion is
on maternity and related situation and very little is said about other
conditions that seriously affect women’s health.
Women get mentioned in the programmes for reducing high infant and
child mortality. However they hardly receive attention in matters of their
own health. Available data show that the range of infant mortality rates
worldwide is between four (in Japan) and 173 (in Mozambique and
Angola) for 1000 births. Whereas for maternal mortality it is between four
(in Denmark) and 1710 (in Bhutan) for 100,000 births [Grant 1991: 102103, 114-115]. Thus the ratio of the lowest rate to the highest was 1:43.5
for IMR, whereas it was 1:427.5 for maternal mortality. Thus, far greater
variation prevails in conditions that govern women than those that govern
infants.
Generally the discussion on women’s health gets much more attention
in the context of illness and death during pregnancy, childbirth and to some
extent issues related to contraceptive use. However to concentrate on
reproductive health of women who are sexually active is limiting the
understanding of the problem. Also, many of the problems arising during
the reproductive years or related to reproductive performance of women
are rooted in their life before they become sexually active and women
suffer beyond their active life. The foundations for the reproductive health
of women are laid in childhood and adolescence, and are influenced by
factors such as nutrition, education, sexual roles and social status, cultural
practices and the socio-economic environment.
Women’s health is seen only as means to achieve other social goals
rather than end in itself. Women’s needs are either unserved or are
underserved and women suffer from several problems with the key aspects
of sexuality and reproductive health such as reproductive tract infections,
infertility, morbidity due to childbirth and violence against girls and women.
Macklin (1989) states that there are three fundamental ethical prin
ciples in women’s right to reproductive freedom. These are liberty, which
guarantees a freedom of action; utility, which defines moral rightness by
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the greatest good for the greatest number; and justice, which requires that
everyone has equitable access to necessary goods and services, Under this
framework, governments have an obligation to provide information and
services for women to exercise their right to reproductive freedom.
Feminist argument for reproductive freedom is based on rights to equality,
self-determination and human dignity.
Perhaps most important, because it is generally ignored and denied, is
the women’s right to enjoy sexuality seperate from reproduction, and free
from fear of negative consequences, on an equal footing with men. The
fact that sexual enjoyment need not lead to procreation is easily accepted
for males, but not for females. In framing policies the women’s needs are
quite often forgotten because by and large, laws and social policies that
affect reproductive health and rights have been shaped by men. Women
have internalised pain and suffering emanating from sexual and repro
ductive roles and they are considered to be the very essence of woman
hood.
Poverty, unhygenic living conditions and several socio-cultural taboos
cause health problems and a ‘culture of silence’. Reproductive tract
infections (RTIs) are common among the third world women and they
have serious consequences for men and children as well. Illnesses and
deaths due to complications of pregnancy, childbirth, unsafe abortions,
diseases of reproductive tract, effects of harmful contraceptives, are the
major causes of ill-health of women.
Reproductive Tract Infections (RTIs) include three types of infections.
(1) Sexually transmitted diseases (STDs) such as chlamydial infection,
gonorrhea, trichomoniasis, syphilis, chanchroid, genital herpes, genital
warts and human immunodeficiency virus (HIV) infection. (2) Endog
enous infections, which are caused by overgrowth of organisms that can
be present in the genital tract of healthy women, such as bacterial vaginosis
and vulvovaginal candidiasis; and (3) Iatrogenic infections, which are
associated with medical procedures, such as delivery, abortion, IUDs and
effects of contraceptives such as oral pills. All these infections are
preventable or treatable causes of infertility, ectopic pregnancy, cervical
cancer, foetal wastage, low birth weight, infant blindness, neonatal Pneu
monia and mental retardation. They facilitate transmission of HIV.
[Wasserheit N and King 1992].
Men also suffer from reproductive health problems, especially the
sexually transmitted diseases (STDs). For several reasons however the
suffering of women is far greater. Jacobson (1991, p 6) says that the
reasons for these are:
1 Women alone are at risk of complications of pregnancy and childbirth.
2 Women face higher risk in preventing unwanted pregnancy: they bear
the burden of using and potential side-effects from most contraceptive
methods, and they endure the consequences of unsafe abortion.
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3 Women are more vulnerable to contracting and suffering from compli
cations of many STDs. Because the semen is retained in the reproductive
tract of the woman, there are greater chances of teh woman contracting
infection from the infection partner, in contrast to such chances for the man
from an infected partner.
Every stage in the complex process of reproduction is vulnerable to damage
from environmental factors. The costs of such injuries are often high, and
include subfertility, intrauterine growth retardation (IUGR), spontaneous abor
tion, and various birth defects. Moreover, the human reproductive process can
be harmed by a tremendous range of complex and multifactorial environmental
influences. Infectious diseases, malnutritionand poor living conditions ae
important causes of reproductive health problems in developing countries. In
richer countries chemical pollution, radiation, and stress have become major
threats [WHO 1994 p 48].
Recently there have been reports of secular declines in sperm concentration
and sperm count during the last 50 years, which some scientists have attributed
to environmental factors. Analyses reveal that mean sperm density of human
semen has fallen from 113 million/ml in 1940 to 66 million/ml in 1990, and
mean seminal volume per ejaculate declined from 3.40 ml to 2.75 ml. There is
also some concern that this decline in semen quality and quantity has been
coupled with an increase in frequency of testicular abnormalities. Although the
effect of the environment on human fertility is not directly related to fertility
regulation, it would be necessary to tudy such effects in the next decade, as they
would have a bearing on the reproductive health of the coming generations
[WHO 1994, p 49].
In women most RTIs originate in the lower tract as vaginitis, cervi
citis or genital ulcers. If untreated they may ascend into the upper tract to
cause pelvic inflammatory disease or PID (endometritis, salpingitis,
oophoritis, parameteritis, or pelvic peritonitis). Some types of genital ulcer
disease may spread to the blood stream to cause systemic infection.
RTIs are also caused by overgrowth of organisms which are normally
present in the reproductive tract (bacterial vaginosis and vulvovaginal
candidiasis).
In several developing countries women are the targets of the population
control policies and the effort to reduce the infant and child mortality.
Consequently the family planning programmes as well as the programmes
for child survival do not attend to the needs of women. Inadequate ante
natal care, poor and unhygienic attention at childbirth, and unsafe abor
tions, continue inspite of known risks. It is reported that the women in
Africa have 1:21 chance of dying due to pregnancy related causes, whereas
the same for women in Asia is 1:54 and in South America it is 1:73, in North
America 1:6366 and in Europe the chance is 1:9850 [Starrs 1987].
Cultural restrictions on woman’s personal freedom, limit dramaticlaly
her access to health care. Women’s mobility under these conditions is
severely restricted. Having male doctors and health care workers limits
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women’s ability to avail of their services. Male dominance in sexual
relations and non-access to contraception makes women have no control
over their pregnancies and childbirths and on contracting diseases. Over
and above this the government policies and indifference to the health of the
women compound the problems for women.
WHO (1986) estimates that annually 5,00,000 maternal deaths take
place and the largest number of them 3,08,000 takes place in Asia,
followed by 1,50,000 in Africa, 34,000 in Latin America, 6,000 in all the
developed countries considered together and remaining 2,000 in Oceania.
Global incidence of severe maternal disease amounts to approximately 7
to 10 million cases per year. This incidence includes only severe chronic
or long lasting diseases like fistulae, severe infections, prolapse conditions
and lacerations (tissue distruction) in the birth canal. It does not include
cases of anaemia, transient pregnancy related disorders and curable
infections [Bergstrom 1994].
Among the causes of maternal mortality are: haemorrhage, sepsis or
infection, toxemia, obstructed labour and the complications of an unsafe
abortion. About 75 per cent of the maternal deaths occur due to these five
causes and remaining 25 per cent lake place due to ‘indirect’ causes, i e,
complications of pre-existing illness such as malaria, tuberculosis, heart
ailment etc. Hepatitis can lead to haemorrhage or liver failure in pregnant
women. STDs may be activated due to pregnancy and may harm the
pregnant woman and the foetus, anaemia, which is rampant among third
world women, also complicates the outcome of the pregnancy [Ascadi and
Johnso-Ascadi 1990]. Anaemia may increase the risk of dying in child
birth by a factor of four: severe anaemia is associated with an eight-fold
risk of death during pregnancy [De-Maeyer and Adiels-Tegman 1985].
Complications of anaemia increase with age and repeated pregnancies.
Increasing family size reduces the nutrition that the woman receives and
with the increasing work burden and blood-loss during menstruation
results in higher incidence of anaemia. The physical effects of anaemia
result in debility and lack of resistance, leading to pregnancy-relatedproblems such as cervical trauma, toxemia, ruptured uterus, infection and
haemorrhage [Ascadi and Johnson-Ascadi 1990].
A study in India, in the 1970s, found that for every maternal death there
were 16.5 cases of illness related to pregnancy, childbirth, and puerperium.
[Dutta et al 1980]. From one gynaecology clinic in northern Nigeria it is
reported that 300 young women a month are treated for the repair of vasicovaginal fistulae, while in other areas the waiting list is said to be 1000
women [Tahzib 1989]. A majority of the women, so handicapped are cast
out by their husbands, with no support and often turn to prostitution or die
a slow, difficult death. In the same area in Nigeria, it has been estimated
that for every woman who died as a result of childbirth, about 15 suffered
permanent handicap [Harrison 1985].
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3 Women are more vulnerable to contracting and suffering from compli
cations of many STDs. Because the semen is retained in the reproductive
tract of the woman, there are greater chances of teh woman contracting
infection from the infection partner, in contrast to such chances for the man
from an infected partner.
Every stage in the complex process of reproduction is vulnerable to damage
from environmental factors. The costs of such injuries are often high, and
include subfertility, intrauterine growth retardation (IUGR), spontaneous abor
tion, and various birth defects. Moreover, the human reproductive process can
be harmed by a tremendous range of complex and multifactorial environmental
influences. Infectious diseases, malnutritionand poor living conditions ae
important causes of reproductive health problems in developing countries. In
richer countries chemical pollution, radiation, and stress have become major
threats [WHO 1994 p 48].
Recently there have been reports of secular declines in sperm concentration
and sperm count during the last 50 years, which some scientists have attributed
to environmental factors. Analyses reveal that mean sperm density of human
semen has fallen from 113 million/ml in 1940 to 66 million/ml in 1990, and
mean seminal volume per ejaculate declined from 3.40 ml to 2.75 ml. There is
also some concern that this decline in semen quality and quantity has been
coupled with an increase in frequency of testicular abnormalities. Although the
effect of the environment on human fertility is not directly related to fertility
regulation, it would be necessary to tudy such effects in the next decade, as they
would have a bearing on the reproductive health of the coming generations
[WHO 1994, p 49].
In women most RTIs originate in the lower tract as vaginitis, cervi
citis or genital ulcers. If untreated they may ascend into the upper tract to
cause pelvic inflammatory disease or PLD (endometritis, salpingitis,
oophoritis, parameteritis, orpelvic peritonitis). Some types of genital ulcer
disease may spread to the blood stream to cause systemic infection.
RTIs are also caused by overgrowth of organisms which are normally
present in the reproductive tract (bacterial vaginosis and vulvovaginal
candidiasis).
In several developing countries women are the targets of the population
control policies and the effort to reduce the infant and child mortality.
Consequently the family planning programmes as well as the programmes
for child survival do not attend to the needs of women. Inadequate ante
natal care, poor and unhygienic attention at childbirth, and unsafe abor
tions, continue inspite of known risks. It is reported that the women in
Africa have 1:21 chance ofdying due to pregnancy related causes, whereas
the same for women in Asia is 1:54 and in South America it is 1:73, in North
America 1:6366 and in Europe the chance is 1:9850 [Starrs 1987].
Cultural restrictions on woman’s personal freedom, limit dramaticlaly
her access to health care. Women’s mobility under these conditions is
severely restricted. Having male doctors and health care workers limits
58
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women’s ability to avail of their services. Male dominance in sexual
relations and non-access to contraception makes women have no control
over their pregnancies and childbirths and on contracting diseases. Over
and above this the government policies and indifference to the health of the
women compound the problems for women.
WHO (1986) estimates that annually 5,00,000 maternal deaths take
place and the largest number of them 3,08,000 takes place in Asia,
followed by 1,50,000 in Africa, 34,000 in Latin America, 6,000 in all the
developed countries considered together and remaining 2,000 in Oceania.
Global incidence of severe maternal disease amounts to approximately 7
to 10 million cases per year. This incidence includes only severe chronic
or long lasting diseases like fistulae, severe infections, prolapse conditions
and lacerations (tissue distinction) in the birth canal. It does not include
cases of anaemia, transient pregnancy related disorders and curable
infections [Bergstrom 1994].
Among the causes of maternal mortality are: haemorrhage, sepsis or
infection, toxemia, obstructed labour and the complications of an unsafe
abortion. About 75 per cent of the maternal deaths occur due to these five
causes and remaining 25 per cent take place due to ‘indirect’ causes, i e,
complications of pre-existing illness such as malaria, tuberculosis, heart
ailment etc. Hepatitis can lead to haemorrhage or liver failure in pregnant
women. STDs may be activated due to pregnancy and may harm the
pregnant woman and the foetus, anaemia, which is rampant among third
world women, also complicates the outcome of the pregnancy [Ascadi and
Johnso-Ascadi 1990]. Anaemia may increase the risk of dying in child
birth by a factor of four: severe anaemia is associated with an eight-fold
risk of death during pregnancy [De-Maeyer and Adiels-Tegman 1985].
Complications of anaemia increase with age and repeated pregnancies.
Increasing family size reduces the nutrition that the woman receives and
with the increasing work burden and blood-loss during menstruation
results in higher incidence of anaemia. The physical effects of anaemia
result in debility and lack of resistance, leading to pregnancy-relatedproblems such as cervical trauma, toxemia, ruptured uterus, infection and
haemorrhage [Ascadi and Johnson-Ascadi 1990].
A study in India, in the 1970s, found that for every maternal death there
were 16.5 cases of illness related to pregnancy, childbirth, and puerperium.
[Dutta el al 1980]. From one gynaecology clinic in northern Nigeria it is
reported that 300 young women a month are treated for the repair of vasicovaginal fistulae, while in other areas the waiting list is said to be 1000
women [Tahzib 1989]. A majority of the women, so handicapped are cast
out by their husbands, with no support and often turn to prostitution or die
a slow, difficult death. In the same area in Nigeria, it has been estimated
that for every woman who died as a result of childbirth, about 15 suffered
permanent handicap [Harrison 1985].
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Abortion is widely resorted to and many women take recourse to unsafe
abortions at the hands of untrained persons. Mortality in legal abortions,
that are performed therapeutically is estimated to be 2 per 1,00,000
procedures in Industrialised countries and 6 per 1.00,000 in Developing
Countries [Hogbers 1985]. But clandestine abortions give rise to very high
mortality - 50 deaths per 100.000 procedures in developed countries and
about 400 deaths per 100,000 procedures in developing countries [Hogbers
1985]. Doubts are expressed about the incidence of deaths in the develop
ing countries and the figure of 400 is feared to be a gross underestimate.
Khan (1986) reports 10 deaths in 412 procedures, giving a death rate of
2,400 per 1,00,000 procedures. Such clandestine abortions are more often
resorted to by poor women. In Latin America it is estimated that about one
in three women has had an abortion and upto 50 percent maternal deaths
are due to complications associated with abortions [Hogbers 1985]. In
Asia, about 20 to 25 per cent maternal deaths are attributed to poorly
performed abortions [Khan 1985 and Rochat 1981]. In Africa, hospital
studies show that abortion-related deaths are reported to be increasing.
More than 25 per cnl in Lusaka, Zambia [Rochat 1985] and more than 20
per cent in Benin City, Nigeria [Unuigbe 1988] are due to abortion
complications. A population-based study conducted in Addis Ababa,
Ethiopia, revealed that 50 per cent of the maternal deaths resulted from
illegal abortions [Kwast 1986].
Reproductive tract infections (RTIs) are syndromes that cause acute
physical discomfort, personal embarassment and marital discord. RTIs
compromise women’s ability to achieve and sustain pregnancy as well as
to produce healthy children. RTIs have a great impact on a woman’s status
within her family and her community, and more significantly, on her
physical comfort. Ironically the current fears of the spread of AIDS has
done more to focus attention on the importance of RTIs in reproductive
health than all the data linking bacterial cervicitis and vaginitis syndromes
with infertility, ectopic pregnancy, chronic pelvic pain, cervical neoplasia
and adverse outcomes of pregnancy [Wasserheit 1989a]. So even ‘safe
sex’, advised as a measure to avoid AIDS, cannot reduce these problems
that women face.
RTIs are caused by a variety of bacteria, viruses and protozoa and they
originate in the lower reproductive tract, which begins at the external
genitals and extends to the cervix. In the absence of treatment, the
infections can spread past the cervix to the upper tract, affecting the uterus,
fallopian lubes and overies. AIDS caused by a blood-bome or ‘systemic’
virus that can enter the body ina variety of ways is not an RTI. It is related
in that it too, is often sexually transmitted. Syphilllis and herpes are RTIs
and may also become ‘systemic’.
Women may contract RTIs through sexual intercourse with an infected
partner or harmful obsteric and gynaecological practice, including unsafe
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methods of contraception, childbirth and an abortion or an unclean
material used to absorb menstrual flow. In Bangladesh village, it was
found that the women who used rags prepared at home, to absorb menstrual
blood, were almost twice as likely to have bacterial vaginosis as women
who used nothing during the menses [Wasserheit et al 1989]. Women also
contract RTIs due to female genital mutilation, improper use of some
contraceptives and unchecked growth of some organisms normally present
in the reproductive tract [Dixon-Mueller and Wasserheit 1991].
Among the RTIs is trichomoniasis, a protozoan infection that causes
chronic, frequently painful, vaginal infections. Another is chlamydia, a
bacterial infection that in women can lead to infertility and even death, and
papilloma virus which is the leading cause of cervical cancer worldwide
[WHO 1989]. Though exact figures are not available, it is known that
annual incidence of the cancer of the uterine cervix is about the same as the
number of maternal deaths. “The pain, horror and suffering in each of these
5,00,000 annual cases should make us feel the challenge to prevent this
mortal disease. This is much more important in the light of the fact that the
cancer of the cervix is now recognised as a viral disease, presumably
transmitted sexually in a way similar to HIV, syphillis, chlamydia and
gonorrhoea” [Bergstrom 1994].
Both bacterial and viral infections remain major health problems in
developing countries. Chancroid is the most common genital viral disease
throughout much of Africa, south-east Asia and south America. A study
in Maharashtra in India, showed that 92 per cent of the 650 women
examined were suffering from one or more gynaecological and sexual
disease related to RTI. On an average the number of infections suffered by
a woman were 3.6. Less than 8 percent of the women in the survey had ever
undergone a gynaecological examination. Infections were observed to be
quite high - bacterial vaginitis, 62 per cent, Candida vaginitis 34 per cent,
PID 24 per cent, trichomonas vaginitis 14 per cent, syphilis 11 per cent,
cervical erosion 46 per cent, cervical dysplasia and metaplasia 2 per cent.
Overall it was observed that 99 per cent of the symptomatic women and 84
per cent of the non-symptomatic women, had gynaecological diseases
[Bang 1989].
Bang (1989) says that generally the diseaes that do not kill are
neglected. Howevertheirconsequences include: difficulty in occupational
and domestic work because of chronic backache caused by PID and cervi
cal erosion (present in 30 per cent of women); foetal wastage due to abor
tions and stillbirths caused by syphilis or chronic PID (38 per cent of the
women had bad obstetric histories); neonatal infections from birth canal
infections; anaemia due to menorrhagia; marital disharmony due to sterlity
(7 percent) or sexual problems (9 per cent to 12 percent) anxiety and stress.
Available data indicate that prevalence of RTIs in both the sexes is
about the same. What however needs to be understood is the gender
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difference in real distribution of many infections and in behaviour patterns
that affect their prevalence in a population. For example the risk of
contracting a sexually transmitted infection from a single episode of
intercourse is higher for women in part because infected semen can be
retained in the vagina for some time [Jacobson 1991].
Once infected, the health threats to women are greater. Typical repro
ductive tract infections in men cause mild to severe genital or urinary
tract problems that are relatively easily treated, in rare cases they can
cause sterility and death. Women by contrast, frequently suffer conse
quences ranging from chronic genital infection to infertility, chronic
pain, and death. Infected pregnant women risk higher rates of maternal
and infant illnesses and death. Research now indicates that the genital
leisons produced by some RTIs increase the risk of transmitting or
contracting HIV, the incidenc of which is already rising rapidly among
women [Dixon-Mueller and Wasserheit 1991 and Mtimavalye and
Belsey 1987].
Women face several physical and social obstacles to preventive and
curative measures of RTIs. Women also lack obvious symptoms and so the
infection is less likely to be accepted. RTIs are also rife with stigmas,
taboos and threats of social ostracism. Fear is reinforced by low selfesteem, illiteracy and the fear of violenc from or rejection by their partners,
thus preventing women from reporting or discussing, so that there will be
early diagnosis and treatment. Physical and psychological deterrants to
care, including strict mores prescribing even married women from dis
cussing sexual problems, can create virtually unsurmountable obstacles
to disclosure of RTIs and the gynaecological ailments among women
[Ascadi and Johnson-Ascadi 1990; Bang 1989]. Women are known to
accept vaginal discharge, itching, ulcers, bleeding, discomfort during
intercourse, or even chronic pelvic pain, painful urination, etc, which
accompanies some RTIs, as an inevitable part of their womanhood
something to be endured, along with other reproductive health problems
such as sexual abuse, menstrual difficulties, contraceptive side-effects,
miscarriages, stillbirths and potentially life-threatening clandestine abor
tions and childbirths (Dixon-Mueller and Wasserheit, 1991).
Five infections - bacterial vaginosis (the most common non-sexually
transmitted vaginal infection), chlamydia, gonorrhea, syphilis and the
human papilloma virus - can lead to permanent disability and even death.
Common outcome of PID - which causes inflammation and scarring of the
upper tract - include infertility, ectopic pregnancy, chronic pelvic pain,
and recurrent infection. Ectopic pregnancy occurs when, because of
scarring and inflammation, a fertilised egg becomes lodged in a fallopian
tube instead of in the uterus, dramatically increasing the chances of
internal haemorrhage.While infections may move from lower to upper
tract, the risk of the disease spreading internally increase greatly when
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women with untreated lower-tract infections undergo unsafe abortions or
gynaecological examinations, have IUD inserted or give birth. Rates of
such infections, in the developing countries are not known, but they are
quite high.
Contraceptive methods also can significantly alter the risk of reproduc
tive tract infections. lUD-uscrs are two five times more likely to develop
PIDs than women not using contraceptives. Risks for lUD-users who have
never given birth may be twice this level. A number of explanations including a possible increase in the risks of developing bacterial vaginosis
- have been offerred to explain this link. Oral contraceptives and barrier
methods tend tareduce the risk of upper tract infections. Although the oral
predispose the user to candidiasis and increase in the risk of chlamydial
cervicitis by enlarging the zone of ectopy, which the site for attachment for
chlamydia trachomitis, they decrease the risk of upper tract infection by
making the cervical mucus plug less penetrable for organisms. Spermicides
offer protection against RIs by killing or immobilising organisms
[Wasserheit 1989].
Clinic-based data indicate that a significant number of women through
out the developing world suffer from lower tract infections related to
gonorrhea. As many as 12 per cent of women studied in Asia, 18 per cent
in Latin America, and 40 per cent in Africa exhibited evidence of
gonorrhea infection [Dixon-Muller and Wasserheit 1991].
In women, chlamydia infections are difficult to trace. Three out of every
four women, affected with chlamydia, will not have any symptoms. In the
absence of routine screening, it is the rising incidence of such disabling or
fatal conditions as PID, infertility, and ectopic pregnancy that often
provides the best measure of where such infections are spreading and how
quickly [Dixon-Mueller and Wasserheit 1991].
Village studies in India, Kenya and Uganda have found rates of PIDs
as high as 20 per cent. Scarring and blockage of fallopian tubes, from PIDs,
is now believed to be a major preventable cause of female infertility in
developing countries [Dixon-Muller and Wasserheit 1991].
In the US, though precise data are not available, still research links
rising incidence of chlamydia infection with four-fold increase in the
ectopic pregnancies between 1970 and 1990. Among the women studied,
a history of chlamydia appeared to be more than double the risk of such
pregnancies. Acute infection was also found to increase the risks of
premature births in normal pregnancies [Cohen et al 1990; Chow 1990 and
Wendy 1991]. In the light of the fact that there is an overwhelming
evidence that chlamydial infection is the most common STD and a major
cause of infertility in women and that it increases the succeptibility of
women to HIV, it is essential that programmes of STD control, family
planning and maternal and child health provide diagnostic testing for these
diseases.
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The absence of testing and treatment outlets for the human papilloma
virus also condemns each year, hundreds of thousands of women in the
developing world, to death. Several strains of human papilloma virus are
linked with cervical cancer; approximately 4,50,000 cases worldwide
annually, of these potentially fatal reproductive tract cancers are diag
nosed. Of these estimated 3,45,000 occur in the third world women,
virtually all of whom die due to lack of access to relatively simple early
treatment measure [Stanley 1991].
For each maternal death several mothers suffer from illnesses. For
example in a study in India, it was observed that this number was as high
as 16 to 17 women who suffered pregnancy-related illness. Calculating
from these figures the World Bank estimates that from 3 per cent to 12 per
cent of all pregnancies worldwide result in serious illnesses among
women. Among the pregnancy-related illnesses sufferred by women is the
vascio-vaginal fistulae - tears between the wall of rectum or the bladder
and vagina. This is particularly common among women who experience
obstructed labour, a condition usually occuring among adolescents and
women who have narrow pelvises. This condition leads to the collection
of uncontrolled leakage of urine and feces. The resultant foul smell
ostracises untold thousands of women and young girls. Pregnancy-related
illnesses far outnumber pregnancy-related deaths. They affect lives of a
very large number of women and need immediate attention.
An increasing incidence of collecting women rejected and abandoned
due to their barrenness, for prostitution, is observed in Niger, Uganda, and
the Central African Republic. Because of their multiple contacts, prosti
tutes are more likely to contract and pass RTIs. Chancroid is the most
common cause of genital sores in Africa and is strongly linked to
prostitution. A 1985 study found genital ulcers, related to chancroid in 42
per cent of the prostitutes from slums in Nairobi (Over and Piot, 1990).
Syphilis can go from the genital area into the bloodstream to cause lung
and heart damage and meningitis. All of which affect adversly women’s
health and increase health risks in pregnancies. Syphilis, along with herpes
and chancroid, also produces genital lesions that, according to WHO, may
increase the risk of contracting HIV by 300 per cent [WHO 1989]. With
the threats of HIV infections, with prevalent RTIs, the possibilities of
finding solutions to RTIs among women seems bleak. The WHO estimates
that more than 8 million adults are currently infected with HIVs including three million women, most of whom are in their childbearing
years. By the end of 1992, an estimated total of600,000 cases of AIDS will
have occurred among women [Petros-Barvazian and Merson 1990].
Infection via vaginal intercourse, is the most common route of trans
mission for HIV in Africa. About 2.5 million Africans are now believed
to carry the virus. Nearly 1 million of these are in Uganda alone. Zaire and
Zambia have the next highest number of infections, with 2,82,000 and
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2,05,000, respectively. In some cities, one-in-five pregnant women, is
infected with HIV.
Traditional sexual patterns in Africa also make HIV more likely to
spread towomen. One such practice, the use of astringent herbs to ‘dry’ the
vagina and give the male more friction, tends to increase the likelihood of
transmission through tears in the vaginal wall. Likewise female circumci
sion also facilitates transmission. As a result, HIV infections among
women in Africa is rising exponentially and deaths from AIDS are
expected to rise in tandem. WHO estimates that from 1.5 million to 3
million of reproductive age in central and east Africa alone will die of
AIDS by 2000 [Petros-Barvazian and Merson 1990].
In many other regions, the rate of increase in HIV infection among
women is now rising rapidly. HIV is increasing rapidly in Asia. In India
and Thailand studies of prositutes in several urban areas found HIV
infection between 10 per cent to 70 per cent of the subjects. In 1986,
according to the Thai government, 17 males were infected for every
female. By 1990 that ratio had fallen to five males to every female. WHO
reports about 200,000 women in Asia are now infected [Mtimavalye and
Belsey 1987; Over and Piot 1990 and Smith 1990].
As heterosexual transmission of HIV becomes dominant route of
infection in most of the regions of the world, Over and Piot (1990) note that
“Proportionately more women and more poor people will be among those
with HIV infection and AIDS.” In other words, HIV is now following the
socio-economic pattern of most reproductive tract infections. This is true
in North as well as in South America. In many cities of these regions. AIDS
is now the leading cause of death among the women between the ages of
20 and 40 [IPPF 1990].
Serious note needs to be taken of the evidence that HIV infection may
accelerate the development of cervical cancer in women and human
papilloma virus and decrease the effectiveness of treatment for chancroid,
syphilis and PIDs. In the absence of a concerted campaign to reduce the
incidence of both the RTIs and HIV, and to treat existing RTIs, the number
of women dying of reproductive tract health causes, will continue to spiral
upwards.
While a given death can always be traced back to a medical condition,
the real ‘causes’ of poor maternal health are rooted deeply in social,
cultural and economic barriers faced by females in the third world,
thoughout their lifetime. Malnutrition is far more prevalent among fe
males than the males in the developing countries and the reasons have
more to do with gender than with geography. Gender discrimination in
allocation of food - as well as in education and in health care — is
widespread and well documented practice in much of south Asia. In
conditions of strong son-preference, girls are perceived as risky invest
ment [Ascadi and Johnson-Ascadi 1990].
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References
Ascadi George T and Gwendolyn Johnson-Ascadi (1990): Safe i o er 00 in
South Asia: Socio-Cultural and Demographic Aspects of Matem
ealth ,
Background paper presented at the Safe Motherhood South Asia Conference,
Lahore, Pakistan, March.
Bang R A et al (1989): ‘High Prevalence of Gynaecological Diseases in Rural
Indian Women’, The Lancet, January 14.
Bergstrom Staffan (1994): ‘Myths and Realities in Population Assistance and
Maternal Health Care’. Paper presented at the conference organised by the
Forum for Environment and Development and the Center for International
Women’s Issue, Oslo, May 25.
Chow J M (1990): ‘The Association Between Chlamydial Trachomatis and
Ectopic Pregnancy: A Matched-Pair, Case-Control Study’, Journal of the
American Medical Association, Volume 263.
Dixon-Mueller Ruth and Judith Wasserheit (1991): 'The Culture of Silence,
Reproductive Tract Infections Among Women in the Third World’, Interna
tional Women’s Health Coalition.
Dutta K K et al (1980): ‘Morbidity Patterns Amongst Rural Pregnant Women in
Al war, Rajasthan - A Cohort Study’, Health Population Perspective Issues,
Volume 3.
Grant James P (1991): The State of the World’s Children 1991, UNICEF, Oxford
University Press.
Harrison K (1985): ‘Child-bearing, Health and Social Priorities: A Survey of
22,774 Consecutive Hospital Births in Zaria, Northern Nigeria’, British Jour
nal of Obtetrics and Gynaecology, Volume 92, Supplement 5.
Hogbers U (1985): ‘Maternal Mortality-A Worldwide Problem’, International
Journal of Gynaecology and Obstetrics, Volume 23.
I Cohen et al (1990): ‘Improved Pregnancy Outcome Following Treatment of
Chlamydial Infection’ Journal ofAmerican Medical Association, Volume 263.
IPPF Medical Bulletin, New IMAP Statement on the Aquired Immuno Deficiency
Syndrome, Volume 24, Number 6, December.
Jacobson Jodi L (1991), Women’s Reproductive Health: The Silent Emergency,
Worldwatch Paper 102, Worldwatch Institute, USA.
Jeffrey Patricia et al (1989): Labour Pains and Labour Power: Women and
Childbearing in India, Zed Books, London .
Khan A R et al (1985): ‘Maternal Mortality in Rural Bangladesh’, World Health
Forum, Volume 6, Number 325.
Kwast B E etal (1986): ‘Maternal Mortality in Addis Ababa, Ethiopia’, Studies in
Family Planning, Volume 17, Number 288.
Macklin R (1989): Liberty, Utility and Justice: An Ethical Approach to Unwanted
Pregnancy , International Journal of Gynaecology and Obstetrics, Supple
ment 3, pp 37-50.
Mtimavalye L A and M A Belsey (1987): ‘Infertility and Sexually Transmitted
Diseases: Major Problems’, Maternal And Child Health And Family Planning
The Population Council, New York.
Over Mead and Peter Piot (1990): “HIV Infection And Other Sexually Transmitted Diseases’, Malawi Country Paper Presented At The Conference On Safe
66
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Motherhood For The S ADDC Countries, Harare, Zimbabwe, October-Novem
ber, 1990.
Petro-Barvazian Angele and Michael H Merson (1990): ‘Women And AIDS: A
Challenge To Humanity’, World Health, November-December.
Rochat R W (1985): ‘The Magnitude Of Maternal Mortality: Definitions And
Methods of Measurement’, paper presented at the international meeting on
Prevention Of Maternal Mortality, WHO, Geneva, November 11-15.
Rochat R W et al (1981) ‘Maternal and Abortion-related Deaths in Bangladesh,
1978-1979’, International Journal of Gynaecology and Obstetrics, Volume
19, Number 155.
Sai Fred T and Janet Nassim (1989): ‘The Need For Reproductive Health
Approach’, International Journal ofGynaecology and Obstetrics, Supplement
3.
Smith D C (1990): ‘Thailand: AIDS Crisis Looms’, The Lancet, Volume 1.
Stanley K et al (1991) Women And Cancer.
Starrs Ann (1987): Preventing The Tragedy OfMaternal Deaths: A Report On The
International Safe Motherhood Conference, Nairobi, Kenya.
Tahzib F (1989), ‘An Initiative On Vascio -Vaginal Fistulae’, The Lancet,
Volume ii, Number 1316.
Unuigbe J A (1988): ‘Abortion - Related Morbidity And Mortality’ , Benin City,
Nigeria, 1973-1985, International Journal of Gynaecology and Obsterics,
Volume 26, Number 435.
Walsh Julia A et al ‘Maternal And Perinatal Health’, Draft Chapter in D T Jamison
and W H Mosley (edsj Disease Control Priorities in Developing Countries,
World Bank, Washington.
Wasserheit Judith (1989a): ‘The Significance And Scope of Reproductive Tract
Infections’, International Journal ofGynaecology and Obstetrics, Supplement
3, pp 145-168.
Wasserheit Judith (1989b): 'Reproductive Tract Infection: Special Challenge in
Third World Women's Health', presentation to the 117 annual meeting of The
American Public Health Association in Chicago, Illionis, October, IQHC, New
York.
Wasserheit Judith J R, J Chakraborty et al (1989): ‘Reproductive Tract Infections
in Family Planning Populations in Rural Bangladesh: A Neglected Opportunity
To Promote MCH-FP Programs’, Studies In Family Planning, Volume 20;
No 69.
Wendy Gibbons (1991): ‘Clueing In On Chlamydia’, Science News, April 20.
World Health Organisation (WHO) (1978)’, ‘Primary Health Care: Report On The
International Conference On The Primary Health Care’, ‘Health For All’ Serial
Number 1, Alma Ala, USSR.
— (1985): ‘Report Of A WHO Meeting On Women And Health’, Peebles,
Edinburgh, May 25-27.’
— (1986): ‘Maternal Mortality Rates: A Tabulation Of Available Information’,
Geneva.
— (1989): ‘Sexually Transmitted Diseases: Research Needs: Report Of A WHO
Consultative Group’, Copenhagen, September.
— (1994): ‘Challenges in Reproductive Health Research’, Biennial Report 19921993, p 32, ibid.
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Communications
Toxic Legacy of Union Carbide
in Bhopal
Hundreds of tonnes of toxic chemicals have poisoned water sources
and the land around the Union Carbide factory'. Nothing is being done
to pressurise the company to initiate or pay for the clean-up.
A EVER the December 2-3, 1994 Union Carbide disaster, workers who
have had more than ten years of experience of working in the factory
reported to the Bhopal Group for Information and Action (BGIA) that the
following chemicals (Table) have been routinely dumped by the manage
ment inside the factor}' premises prior to the disaster.
From 1969 to 1977 all effluents used to be dumped in an open pit near
the eastern wall of the factory. From 1977 onwards most but not all
effluents were discharged into the solar evaporation ponds (SEP) behind
the factory. Every' year during the rains the ponds overflowed and con
taminated large areas. Effluents were also routinely discharged into the
sewage drain behind the nearest community, Jai Prakash Nagar.
People in Jai Prakash Nagar made persistant complaints about the strong
smell and taste of chemicals in the community wells and hand pumps. This
was verified by BGIA. Also verified were accounts of cattle falling sick and
dying after drinking water containing effluents from the factory. Farmers
who had their fields next to the SEPs complained of low yields.
In early 1990 BGIA contacted a few scientists at government research
centre including Regional Research Laboratory, Bhopal for analysis of
samples of soil and ground water from the vicinity of the Carbide factory.
The BGIA was told that anything connected with Union Carbide was
highly sensitive and required clearance from lop officials.
In April 1990 the BGIA sent samples of soil from near the factory and
water from the community wells in Jai Prakash Nagar to the Citizens
Environmental Laborator}' (CEL) Boston for analysis. The report of CEL
pointed out the presence of high levels of toxic materials in the soil samples
from the SEP. Dichlorobenzenes that causes damage to liver, kidneys and
respiratory system were found in samples of well water. Pthalates toxic to
the liver were found in samples of surface soil and in soil samples from
SEPs. In all, seven toxic chemicals including known cancer causing agents
were reported by the CEL.
In the annual shareholders meeting of Union Carbide Corporation
(UCC) USA in April 1990, Marco Kaloften of CEL raised the issue of
contamination of soil and community wells. He pointed out that the
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average clean-up cost for contaminated sites under the Superfund
programme was 20 million US dollars and asked for a schedule for clean
up of the toxic materials by Union Carbide. Robert Kennedy, chairman
UCC requested Kaloftcn to pass on the information to C C Smith, vice
president of health safety and environment.
In May 1990, the BGIA sent a letter to the minister of petroleum and
chemicals, Government of India, along with the test report from CEL. In
the letter the government was urged to undertake a thorough investigation,
and support towards such an effort was offered. Having received no
response for a month, the BGIA sent another letter to the minister on
June 14, 1990. Mention was made of the BGIA’s meeting with the
chairman, Madhya Pradesh Pollution Control Board (MPPCB) in
which the BGIA was informed that a study carried out by the National
Environmental Engineering Research Institute (NEERI), Nagpur had not
found any harmful chemicals around the factory. This letter too went
unresponded.
The examination by the BGIA of the NEERI report found it to be based
on incomplete data — at least nine organic chemicals whose presence was
indicated during high performance liquid chromatography had been left
unidentified in the report. The conclusion that there were no hazardous
chemicals within 10 km radius of the factory had been prematurely drawn.
Having received no response from the ministry of petroleum and
chemicals, the ministry in-charge of all Bhopal related matters, the BGIA
wrote to the minister of environment and forests on July 2, 1990. In
response the BGIA was asked to meet with the chairman MPPCB who had
nothing new to say. A meeting with Maneka Gandhi, the then minister of
state for environment and forests was sought and fixed. But the minister
was too busy to keep her appointment with the BGIA.
The New Scientist (February 2, 1991) reported the issue of contamina
tion around the Carbide factory in Bhopal. The report mentioned that
Union Carbide hoped to commission Arthur D Little (the consultancy
company that concocted and propogated the dubious sabotage-by-adisgruntled worker theory to explain the cause of the disaster) to evaluate
Table
Chemical
Use
Ortho-dichlorobenzene
Carbon tetrachloride
Chloroform
Methylene Chloride
Methanol
Mercury
Sevin
Alpha-Napthol
Solvent in Napthol Plant
Solvent in Sevin Plant
Solvent in MIC Plant
Solvent in Temic Plant
Solvent in Temic Plant
Solvent in pan filter
(Slurry and dust)
(Slurry and dust)
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1996
250 MT
200 MT
100 MT
50 MT
10 MT
1 MT
50 MT
50 MT
69
wavs of decontaminating and reclaiming lands alfectcd^ j^are still
organisation took up the issue in late 1991 and repeated demands are
being made by them for a proper investigation of the contami
pavtnent of clean-up costs by Union Carbide.
relief
’in earlv 1992 the BGIA met with Babulal Gaur, minister of gas
>
Madhva Pradesh eovemment who declined to make any comment on tn s
•technical subject’ and said that he had not received any report of death du
to the contaminated ground water and soil. The minister had, as a aw> er,
represented fanners claiming damages for the death of their callt e y
effluents from Union Carbide’s factory prior to 1984. The matter had been
settled out of court.
On January 13. 1995 Union Carbide India (UC1L) proposed a method
ology for sampling from dump sites to MPPCB and sought guidance. The
MPPCB on April*?!, 1995 informed UCIL that the factory being in the
custody of the court before whom the criminal case against Union Carbide
was pending, permission of the chief judicial magistrate (CJM), Bhopal
was essential before carrying out any investigation.
The MPPCB on September 19, 1995 moved two applications before the
CJM. Bhopal. The first application mentions that “the following residues
and chemicals some of which may be hazardous are lying for final
disposal” at the Carbide factor)':
(1) Sevin tar residue 44.558 MT, (2) Napthol tar residue 2.54 MT,
(3) Inprocess material obtained during dismantling of formulation plant.
18.386 MT, (4) Material from dumping site (illegible). It says that MPPCB
desires to entrust NEERI and the Indian Institute of Chemical Technology
(IICT). Hyderabad with the work of evolving methodology for safe
disposal of the above residues. The application sought permission to
collect samples from inside the premises of the Carbide factory.
The second application moved by the MPPCB was for permission to
shift seven tar residues and napthol tar residues from the present place to
the formulation plant within the factor}' premises. Both applications were
opposed by the Central Bureau of Investigation (CBI), the prosecution, on
the grounds that they were not maintainable under judicial principles. On
September 23-24, 1994 the committee for safe disposal of tar residues of
UCIL, Bhopal set up by the MPPCB held a meeting in which it was
concluded that the two options to be investigated for disposal would be (a)
incineration (b) biodegradation. The committee noted that “extremely
toxic dioxines can get formed by low temperature incineration”
On October 6. 1994, the MPPCB chairman P K Banerjee wrote a letter
Sev?n andCN r
reqUeS‘‘ng him t0 take UP
study for disposal of
Union r ^P r°' tar res,dues “about 27 MT" of which were lying at
J995 den^d
017
Bh°PaL The CJM’ Bh0pal on November 15,
esidues
MPPCB ‘° take Samples from
shift ta
residues lying inside the Union Carbide factory.
70
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In the US, the Union Carbide faces a potential liability of US $ 250
million in costs for remedial actions at Superfund sites in New Jersey,
West Virginia, Tennessee, Ohio, Alabama, Texas and California be
cause of land disposal of hazardous and industrial waste on its own
property. This liability is in addition to US $ 421 million liability Union
Carbide faces at the 21 Superfund sites where the company is “potential
responsible party’’.
Satinath Sarangi
Bhopal Group for Information and Action.
Bhopal
Rationalising Expenditure in
Health Care Sector
Is there really a resource crunch in the health sector? Oris it merely
a question ofan utter lack ofefficiency in resource use both in the public
and private sectors?
AT present, expenditure on health sector in India, both by the centre and
states is only a little over 1.5 per cent of GDP. As against it, WHO
guidelines suggest a spending of at least 5 per cent of GDP. This is thought
to be necessary to maintain universal coverage and equity. Even the Plan
outlay of the centre does not exude optimism. In 1993-94, it remained
around Rs 483 crore which was only slightly above that of
1992-93
(around Rs 447 crore). The inadequacy of this expenditure, especially in
the face of inflation in the cost of medicines and large maintenance
expenditure is reflected in a general decline in the quantity and quality of
public health services.
How far this inadequacy of budgetary resources has affected the
outcomes of some of the target oriented programmes is a pertinent
question for policy formulation. From time to time, many of the national
level programme evaluation studies, for instance, have looked into
some of these programmes. Micro as well as macro studies by individual
researchers, planners and sponsors have also revealed a mix of eco
nomic, ad-ministrative and managerial factors affecting various health
programmes.
The ICMR survey of MCH rural schemes, for instance, emphasised the
inadequacy of inputs, e g, antibiotics, oxygen supply and supportive drugs
meant for emergency. The blindness control survey of ORG also pointed
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71
\.k ..x .V e. c.j.a
j.u ihik s, propel silting arrangements, essential
> i.u>
opl\ o( medicines, as the causes of the incomplete
sx.kkoax';
. • "c \nothci suivex ol 266 rural private doctors across
\
s > w.-b.cj Lu k ot training, inappropriate prescriptions and
.a ae.
c.'cas about OKS <only 60 percent were aware) as the factors
e c.vs than successful implementation of diarrohea control
sty i * "c ' these aieas
‘ *x csa’-cac.ea s’.v.Jics othural area development projects, for instance,
v. we e<\ Ost1, the improved availability of health services due to these
ho.ecvs \\si>
c> below the desired level due to reasons like defective
Cxsieo* ot ce cc. \e location of facilities coupled with no funding for
\ ‘ c
xv. SmuLulx the evaluation studies of immunisation coverage
\;c - xv 'ev. deficient sub-centres (nearly 30 per cent), inoperational
?r*C ' • c-sc.v.ccc.’.v, manpower, eg ANM, nearly 30 per cent of them
vxc. *g eoLstsV the sub-centre area as the cause of inadequate success of
Scs:ces national evaluation studies different micro level studies across
v cw
ha\e covered some of the economic aspects of various health
ser-xvs. The studies convering MCH services, for instance, have mostly
;v. r.rse cu: the inadequacy of various inputs, namely, lack of supply of
•^ec-cw.es. iron and folic acid, accommodation, conveyance, trained birth
imai-r:. quality of govemement services, outreach facilities, proper
• cric’.g conditions, availability of lady doctors, proper maintenance and
honorium for health workers guides.
Studies have estimated that due to these inadequacies in various inputs,
me unlisadon of MCH services, for instance, in Uttar Pradesh, was only
15 per cent of optimum. Some studies in north eastern parts of India
mclmzmg Manipur, Sikkim, Tripura and Nagaland have established lack
:: a • liability of antenatal care in the range of 9-13 per cent. In Himachal
Pradesh. another study estimated that (a) 20 per cent of PHC vehicles were
mere -zz in working condition, (b) 7 per cent of PHC operation theatres
ZTi ~ ere r.on-functional, (c) telephone, staff quarters, lab, labour room
m: CT were grossly inadequate. Likewise in Rajasthan, 40 per cent of
K±-cemres w ere found non-functional.
2* mrilon related studies either independently or covering evaluation of
5CLS or pl'GH had their focus more on urban slums or rural areas. A study
m Amdhra Pradesh highlighted factors like short supply, poor coverage,
oo replenish slocks, lack of effective health education and supervi.or ai me causes that came in the way of realising the objectives of
r. zrit.or.ai anemia prophylaxis programme. Studies in West Bengal, e g,
. .ggeo- unchanged nutrition status of children due to PVOH. Studies on
o.arronea. diseases point to lack of basic amenities like water sanitation
m.o rzz-lr.g as well as higher utilisation of private doctors’ facilities for
.-ear men: of such diseases.
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While the lack of availability of resources hindered adequate utilisa
tion of MCH services, examples of wastages of resources is provided by
studies focusing on treatment of TB. In Bengal, Himachal Pradesh and
Manipur, over-diagnosis in the form of unnecessary or overuse of
dignostic labs and tests to the tune of 50-60 per cent which accounted for
overall financial losses of Rs 8-9 crore. Likewise, the study of private
prescription practices in urban Maharashtra indicates the presence of 80
different treatment regimes for TB, most of which were inappropriate
and expensive.
Efficiency of resource use of public hospitals has also been dealt with
some of the studies. In Andhra Pradesh, for instance, public hospitals
might not be inefficient in resource use but there exists a real dearth of
resources. Some 40 per cent of public hospitals in Andhra Pradesh were
not geared up for providing emergency services and 10 per cent of them
were not able to provide any diagnostic tests. By contrast in Rajasthan,
operational efficiency in general surgery of teaching hospitals was found
affected by a mix of factors including lack of resources for building and
equipment maintenance as well as potential scope of hitherto unapplied
managerial methods in laundry and drug prescription.
By contrast, there have been studies which also pointed to lack of
awareness as the cause of low utilisation of government health facilities.
For instance, the ICDS evaluation found utilisation as low as 30 per cent
in terms of health check-ups and 60 per cent in terms of supplementary
nutrition. In slum areas the efforts aimed at nutritional supplement were
observed to have generated much less demand thereby widening the gap
with its supply. Studies in rural Bihar, Madhya Pradesh, Orissa indicate
that only 20-28 per cent of mothers consulted anganwadi workers (AWs).
Rarely, some studies indeed pointed out some good features of govern
ment facilities as the factors leading to higher utilisation of government
MCH facilities.
The foregoing suggests thus the lack of adequate resources as well as
inefficiency in resource use which have led to low availability and low
utilisation of health services in public sector. The simultaneous trend of
increasing utilisation of private facilities in many states has also led to a
sort of mushrooming of private health facilities. In Rajasthan, for instance,
it was revealed that private facilities in recent years have risen by 9.5 times
with the commensurate rise in outpatient and inpatient attendance at
private practitioners respectively by 12 and 17 times. Another study in
Maharashtra found a proliferation of nursing homes with no regulation on
their quality. It was observed that among these private nursing homes: (a)
50 per cent were poorly constructed, (b) one-seventh of them were run
from sheds or slums, (c) 77 per cent had no scrubbing room or sterilisation
room, (d) 66 per cent had no generators and (e) two-third did not have
qualified nurses.
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The overview indicates that resource crunch in health sector apparently
could be overcome by means of improved efficiency in resource use, both
in public and private sectors, through improved managerial skills and a
changed value system. The latter, for instance, would mean diverting from
the traditional notion that health is solely a welfare objective. A focus on
cost recovery especially in curative health care in the public sector may
help to raise resources and achieve self-sufficiency, particularly in diag
nostic facilities. This may help reduce unnecessary use or overuse of
government facilitates, create awareness about the quality of services
among the health service users and optimise allocative efficiency of
resources in this sector. Simultaneously, the flaws of another important
resources mobilising measure in the health sector namely, health insur
ance schemes are formulated in a manner such forged claims, settlement
delays, omission in coverage of minor ailments, sole urban orientation and
lack of aggressive marketing, all of which have indeed plagued the earlier
schemes.
- Brijesh C Purohit
Associate Professor,
Indian Institute of Health Management Research,
1, Prabhu Dayal Marg,
Sanganer Airport,
Jaipur - 302011
Subscribe to
In Defence of Democratic Flights
The Monthly Bulletin of the
All-lndia Federation of Organisations
For Democratic Rights
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Rs 10 for outstation cheques.
74
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1996
Reviews
Historiography of Colonial Medicine
Leena Abraham
Public Health in British India: Anglo-Indian Preventive Medicine
1859-1914 by Mark Harrison, Cambridge History of Medicine Series,
Cambridge University Press, 1994, p 324, Rs 395.
THE last decade and a half has seen a surge in studies on the colonial
historiography of medicine in India (Arnold, Ramasubban, Jeffery, Klein
Catanach, Muraleedharan). These studies have focused their attention
mainly on the colonial policies that influenced medicine in India and on the
disease/death profiles of the colonial period. The book by Harrison is an
addition to this genre of colonial medical historiography for it attempts a
wide coverage of both these aspects of public health in British India.
The literature on the colonial historiography of medicine (in India and
elsewhere) has shown that medicine was a significant part of the ‘colonising
discourse’. It has been argued that medicine became a ‘tool of empire’ in the
consolidation and legitimation of European Imperialism, and also that med
icine came to be used as an ‘instrument of social control ’ and contributed in
important ways to the creation of the colonial ‘subject’. Further, medicine did
not represent a benevolent extension of science and technologies to the
colonies but was part of a larger agenda of a ‘civilising mission’. It has been
thus argued that medicine was essentially colonial in character despite the fact
that specific medical interventions were of limited scope and effectiveness.
Harrison states that his goal is not to challenge these arguments, but
nevertheless he attempts to undermine their force through a detailed study of
public health in India during the period 1859-1914. His stated position in the
introduction is that his work does not represent a fundamental historiographical
revision. According to him the work differs from the other writings on the
history of colonial medicine mainly in the ‘weightage’ given to the various
factors that limited the scope and effectiveness of medical intervention. The
factors considered are (i) the political relationships with the indigenous
population especially after themutiny of 1857; (ii) the role of Indians as policy
makers at local and municipal levels; (iii) the varied and conflicting views of
the administrators and medical officers; and (iv) the various economic
constraints. Tracing the colonial public health policies through the interplay
of these factors and actors, the author argues that the role of preventive
medicine in the consolidation of imperial rule in India “was less central to this
process than is sometimes imagined”.
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Tracing in great detail the development of public health in India through
the various professional, cultural and administrative dimensions of pre
ventive medicine during the period of 1859-1914, the author arrives at the
following conclusions. He agrees with the claim that medicine did contrib
ute to the construction of a negative image of India and its people, and that
public health measures did intervene in the lives of people. However he
argues that the impact of the above could not have been significant as the
negative images that the medical texts contained could not have influenced
the way Indians perceived themselves. This is a rather naive view of how
the ‘colonial subject’ or the identities of natives were constructed by the
colonisers and in turn internalised by the colonised. The processes of
construction and internalisation are now well documented in the literature.
With regard to the successful implementation of medical measures the
author argues that it was severely constrained by the cautious stand
adopted by the government in the post-mutiny period, the prevalence of
conflicting theories of disease causation combined with the shortage of
funds available for public health. To these factors Harrison adds the
negative role played by the indigenous elites through the local administra
tion. According to him the “economic interests of the city’s rentier class
constituted the single greatest obstacle to sanitary reform” (p 45). Thus
Indians themselves came in the way of proper implementation of public
health reforms.
One of the chapters in the book provides a detailed account of the
educational qualifications, the class and ethnic composition of the recruits to
the Indian Medican Service (EMS) and how their social origins affected their
professional status with respect to their counterparts in Britain and also with
respect to other sendees in India. A large section of the IMS came from the IrishScottish ‘fringe’ and from the anglo-Indian community living in India. Both
these groups occupied lower social status as compared with the British. The
social and professional status of medical men in India was low owing to their
lower middle class origins and lower qualifications. The medical service in
India was hierarchical with limited opportunities for promotion. There were
strong racial feelings against the Indians in the IMS. The legal status of medical
men in India was low which is attributed to the absence of any regulation of
medical practice in India at that time. While the Medical Registration Act was
passedin 1858 in Britain such an act was not passed in India until 1912.In this
otherwise detailed account, an important omission is the role played by the
LMPs who formed a sizeable segment of medical prationers.
The discussion then moves on to the state of medical theory concerning
‘tropical hygiene’ in 19th century India. Medical theory in the first half of the
19th century was still steeped in the Hippocratic tradition with an emphasis
onclimate, ‘temperament’, diet and their influence on ‘constitutions’ ofthe
Europeans - notions that where close to those found in the indigenous
medical knowledge. There was general interest in the knowledge of
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indigenous ayurveda and unani resulting in the publication of many texts
and articles reviewing Indian pharmacopoeia and treatises on Indian
medicine. Ainslie’s Materia Medico, first published in 1826, “enjoyed a
good measure of popularidy among medical men in India” (p 41). Those
who were not attracted to the traditional texts, nonetheless believed that
some of the traditional hygenic and other practices contained in these texts
were useful. However this interest completely vanished from the writings
and even from the attitudes of the medical men by the middle of the 19th
century. By this time, a complete reversal of attitude towards indigenous
practices took place. From being perceived as useful, they came to
symbolise all that was unhealthy and degenerate in indigenous society.
Harrison does not consider the question why such a reversal occurred and
what purpose it served. A careful reading of the evidence provided in
support of this transformation shows that the colonial administration with
the support of a section of medical men did play a significant role in
shaping the colonial discourse contrary to the author’s position. When one
looks at such evidence in combination with what happened in other areas
of colonial policies such as education and scientific research [Kumar
1995] it becomes doubly difficult to accept the line of argument put forth
by the author. But, certainly if one were to disaggregate the impact of each
segment of colonial policy as the medical policy and within it the public
health policies as the book does, it would be difficult to establish in any
conclusive manner how medicine enabled the colonial state to shape
colonial discourse.
The spread of cholera out of its ‘home’ in Bengal, the subsequent spread
of epidemics and the increasing deaths among the European troops brought
attention on public health measures in India. But the measures that followed
were based on the understanding of the ‘tropical environment’, by then wellestablished, and the influence of the theory of contagion prevalent in Britain.
The author suggest that the interest in the ‘salubrious hill stations’ and the
romanticisation of it in the official reports during this period was to lure
reluctant British men to India with its hostile climate. It needs to be
remembered however that there was a strong racist content in these moves
and moreover, it reflected the desperate attempt on the part of the British to
tackle the mortality of their men and women. Such measures were also based
on the miasma theory strongly held by a section of medical men in India and
in Britain that the miasma (‘vapours’) emanating from the filth was the main
cause of diseases such as cholera and malaria. Thus hill stations could provide
an escape from the filthy indigenous populace, the source of all diseases. The
sanitary policies were caught between the contagionist and anti-conlagionist
theories that were prevalent during this period. The tension between the
theoretical ambiguities among medical men and the practical constraints of
the colonial administrationn that formed the basis of the constantly shifting
policies is well-described in the book. The mutiny resolves this tension,
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temporarily though, by giving priority to the practical constraints of
administration.
The possibility of the epidemics spreading to European countries from
India led to the imposition of a quarantine on pilgrim and trade ships from
India and brought pressure on the Indian government to introduce sanitary
measures. The quarantine and the sanitary cordons antagonised the indig
enous population. A controversy surrounding pilgrimage during a plague
epidemic led to tensions between the Hindu and Muslim communities.
It was in a situation worsened by the higher rates of death and
invalidation among the European troops on the hand and the increasing
threat of unrest among the Indians on the other hand that the public health
administration was transferred to the local governments and municipali
ties. It is argued that there were significant regional variations in the public
health expenditure and a diversity of factors affected the development of
public health such as shortages in local revenue, inadequate support from
the centre and the attitude of the population. The conclusion drawn by the
author that there was a dearth of funds for public health measures are
mainly based on the reports of colonial administrators themselves. These
reports frequently mentioned both revenue loss and expenses in famine
and plague measures as reasons for shortage of funds. However, the
expenses on railways and other economic infrastructure were far greater
than that on public health. One wonders then to what extent the economic
constraints cited were ‘real’. These constraints rather appear to be merely
‘instrumental’, which suited the overall economic interests of the colonial
power. Similarly the cautiousness reflected in the correspondences and
reports after the mutiny was again a convenient stand serving larger
economic interests. The fear of unrest, so often cited in the cautionary
notes, did not prevent the excesses which were committed in the anti
plague measures. The author sees these measures as exceptions.
Colonial medicine’s inability to control the death and disease situation is
one of the reasons cited by the author which limited the role played by
preventive medicine. While it is true that medicine could not meet the
magnitude ofpublic health requirements especially from the second half ofthe
19th century onwards, it is also true that medicine came handy in segregating
populations, in dealing with unrest, in the establishment of the inferiority of
Indian culture and its knowledge systems. The Compulsory Vaccination Act
with its ban on indigenous variolation practices and other accompanying
measures taken in order to denigrate Indian knowledge and practices are
completely overlooked by the author [Marglin 1990]. The political and
personal violations committed on Indian people in the name of vaccination,
sanitary and anti-plague measures, the Contagious Diseases Act and its
imposition and a range of specific interventions indirectly motivated by
medicine such as restrictions on pilgrimage, filling up of tanks meant for
irrigation in the name ofanti-malarial measures and so on shows how medicine
78
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sometimes insidiously and sometimes openly was used by the state for its
political purposes. Medicine failed in many ways in achieving the imme
diate objectives of preventing deaths and curing diseases but nevertheless
succeeded in bringing about disruptions which later became a colonial
legacy.
The argument that it is the cautious move adopted by the administration
from the post-mutiny period onwards that applied brakes to the public health
measures is questionable in thecontext of the evidence provided by the author
himself and other writers. A number of ‘medical interventions’ not only
continued but new ones were introduced in the post-mutiny period. There
was of course caution. Indeed sometimes brakes were applied in the form
of resistance put up by people when excesses were commited in the name
of medicine. Such resistance was sometimes sporadic and mild as against
the small pox vaccination or sometimes violent as in the case of the murder
of the sanitary inspector in plague intervention, but was always related to
specific health measures.
The state-medicine relationship during different periocls is conceptualised
by the author in terms of what hecalls ‘authoritarian paternalism’ and ‘liberal
decentralism’. The former is linked to the utilitarian era of the early 19th
century which guided government intervention in public policies. The colonial
responsibility thus manifested itself in the form of a ‘civilising impulse’.
According it the author, “at its best the ‘civilising mission’ was an expression
of genuine humanitarian concern for the plight of indigenous peoples; at its
worst, i t reflected notions of racial superiority and complete disregard for the
sensibilities of the Indian population” (p 230). The ‘liberal decentralism’
which began with Lord Mayo and through the Rippon reforms of the 1880s
guided public health policies in India during this period and after. The guiding
principle was that policies and reforms should not be imposed on an unwilling
population and should retain the confidence of the people.
The sanitary policies swayed more often than not according to political and
economic considerations rather than public health ones. The economic reasons
considered by the author are the lack of funds for public health provisions and
more importantly, the resistance put up by the ‘rentier class’ and the ‘Indian
ratepayers ’ (of Calcutta) against moves to increase taxation towards sanitary
reforms. The Europeans were willing to pay additional house tax and other
taxes for public water supply and cleaning up of the bustis. The Indian
commissioners were against such taxation and were of the opinion that loan
should be obtained from the government for the purposes ofpublic water supply.
The discussion on ‘The Politics ofPublic Health in Calcutta, 1876-1899’ shows
other more important reasons perhaps than those stated in the conclusion. There
was ‘mutual distrust and recrimination’ among the Indian corporators and the
British counterparts. This division was also evident in the demands made by
the two groups and in the press that supported them. The division was further
intensified by the outrageous attitude of Dr J Simpson, the newly appointed
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health officer, towards the Indians and his open allegiance to the British
camp. The ‘resistance’ put up by the ‘Indian elites’ needs to be understood
in its broader political context than only in terms of their economic
interests. The question also arises whether there were public health
measures which were accepted by Indians. What was the context or the
reasons for the acceptance of such measures? A consideration of these
questions would have thrown more light on the nature of resistance by
Indians.
The enormous volume of archival and other evidence that the author
provides does not fundamentally challenge the arguments put forth by the
earlier authors, but provides mainly contextual details. The ‘weightage’
given to the various factors do not measure upto a qualitatively different
understanding of the issues involved. Very often the thrust of the argument
is lost in a sea of details. At the same time, the book provides a number of
valuable references not mentioned by any other writings on this topic.
The colonial history of medicine has so far been studied mainly from
the point of view of modem medicine and the tensions between it and
the indigenous population. Calcutta as an example dominates these
studies. Colonial history of medicine in India needs to come out of this
‘enclave’ to include other regions. It also needs to include other aeras
of ‘conquest’ - such as the ‘conquest’ of traditional systems of medicine
and its practitioners.
References
Kumar, Deepak (1995): Science and the Raj, New Delhi, OUP.
Marglin, F A and S A Marglin (eds) (1990): Dominating Knowledge: Develop
ment, Culture and Resistance, Oxford, Clarendon Press.
Leena Abraham
Tata Institute of Social Sciences
Deonar, Mumbai 400 088
Note to Contributors
We invite contributions to the RJH. Original research articles,
perspectives, field experiences, critiques of policies and
programmes in health care, medicine and allied areas are
welcome. Please send manuscripts, preferably typed in
doublespace. If the material is on a word processor, please send
us a hard copy along with the matter on a diskette preferably in
WS4. Address all communications to the editor at the address on
the inside front cover.
80
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J 996
Towards a New Perception of
Women’s Health
Roopashri
Na Shariram Nadhi (My Body is Mine) by Sabla and Kranti (edited by
Mira Sadgopal), 1995.
EQUALITY of status for women has basically meant control over their
own lives. Since the early years of the ‘Decade For Women’, there has been
a growth in the understanding of essential inputs needed for control over
one’s own life. They have been defined as good health (including control
over children and child spacing), education, and training to opt from a
wider range of income-earning possibilities, control over their own
earnings as well as independence and dignity of their work (vocation or
career).
This book with colourful ‘enadi’ and ‘lambadi’ styles of drawings and a
little declaring My Body is Mine is much more than a book on health literacy
and self-help. The authors have used the title which has emanated from the
participants themselves during the training. They express their right over
their bodies and the need for control over their lives. Rather than sounding as
an individualistic challenge, it speaks of the realisation that “to bring about
a broader change, we have to begin with ourselves”.
One striking thing about the book is that the authors have themselves
participated in the entire training breaking down caste and class barriers and
the distances inherent in formal education and classroom situations. Most
classroom interactions are unequal basically because there is a power imbal
ance in the relationship between the teacher and the student which get
compounded because of class differences. The question of reducing these
imbalances should be central to our concerns, especially as feminists. Literacy
necessarily distances and separates people: the learner from the doer, the
scholar from the worker. But the challenge of feminist padagogy has been to
use literacy to connect people with ideas and histories across racial, gender
and class boundaries. The present book promises this possibility.
One of the authors has said “Experiencing the self-help training has been
a radical experience. I had to share myself and my life choices. I had to
uncover a lot of inhibitions and release a lot of restraints. It was the first time.
I looked at my body - that too - in front of women. Once I had broken my
culture of silence and turned down the volume of do’s and don’t in my head.
I felt greatly liberated.” This tone and approach runs all through the book and
is a refreshing change.
The contents page is unassuming and simple without sounding heavily
academic nor carefully chatty and thus the titles inform the reader about what
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1996
»ocO'‘u«n _>'*/
to expect The authors have incorporated cxci< i
m<»ii«
flip ‘ hart*, role
pia\s. demonstrations, assignments, activities, ciralivr rxpi<••.•.iorr* like
drawing and song making, and most importantly what they ‘ all tftc live
'isual . AU these different forms and media aic huillully iwl Io bring out
debates and develop analytical understanding about tlic-tir.<*l veo and women
in general.
The chapter on ‘We the participants’ gives live dynamic histories of
women who have endured suffering and strife like majority of women in our
country but which arc rarely recorded in socio-cultural anthropology, or
medical sociology. The participants speak about depr i vat ion, marginalisation,
abuse and repression in the institution called family forcing the reader to
rethink about the institution. The gender specific r isks beginning with birth
which continue throughout a woman’s life involving differential risks
assiciated with educational opportunities, reproductive health, marriage
norms, life-style, employment, personal violence, mental health and ageing
are described in sensitively portrayed personal narration by women.
The longest section on Training, with topics like ‘Gender Sensitisation’,
‘PoliticsofHelath’ and ‘Population’, ‘Body Politics and Beyond’, ‘Fertility
Awareness and Sexuialty’, ‘Sclf-helpand Selfexam’, ‘Gyn-Ecological Dis
orders’ and ‘Healing’ and ‘Child Bearing Supports’. All these chapters not only
give the biological make up of women’s bodies but also the social understand
ing and perceptions of the same which need to be corrected. The aim is to
provide skill which in itself is defined as the “ability to transform and recreate
situations and relationships which help us to find solutions and come to
decisions”. The skills emphasised in this training are:
* becoming sensitive and appreciative of each other and oneself
* becoming sensitive and appreciative of each other and oneself
* to think critically, analytically and creatively
* building confidence in self and others
* surveying and planning
* recording and reporting
* ‘self-help’ health work skills like self-exams knowing the disorder and
healing measures
* individual and collective action and networking
* dealing skillfuly with persons in power in the health and medical
systems, in the local government and police, and within our projects and
communities.
They have discussed the ‘Politics of Health and Population’, at length with
emphasis on sterilisation and contraceptive abuse of women in the family
planning programme. Another form of invisibiled hidden violence, carried
on through the media where women are portrayed in stereotyped roles as
mothers, wives and sisters - always sacrificing, loving, with pride in their
faithfulness, loyalty and service to their husbands and family. However, this
aspect which has wide connotations should also have been discussed if not
82
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in a full chapter at least in a few more meaningful paragraphs. This chapter
rightfully carries a critique of western, allopathic, modern medicine and the
same for indigenous systems of medicine would have been welcome.
The authors have used yogic ‘asanas’ and the ayurvedic method of
differentiating substances according to aetiology. Therefore a compilation
which provides a comprehensive training module would have gained if the
rationale for using alternative systems for self-halp were also put forth.
The persistent questions by proponents and opponents of the integration
of relevant systems in health care have been whether yoga gives us newer
insights into human physiology, meditation into brain physiology, acu
puncture into neurology, traditional healing into psychotherapy etc. It
would have been good to know the views of the authors.
In the chapter ‘Body Politics and Beyond’, the section on man’s sexual
and reproductive system covers only half a page whereas the woman’s
sexual and reproductive system is given seven pages. Of course one can
understand the reason fordoing so. First that there are live visual in the case
of woman’s body. Moreover, one agrees with the authors that there is a
need to bring forth a feeling of pride and dignity to the woman’s body
which is otherwise much abused and distorted. However, I could not help
wonder whether there could have been a greater exploration of the
generally known male code of conduct in the section on male body politics.
Myths like ‘Its unaccptable for a male to be a virgin; Boys cam their
manhood via sexual conquest; Men don’t talk about sex, they just do it;
intercourse is the only real sex; the penis has a mind of its own, once
aroused it can’t be controlled’ could have been dealt with in this section.
The chapter on ‘Fertility Awareness and Sexuality’ cover, issues like
myths relating to fertility and sexuality and the link between the two, fertility
awareness for gaining control over fertility and sexuality and to understand
sexuality beyond sex. While reading about the self exams one could not help
ponder about how rapid scientific and technological advances have made the
diagnosis of disease much more refined but have invariably developed
phobias and fears about the same. Here the simplification of the self-exam
method helps to overcome fears doubts, and unnecessary andieties without
trivialising health problems.
The chapters on ‘Gyn-ecological Discorders’ and ‘Healing’ and ‘Child
Bearing Support’ there is a full-fledged discussion on the range and nature of
disorders in women’s bodies and to encourage women’s traditional healing
knowledge and practice, to understand and acquire skills to support women
through infertility, pregnancy, child birth and post partum. Here we are
exposed to the concept of gyn-ecology “as opposed to Gynaecology, the
standard outlook of “women’s diseases” connected with the womb and
reproduction only. Gyn-ecology is women’s total health in balance, crossing
the limits of women’s bodies into society and back. Even now, we feel there
is much conceptual tidying up to be done, but we had to tell ourselves, it is
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83
ECONOMIC
AND
POLITICAL
REVIEW OF WOMEN STUDIES
October 28, 1995
Women’s Rights and Social Change
Cultural Imperialism and Women’s Movements
Sheila Rowbotham: Builder of Bridges
... Vinay Bahl
Judiciary, Social Reform and Debate on
‘Religious Prostitution’ in Colonial India
...Kalpana Kannabiran
Images of the Body and Sexuality in Women’s
Narratives on Oppression in the Home
...Meenakshi Thapan
Fertility and Frailly: Demographic Change and
Health and Status of Indian Women
... Kirsty McNay
Women and Land Rights in Cambodia
...Kyoko Kusakabe, Wang Yitnxian, Govind Kelkar
The Review of Women Studies appears twice yearly as a supple
ment to the last issues of April and October. Earlier issues have
focused on: Women’s Movement in Third World (October 1994);
Gender and Structural Adjustment (April 1994), Women and Public
Space (October 1993); Community, State and Women’s Agency
(April 1993); Gender and Kinship (October 1992); Women: Rights
and Laws (April 1992): Women and the Media (October 1991).
For copies write to
Circulation Manager
Economic and Political Weekly
Hitkari House, 284, Shahid Bhagatsingh Road,
Bombay 400 001
84
RJH
(New Series)
Vol II: 1
1996
not the work of this book!” One would certainly look forward to this
conceptualisation in future.
The book is full of interesting exercises, anecdotes, reactions from the
women participants and therefore even while one is reading it, one gets
invariably drawn in the vortex of one’s own experiences in the community,
personal struggles and the task ahead. The exercise of breaking down the norm
of an ideal body, finding the ‘santosam button’ which was so liberating forthe
women, was an extremely honest and brave approach. The realisation that one
carries the baggage of societal norms, restrictions, fears and self-denials
brings in its wake a kind of soul searching.
The question that stayed in the authors’ minds are put forward honestly.
“Might she turn into a petty 'doctor’ like those that roam the desperate
countryside?... Would Navneethaget enough appreciation and encouragement
from her organisation or from her team of women...’’Thechallenging task for
the future would be getting the participant women and their sanghas and
organisations to act on thedaunting task ofgendersensitisation and changing
the socio-economic context for women on the whole. How the new personal
awareness about issues like child marriage would withstand the whole
complex of social pressures - subtly control ling the labour, property, fertility
and sexuality of women - which perpetuate child marriage!
Generally a study on women’s health follows two orientations. One, where
the bodily problems are used for making statements about women’s social
relations or positions. And the other is where social scientists who are attached
to medical schools/public health organisations work in an auxiliary manner to
add a social science perspective to medically defined problems. This book
moves towards a new kind of social science interest in health lhatcombines
a strength of theoretical as well as applied orientations. All though the book,
the authors have used a methodology where the learning process is based on
concrete activities that permit the learner to actively experience, integrate
new ideas into the conceptual framework they already use and therefore
understand, assimilate and remember them better.
Traditionally, we have regard formal education as the conscience of the
nation in ademocratic, secular and participatory society. An educated person
- man or woman - is a growing person and we need a system to measure this
growth for improved participation of women in our process of socio-economic
development. However, literacy itself has class connotations because it also
means having the time and space to read and write, usually in isolation from
one’s family and kin. We now need a new system to acknowledge and measure
the growth of women who are getti ng informed, educated, trained and therefore
empowered in the process. There is also a need to make scholarship accessible,
unified, coherent and connected to people’s lives’.
- Roopashri
CEHAT, 519, Prabhu Darshan
S S Nagar Andheri (W), Mumbai
RJH
(New Series)
VolII: 1
1996
85
Facts and Figures
National Disease Control Programmes
Ravi Duggal
Sunil Nandraj
Selected diseases have at different points of time received special attention and
separate allocation of resources. In the past small pox was one such disease which
had a separate budget and staff to tackle the problem on a war footing. In the past
many such programs were of a vertical nature having their own budgets and staff.
Malaria and leprosy programmes, apart from small pox were the main vertical
programmes. While the war against small pox was successful, that against malaria
reached a certain success in the mid-60s but after that malaria has come back with
a vengeance and continues to be a major programme (but without its vertical
structure). Leprosy continues to be a vertical programme and in recent years has
shown good results. The tuberculosis and the blindness control programmes have
had no such luck and have always received a step-motherly treatment under public
health care.
Disease programmes on an average during this decade have received 10 per
•cent of the state’s health care budget and the trend is a declining one1. In.per
capita terms at the national level today a measly amount of Rs 8 per person is being
spent on these programs. If one looks at the disease profile of the country then this
expenditure itself is very low to fight these diseases. (Of course, it must be noted
that three-fourths of health care is sought in the private sector hence the actual per
capita value would be four times.) If we break down the expenditure by various
diseases we find that between 80 per cent and 95 per cent is spent on just four
programmes malaria, leprosy, in tuberculosis and blindness. Further, of the total
disease program expenditure 50 per cent to 60 per cent is spent on the malaria
programme alone, followed by about 20 per cent on leprosy. Tuberculosis and
blindness control get under 5 per cent.
The prevalence of malaria is very high right across the length and breadth of
the country, with only Kerala and Goa being exceptions. The NFHS study in
1992-93 gives a 3 month incidence rate of 3324 per 100,000 population, which
means about 105 million new cases every year. The rural areas recorded an
incidence of nearly twice that of urban areas. While most states show a fairly
high share of expenditure for the malaria programme from the total disease
programme budget, it must be noted that most of it goes to salaries of staff who
may not be doing any work related to malaria. For historical reasons most
multipurpose workers (MPWs) get their salary from the malaria department
because they were erstwhile malaria workers and today are MPWs who may be
doing very little malaria related work. Hence, what actually is spent to treat or
control malaria may be a very small amount of the national malaria budget of
about Rs 5000 million which initself may be quite adequate to fight malaria
under a comprehensive health programme.
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According to the 1981 census India had 4.2 million active leprosy cases. The
NFHS survey a decade later in 1992-93 recorded a prevalence rate four times less
than the 1981 census making for acaseload of 1.2 million cases. While one may argue
that the NFHS may have made an undercount there is no doubt that the leprosy
program has had a major impact, and this perhaps due to three reasons - reasonably
sufficient allocation of funds, better management of the programme albeit through
a vertical structure, and treatment largely being availed in the public sector.
The tuberculosis control programme is perhaps the worst performer and the
main reason is very poor allocation of funds in the public system. Further, since
tuberculosis begins symptomatically with cough and fever it is treated mainly in
the private sector which exploits patients with irrational therapy comprising of
cough syrups, tonics and broad spectrum antibiotics. Today there are about 14
million estimated active cases of TB in the country and the state pays very little
attention to it. An evaluation team of GOI-WHO-SIDA found that the drugs
available in the public system were sufficient to treat only one-third of the patients
who actually were receiving care within the public system - this means that the
average patient would get only one-third of the treatment required and hence would
return with a relapse
With nine million blind persons and 45 million with severe visual impairment
this is a very serious scenario. The present focus is on cataract surgery and vitamin
A deficiency. The care of the completely blind is under the social welfare
department. The resources available for handling cataract and vitamin A defi
ciency cases is very meagre and needs to be enhanced substantially.
Of the budgets allocated for various programs salaries take away 70 per cent to
90 per cent of the resources leaving very little behind for other inputs like drugs,
equipments, travel etc. While one recognises that the health sector is clearly a labour
intensive one where human resource is the most valuble input, it cannot be denied
that without adequate drugs, diagnostics etc, the human resource has little value.
Thus if in the present situation 80 per cent of the resource, and increasingly so, goes
for paying salaries then the health workforce cannot be effective with the meagre
resources left over to treat patients, and for preventive and promotive care. If for
instance we look at the teaching hospital or other large city hospitals we find that
salaries account for about 40 per cent of the budget and thus these hospitals perform
more effectively than their rural counterparts like rural hospitals and primary health
centres. It must be emphasised here that percentages have been used in the data only
as a proxy tool. A more realistic analysis would include using morbidity data to
determine the financial requirements or costs needed to deal with it. Unfortunately
at the present moment such data is difficult to come by, though we have made a brief
attempt in Table 4, but its limitations are explained in the table itself.
Note
1 The data in the tables have been extracted from the CEH AT database which was
put together for the national research programme on Strategies and Financing
for Human Development and this is available presently as a monograph titled
Financing of Disease Control Programmes in India by the present authors.
RJH
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87
Table 1: Expenditure on Selected Disease Programmes (Selected States)
Year
Malaria TB Leprosy Blindness
(Aspercentages to totsil health)
Andhra Pradesh
1990-1991
10.11
9.82
1994-1995
Assam
7.36
1990-1991
1994-1995
3.90
Bihar
4.96
1992-1993
5.41
1994-1995
Gujarat
1990-1991
4.59
1994-1995
7.12
Haryana
1990-1991
10.72
1994-1995
11.57
Karnataka
1990-1991
3.40
1994-1995
3.27
Kerala
1990-1991
1.43
1994-1995
1.75
Madhya Pradesh
1990-1991
.7.18
1994-1995
7.12
Maharashtra
1990-1991
8.58
1994-1995
6.60
Orissa
1990-1991
5.36
1991-1992
5.73
Punjab
1990-1991
8.43
1994-1995
5.67
Rajasthan
1990-1991
6.66
1994-1995
5.74
Tamil Nadu
*
1992-1993
♦
1994-1995
Uttar Pradesh
1990-1991
7.84
1994-1995
7.11
West Bengal
1990-1991
6.89
1994-1995
4.27
Arunachal Pradesh
1990-1991
2.60
1994-1995
4.57
Goa
1990-1991
.99
1994-1995
.77
AIDS
All
Diseas;e
Total
Health
1.25
1.42
4.62
4.97
.21
.28
.00
.48
16.11
18.79
(Rs millions)
3325.10
5043.53
1.42
.97
1.48
1.32
.75
.80
.00
.00
17.29
7.26
941.22
1883.92
.27
.19
3.39
2.89
.12
.08
.00
.00
9.18
10.34
3856.38
5574.54
2.48
2.95
1.78
1.60
.84
.78
.00
.41
10.89
13.76
2478.16
3593.73
1.81
4.36
.08
.05
.24
.75
.00
.50
12.30
15.33
917.60
1396.29
1.80
1.90
.84
.95
.29
.47
.00
.69
4.70
5.58
2698.20
5077.72
.80
1.01
.99
1.53
.20
.45
.00
.05
3.96
5.98
2224.32
3759.77
.37
2.31
2.36
1.-86
.70
' .86
.00
.60
11.02
8.84
2647.20
4609-.97
2.80
2.48
3.00
2.85
.10
.07
.07
.41
14.34
11.87
4341.15
6803.92
1.46
1.67
3.66
4.33
.17
.27
.00
.00
11.29
10.98
1550.21
1565.99
1.72
2.31
.14
.19
.18
.38
.00
.48
11.88
6.90
1765.76
2312.75
2.56
2.23
.40
.36
.26
.44
.00
.14
8.65
8.18
2555.20
4556.96
1.38
1.57
3.54
3.63
.28
.26
.04
.02
4.83
6.20
4894.22
5982.37
3.07
2.16
2.45
1.93
.51
.34
.00
.14
15.85
17.35
5826.32
8003.05
3.74
3.07
2.43
1.63
.23
.23
.00
.15
13.20
9.18
3256.13
5397.64
2.24
2.40
.86
.68
.33
.21
.00
.00
19.14
11.73
144.86
278.07
2.77
2.31
1.70
1.43
.36
.33
.00
.29
5.51
5.13
232.15
350.86
Notes'. * Data breakup not available; 1994-95 data are budget estimates
Sources: Respective State government. Demand for Grants, 1993-94 and 1994-95.
88
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Table 2: Expenditure on Salaries for Disease Programmes (Selected States)
Year
Tuberculusois
__ Leprosy___ Blindness
Malaria
As Per Actuals As Per Actuals As Per Actuals As Per Actuals
Cent
Cent
Cent
Cent
Andhra Pradesh
1990-1991
80.00 336.46
1994-1995
93.29 495.42
Assam
1990-1991
.00 69.32
1994-1995
9.55
73.51
Bihar
1992-1993
95.25 191.25
1994-1995
86.88 301.39
Gujarat
1990-1991
5.90 113.95
1994-1995
3.80 256.03
Haryana
81.14 98.41
1990-1991
1994-1995
77.95 161.51
Karnataka
.00 91.97
1990-1991
1994-1995
24.06 166.27
Kerala
1990-1991
92.05 31.95
1994-1995
90.80 65.86
Madhya Pradesh
1990-1991
79.81 190.22
1994-1995
66.18 328.04
Maharashtra
1990-1991
68.25 372.50
1994-1995
76.40 448.81
Orissa
82.74 83.14
1990-1991
1991-1992
84.05 89.68
Punjab
68.28 148.98
1990-1991
83.45 131.15
1994-1995
Rajasthan
1990-1991
71.46 170.37
71.41 261.60
1994-1995
Tamil Nadu
♦
1992-1993
.00
*
1994-1995
.00
Uttar Pradesh
72.48 457.20
1990-1991
1994-1995
75.09 569.33
West Bengal
1989-1990
96.31 147.75
1994-1995
94.72 230.59
Arunachal Pradesh
1990-1991
93.39
3.78
12.71
1994-1995
78.52
Goa
78.88
2.32
1990-1991
2.70
1994-1995
85.93
82.53
81.91
41.85
71.58
85.22
88.88
153.69
250.64
10.21
8.43
7.05
14.36
16.60
56.59
13.43
18.20
.00
56.64
14.02
24.91
.00
.00
7.10
15.06
2.90
3.24
10.34 99.54
10.49 104.70
130.74
161.19
38.66
34.34
4.63
4.63
57.38 61.47
41.70 105.85
68.54
67.63
44.22
57.67
62.75
79.57
21.02
28.10
60.75
39.60
16.61
60.83
58.11
77.27
.74
.66
11.76
.00
2.21
10.54
66.92
48.26
48.82
96.65
35.60
10.50
22.67
48.48
.00
00
7.85
23.80
51.96
53.59
17.90
37.90
97.69
96.67
22.04
57.37
89.24
70.80
4.46
16.92
35.36
73.61
10.04
106.56
83.83
86.50
62.72
85.95
66.29
61.13
18.66
39.46
49.66 121.84
48.48 168.50
80.87
78.59
130.39
194.07
.00
.00
4.43
5.04
69.37
72.72
22.72
26.21
85.53
86.88
56.88
67.75
92.83
32.70
2.79
4.22
79.32
65.38
30.41
53.50
91.13
87.05
2.48
4.48
52.94
55.77
3.23
8.75
67.49 65.61
62.84 101.57
88.96
92.04
10.24
16.59
33.53
17.98
6.77
19.85
55.52
52.20
67.53
94.00
92.93
93.32
173.10
217.01
78.92
85.02
13.66
15.75
86.11
59.15
179.33
172.87
77.41
80.34
143.09
154.19
62.14
50.92
30.16
27.20
77.01
72.52
96.05
165.56
87.97
91.81
63.36
87.87
92.53
81.29
4.82
12.56
88.62
68.97
3.25
6.67
92.80
89.95
1.25
1.89
.00
.00
.49
.59
.84
1.16
Notes-. * Data not avaiable; Actuals are in Rs millions spent on each disease programme.
Sources'. Respective state government, Demand for Grants, 1993-94 and 1994-95.
RJH
(New Series)
82.61
86.42
Vol II: 1
6.44
8.10
1996
82.78
87.20
3.95
5.00
92.86
93.10
89
Table 3: Prevalence of Selected Diseases, 1992-1993
(per 100,000 population)
State
Malaria
Tuberculosis
Leprosy
Blindness
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Jammu and Kashmir*
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
Arunachal Pradesh
Goa
Mizoram
Himachal Pradesh
Manipur
Meghalaya
Nagaland
Sikkim
Tripura
India
7776
10828
5712
12912
3732
3412
1828
448
18912
14968
20592
10184
204122304
29580
2712
16852
972
18544
4564
6564
22892
11112
NA
10476
13296
407
638
595
308
327
245
136
586
435
293
555
238
724
703
560
357
938
179
311
242
941
321
491
NA
289
467
118
36
123
29
14
18
132
18
136
72
96
28
1-28
209
. 222
47
110
16
33
56
199
17
153
NA
0
120
5984
1106
2749
3266824
869
4900
1404
3831
3534
3161
863
4661
836
3101
914
1012
2714
1524
1384
1442
759
1373
NA
1430
3001
Notes'. 1) * = Refers only to Jammu region.
2) Malaria data is incidence of cases. The NFHS data was for three months, we
multiplied it by 4 to arrive at the annual figure. For other diseases it is point
prevalence.
Source: National Family Health Survey 1992-93 : All India,International
Institute for Population Sciences, Bombay, August 1995 (P 205, Tables 8.2).
90
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1996
Table 4: Normative Expenditure Incurred Per Case 1992-1993
The per case expenditure is a normative figure because it is well known that a)
actual utilisation of these government programs is only by one fourth to one third
of the population and b) the establishment costs (salaries etc.) takes away about
three fourth of this expenditure. Therefore, the real expenditure per actual case is
much higher, but this data helps us look at allocations in terms of disease
prevalence across diseases.
ees^
State
Malaria
Tuberculosis
77
29
37
29
210
NA
157
274
14
33
13
76
22
NA
15
109
43
212
52
186
46
42
116
NA
33
NA
186
52
19
587
567
NA
1001
96
214
529
146
567
207
167
158
448
658
3426
1985
593
270
733
1386
NA
124
NA
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Jammu and Kashmir*
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
Arunachal Pradesh
Goa
Mizoram
Himachal Pradesh
Manipur
Meghalaya
Nagaland
Sikkim
Tripura
India
Leprosy
2445
2448
1175
4693
189
NA
427
5875
811
3002
2185
390
281
1438
891
2484
2431
24070
12444
3628
1690
19265
2919
NA
NA
NA
Blindness
3
24
2
18
43
NA
5
12
9
2
4
22
6
28
8
25
280
47
136
49
56
139
68
NA
59
NA
Notes. 1) * = Refers only to Jammu region; 2) The expenditure figures for Orissa
and Manipur refer to year 1991-92
Source: Prevalence data: National Family Health Survey 1992-93: All India,
International Institute for Population Sciences, Bombay, August 1995 (Pg. 205,
Tables 8.2)
Expendiute data : Respective state government Demand for Grants, 1994-95.
RJH
(New Series)
Vol II: 1
1996
91
South Indian Studies
A multi-disciplinary journal
Editor: M.S.S. Pandian
Re-evaluating old themes and problematising received forms of
knowledge is a refreshing aspect of recent social science enquiries.
Areas and aspects of social life which have remained outside the
domain of academic knowledge, are now being brought under
investigation. While conventional terrains of research show signs
of having been overworked, there are indications of new ones
emerging, provokingfresh insights and keen debates. These enquiries
and debates, dispersed across disciplines, are recasting our
understanding of South Indian society' in a new light.
South Indian Studies intends to consolidate the gains of such
enquiries by offering a broadforum to present and discuss current
research on South India. In addition to papers and reviews, the
journal plans to carry resume of major debates taking place in
South Indian languages.
The journal invites papers, research notes, review articles and
reviews for publication. All papers will be refereed before being
accepted for publication.
Editorial correspondence
M.S.S. Pandian, Madras Institute of Development Studies
79, Ilnd Main Road, Gandhi Nagar, Adyar, Madras 600 020
Business correspondence
Chithira Publishers
a division of
Chithira Communications Co. Pvt. Ltd.
39/3006, Manikath Road, Kochi, Kerala 682 016
Phone : 364005, 354106
92
RJH
(New Series)
Vol II: 1
1996
radical
JOURNAL OF HEALTH
Editorials: Medicos’ Strike: Relevant Issues Amar Jesani
Signs of Distress
Padma Prakash
Indian Criminal Law and Industrial Offences
Critique and Case Studies
Sapna Malik
Economic Aspects of Tuberculosis Control in India
Sujata Rao
Family Experience of Epilepsy
Premilla D’Cruz
Document
Leeds Declaration: Reorienting Public Health
Research
Communications
Utilisation of Maternal Health Services
Report from Rajasthan
P R Sodani
Interpreting Demographic Data
SRS, 1995
S Ramasundaram
Review Article
Sustainable Development: A Limited
Framework
KJ Joy
Index 1995
The problem of how man should act if his govern
ment prescribes actions or society expects an attitude
which his own conscience considers wrong is indeed
an old one. It is easy to say that the individual cannot
be held responsible for acts carried out under irre
sistible compulsion, because the individual is fully
dependent upon the society in which he is living and
therefore must accept its rules. But the very formu
lation of this idea makes it obvious to what extent
such a concept contradicts our sense of justice.
External compulsion can, to a certain extent reduce
but never cancel the responsibility of the individual.
In the Nuremberg trials this idea was considered to
be self-evident. Whatever is morally important in our
institutions, laws and mores can be traced back to
interpretation of the sense of justice of countless
individuals. Institutions are in a moral sense impotent
unless they are supported by the sense of responsi
bility of living individuals. An effort to arouse and
strengthen this sense of responsibility of the indi
vidual is an important service to mankind.
-Albert Einstein
[An open letter to the Society for Social Responsibility
in Science, published in Science, December 22,1950.]
Position: 3735 (2 views)