Radical Journal of Health 1996 Vol. 2, No. 4, Oct. – Dec.
Item
- Title
- Radical Journal of Health 1996 Vol. 2, No. 4, Oct. – Dec.
- Date
- December 1996
- Description
-
Surat epidemic 1994: was it plague?
Bio social determinants of abortion: interpreting NFHS data
Educating women doctors: an experiment in Sudan
Document: National population policy
How useful is primary data in understanding health needs? - extracted text
-
1996
OCTOBER-DECEMBER
radical
jourso o f he a lt h
■
A SOCIALIST HEALTH REVIEW TRUST PUBLICATION
New Series VOLUME II
SURAT EPIDEMIC 1994: WAS IT PLAGUE?
BIO SOCIAL DETERMINANTS OF
ABORTION: INTERPRETING NFHS DATA
EDUCATING WOMEN DOCTORS:
AN EXPERIMENT IN SUDAN
DOCUMENT: NATIONAL POPULATION
POLICY
HOW USEFUL IS PRIMARY DATA IN
UNDERSTANDING HEALTH NEEDS?
Rs 25
Consulting Editors'.
Amar Jesani.
CEHAT. Mumbai
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
Manisha Gupte,
CEHAT, Pune
V R Muraleedharan,
Indian Institute of
Technology, Madras
Padmini Swaminathan.
Madras Institute of
Development Studies, Madras
Sandhya Srinivasan.
Harvard, USA
C Sathyamala. New Delhi
Thelma Narayan.
Community Health Cell.
Bangalore
Veena Shatrugna. Hyderabad
Irudaya Rajan. CDS,
Trivandrum
The Radical Journal if Health is an
interdisciplinary social sciences
quarterly un 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
analy sis 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 1984and continued to be brought out until
1988. This new series of RJH begins
with the first issue of 1995.
Editor. Padma Prakash
Editorial Group: Aditi Iyer, Asha
Vadair. Ravi Duggal, Sandeep
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Volume II New Series Number 4 October-December 1996
Editorial: Overburdened Underutilised
Padma Prakash
197
Surat Epidemic, 1994: Was it Plague
Nimitta Bhatt, Ashvin Patel
199
Bio-Social Determinants of Abortion
among Indian Women
US Mishra, Arvind Pandey, S Irudaya Rajan
213
Branded Health Care
K S Sebastian
Educating Women Doctors:
An Experiment in Sudan
223
228
Communications
Learning to Know Differently
Subhadra, Rahul
234
Book Review
Genome Research and Justice
K Ravi Srinivas
239
Document
Statement on National Population Policy
i
242
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RJH
(New Series)
Vol 11:4
1996
Overburdened Underutilised
For decades now there has been constant criticism that urban health
care is gobbling up the state’s meagre resources leaving little for the
villages in which, ‘80 per cent of the population live ’. And yet, just what
kind of care do the state’s urban helath systems provide? Does the
solution lie in cutting down on urban health investment?
WITH a public health system that has, historically, grown from the top
down, lower levels of urban care are almost non-existent. And the large
hospitals, dating back to the first quarter of the century, are mostly
concentrated in the old city areas and do not service the growing suburban
population. For example, more than two-thirds of Mumbai ‘s (formerly
Bombay) 37,500 public hospital beds are in the southern tip of the island..
none of this is new so it should not surprise us at all that two hospital
studies being undertaken are coming up with interesting information
about the type of patients who access these hospitals. The government
hospitals it is clear is overburdened with two types of patients: those
requiring primary level care and good diagnostic skills, and those whose
illness conditions have been neglected, and the cost of care is now high
with the chances of full recovery diminished. For example, about 40
per cent of those who attended the general medicine OPD in one of
Mumbai’s largest public teaching hospital needed only primary level
care. This means that public hospital services that constitute secondary
and tertiary level care, are both overburdened and underutilised. And
unfortunately, these arc the institutions that account for increasingly
larger share of expenditure on health care.
This scenario is typical of most ex-colonial countries. Gaining inde
pendence in the 50s and even the 60s, these countries adopted welfarist
models with state planning. In the health sector the entire focus was on
developing the state services, which grew rapidly in the first two decades.
The sharp growth of the private health sector towards the end of the 1960s
was prompted by several factors: the falling state spending on health, the
continuing production of medical personnel, who could not find adequate
employment in the state institutions, a growing middle class, dissatisfied
with the public sector and willing to pay for private care. While there are
only varying estimates of the size of the private sector, everybody agrees
that it is much larger than the public sector. By the 1990s per capita private
out-of-pocket spending on health care in India was a whopping Rs 240 or
75 per cent of total national health expenditure according to a survey
conducted by the National Council of Applied Economic Research.
This mammoth private sector in health care includes individual
practitioners, small nursing homes, as well as corporate, for-profit
RJH
(New Series)
Vol II: 4
1996
199
institutions. Even as state institutions have become the focus of public
criticism and ire for their inefficiency and falling standards , the private
sector has been enjoying a completely unfettered existence. Ironically in a
country that has strictly monitored and controlled industrial growth through
the ‘licence-permit-raj’, in most nursing homes, which means that there are
no mandatory norms, no minimum physical standards for private institutions
and the service they render. A recent survey of nursing homes in two districts
in the state of Maharashtra found that only 18 per cent of the institutions had
pathology laboratories and more than 30 per cent did not have an operating
theatre, and most did not have emergency care equipment.
Ironically enough this deepening crisis in health care has been rather oddly
affected by the new economic policy and the structural adjustment programme.
Since the 1990s, the slates are receiving decreasing financial support from the
centre, from constituting 19 per cent of state budgets it was a mere 3.3 per cent
in 1992-93. This has sharply affected health funding. In any case, the share
of health expenditure has actually fallen since 1974-78 hitting a new low at
2.6 per cent in the early 1990s. So even though many of the national
programmes such as for instance National Tuberculosis Control Programme,
have benefited from massive infusions of funds from unilateral agencies such
as the WHO, and the World Bank, the infrastructure support for these
programmes is crumbling due to lack of funds.
This situation has prompted on the one hand a sharper focus on the long
ignored private sector in health care. There is also a desperate attempt to
streamline the public system, cut down waste and to search for new
sources of funding. Following World Bank recommendations some states
introduced user charges at higher levels of the structure, but had to
abandon the move under popular pressure. The protest was hardly
surprising. As the Mumbai study by the Foundation for Research in
Community Health shows, more than two-thirds of public hospital users
belonged to households with a per capita income of less than Rs 500 per
capita. However there is little effort to review the Employees’ State
Insurance Scheme which is as old as the post independent health system.
In short, the urban sector, for long the target of critics of the state’s
spending on health, is grossly underserved .
In a sense it reflects the needs of an emerging capitalist state and its
priorities. Until now, the sustenance of the working class was not a major
issue - it was replaceable. But as the expanding industries require higher
skills and the changing nature of labour, itself, a point is reached where
the worker’s longevity and ability to deliver becomes more and more
important. And investment in keeping workers sound becomes less
expensive than investing repeatedly in the upgradation of skills. These
and other factors are making urban health a greater concern.
-Padma Prakash
200
RJH
(New Series)
Vol 11:4
1996
Surat Epidemic, 1994
Was it Plague
Nimita Bhat
Ashvin Patel
This is a preliminary exploratory study aimed at determining
the real nature of the epidemic which was understood to be plague,
undertaken by the Gujarat Voluntary Health Association
I
Introduction
THE unusual epidemic of plague caused an unusual scare given the nature
of morbidity and number of deaths. Severe morbidity and mortality
caused by hepatitis, gastroenteritis, malaria, etc usually go unnoticed
even by media. Early labelling of the disease as ‘Plague’ was the source
of panic. It was reinforced by the alleged nature of its spread i e, from
human to human by air. Tuberculosis which is spread similarly and
infects larger population causing disease and death is not so feared maybe because it is a usual affair and not acute in nature.
Even though, it caused so much fear and attracted attention of all and
inspite of large number of expertise available, the nature of the event was
mystified, resulting in confusion and chaos. The authority behaved in a
strange way as if it was a great secret concerning national security. No
information was available to the medical professionals nor to other
concerned groups. Entry to Surat Civil Hospital was almost impossible
and information was denied.
Controversy continued without muh evidence based on conjectures
whether it was plague, mellidiosis or something else. Even today after so
many days controversy is still no resolved. The government of Gujarat
appointed a committee to prepare a scientific report. We should await its
findings, whether it tells us clearly about the disease with clinical,
laboratory and epidemiological evidence. In such a state of chaos,
confusion, inaccessibility to patients’ records, added with hesitation of
the people to cooperate any inquiry, unavailibility of the serological
events, it would be unwise and, impractical to conduct any valid
epidemiological (analytical) study. Even then to have some under
standing of the problem, we ventured to conduct a preliminary explor
atory study.
In the absence of serological tests and unavailability of primary results
with serological titers to compare with, our study would not focus on
RJH
(New Series)
Vol II: 4
1996
201
finding the agcnl/causative organism of the epidemic. However, keeping
in view various possibilities in mind (e g plague, mellidiosis etc) one can
try to determine the possible factors-exposures both behavioral and
environmental.
The study proposed to determine: (1) Whether any contact developed
illness within one month of exposure; (2) Role of migration from/to Bccd,
Latur, etc; (3) Role of exposure to flood waler: (4) Role of open drainage
or puddle in vicinity; (5) Role of garbage; (6) Role of pels and street
animals; (7) Role of congestion; (8) Role of kind of house, and household
belongings (economic status); and (9) Role of alcohol and smoking.
II
Material and Methods
The study population: All (age > 14 years) sputum positive cases
(positive = gram negative coco-bacilli), all death cases and serologically
positive cases admitted to Civil Hospital. Surat between September 19,
1994 and October 12, 1994 formed the universe of the study.
Total number of adults cases (age > 14 years) admitted as likely cases
of plague was 545. Total number of urban cases among the various
categories was as in Table A.
Table A
1 Sputum Positive cases and live
2 Serologically positive cases
(No death among this group)
(79)
79
(26)
3 Death Cases
(25)
i e. Total number of cases
=
01 Sputum positive
25 Sputum Negative
06 Sputum Positive
19 Sputum Negative
130
We decided to study only urban cases (130) i e, those residing in the
city of Sural. A questionnaire was designed. Il was in Gujarati and for
specific factors/exposures. A number of teams, each consisting two
persons, one medical and one non-medical tried to locate the houses from
inomplete addresses which were available to us . Out of 130 cases only
40 could be located. Other ad
Table 1: Detailes of Non Response
dresses were either incomplete
Number
or incorrect. Some had left the Category
77
city either temporarily or Incomplete Addresses
Left Sural
09
permanantly.
04
The controls: We also se Refused
Total
90 (69 per cent)
lected two controls for each
202
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1996
case from neighbourhood by random sampling. Thus we could interview
80 persons as control group.
Observations and Discussion
The figures in Table 1 show that nearly 69 per cent of the cases were
non response. The study team spent lot of efforts and time to trace ech and
every case. This includes walking log distances, visiting the area number
of limes, taking help of local volunteers (area people), visiting at late
hours, etc. Since the addreses of the cases were incomplrte, 77 (i e, 59 per
cent) could not be found, nine cases (7 per cent) had left Sural and four
(i e, 3 per cent) cases refused to answer. Two persons out of the four who
refused were employed in a hotel. The hotel manager refused to allow the
interviews by saying that the boys were not available. Obvious, he was
worried about adverse implications upon his business. Thus only 31 per
cent of the 130 cases could be interviewed.
The size of response/non-availabilily of the study-cases, is a big
limitation of our study to draw any valid conclusions so we have also not
applied the statistical tests of significance. However the information
gathered may give some clue and so we have tabulated the same.
Table 2 shows that out of 40 cases 28 i e, 70 per cent are males and out
of 80 controls 66.25 per cent are males. Selection of control was by
random method. No matching was done for sex or age. It seems that the
age group 14-20 yrs and 46-60 yrs are more vulnerable to get the disease.
Table 2: Age-Sex Distribution of Cases and Controls
Age Group
Years
Controls
Cases
M
6 [21.4]
1 [8.3]
16 [57.1] 9 [75.0]
5 [17.9] 2 [16.7]
0
1 [3.6]
28 [100] 12 [100]
14-20
21-45
46-60
60+
Total
M
F
6 [11.3]
39 [73.6]
7 [13.2]
1 [1-9]
53 [100]
2 [7.4]
22 [81.5]
2 [7.4]
1 [3.7]
27 [100]
F
Case
Total
Controls
7 [17.5] 8 [10.0]
25 [62.5] 61 [76.3]
7 [17.5] 9 (11.3]
2 [2.4]
1 [2.5]
40 [100] 80 [100]
Table 3: Occupation
Occupation
Cases
Contois
Diamond workers
Loom workers
Casual labourers
Working at home
Vendors
Others
Total
3 [7.5]
5 [12.5]
3 [7.5]
8 [20.0]
1 [2.5]
20 [50.0]
40 [100]
4 [5.0]
9 [11.5]
12 [15.0]
16 [20.0]
3 [3.8]
36 [45.0]
80[100]
RJH
(New Series)
Vol JI: 4
1996
203
It appears from Table 3 that the casual labourers and vendors had some
protection from the illness. (This may be because of the reason that they
do not work in close and congested space for long hours).
Migration is considered positive in two conditions.
[ 1 ] If any members of the family has visited the areas mentioned in the
table after 1st Sept till development of disease in the case.
[2] Anybody from these areas has visited the family for the same
period.
There is no migration from or to Plague-prone area of Maharashtra in
both groups-cases and control. Thus we can say that the disease in Surat
is unlikely to have come from Maharashtra.
Exposure to flood water is considered positive in two situations (1)
History of abrasion/cut during the period of flood and walking into flood
water or (2) Contact of flood water with mucous membrane of oral and/
or nasal cavity.
The table shows that there is not much difference between the case and
control groups regarding exposure to flood water. However, there seems
to be some additional amount of risk because of exposure to food/water.
Exposure to animals is considered positive in two conditions:
(1) Any per animal in the house or
Table 4: Migration
Migration
1
1.1
1.2
2
4
Cases
Controls
0
0
1
2
37
40
0
1
5
1
73
80
Cases
Controls
3(7.5]
37(92.5]
40(100]
4(5]
76(95]
80(100]
Maharashtra
Latur, Beed
Rest of Maharashtra
Other States
No Migration
Total
Table 5: Exposure to Flood Water
Exposure
No Exposure
Total
Table 6: Exposure to Animals
Exposure to Animals
Yes
No
Total
204
RJH
Cases
Controls
9(22.5]
31(77.5]
40
7(8.75]
73(91.25]
80
(New Series)
Vol 11:4
1996
(2) Any street animals regularly coming into the house.
It shows that cases have higher (2.5 times higher) exposure to animals
than controls. It is likely that the disease transmission was related to
contact with the animals. The animals include street animals (like goats,
pigs and dogs) and domestic animals (like cat, dog, buffalo, goat, cow
etc.) The above table shows that cases and control have similar pattern
of housing.
This table shows that persons having less or no belongings ic
people in lower economic class have a higher risk of contracting the
disease.
The table shows that congestion is a possible risk factor for the disease.
Cases have almost 2.4 times higher exposure to severe congestion.
The table shows that the distance of garbage heaps is less than 100 ft.
for 90 per cent of the cases.
Table 7: Type of House
Cases
Controls
13(32.5]
7(17.5]
20(50.0]
40
22(27.5]
16(20.0]
42(52.5]
80
Type
Cases
Controls
Luxurious items
Washing machine, VCR TV, etc
Upper Economic class
Moped/Scooter/TV
Middle class
Only Bicycle
or
None of above lower economic class
Total
2(5.0]
6(7.5]
10(25]
27(33.75]
28(70.0]
47(58.75]
40
80
Cases
Controls
12(31.6]
17(44.7]
9(23.7]
40
2(5.0]
34(47.2]
31(43.1]
7(9.7]
80
8(10.0]
Type
Hut
Pakka without slab
With slab
Total
Table 8: Household Items
Table 9: Congestion in Residence
No of persons/room
3 -or less than 3
4-6 (congestion)
More than 7 (severe congestion)
Total
Non response
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1996
205
The table shows that more than 50 per cent cases have the waterpools
with 100 ft of their residence.
Number of rat-deaths is ver}' low and not confined to small locality. So
this can not be considered as typical rat fall which precedes plague
epidemics.
Addiction is considered positive if the habit is for more than 3 months
duration. Alcohol addiction is higher among the cases than in the controls.
At the very outset we would like to clarify that the study objective
was to explore the epidemic for various possibilities which were
being discussed at that time.
Table 10: Distance of Garbage Heaps
Secondly the big limitation al
from Residence
the time of study was that there
Cases
was no possibility to know Distance
about the causative organism within 10 ft
29(72.5]
due to (a) Unavailability of the
7(17.51
11 to 100 ft
relevant test kits and (b) Re more than 100 ft
4(10.0]
40
luctance of the administration/ Total
medical authorities to give cor
rect information in a con
Table 11: Distance of Waterpools/
vincing way. thirdly, non
Open Drainage from Residence
traceability of the patients due
to various reasons (such as Distance
Cases
lack ofcomplete address, scare
18(45.0]
within 10 ft
due to situation, escape from
5(12.5]
11 to 100 ft
Surat, etc) also played a major more than 100 ft
17(42.5]
role in reducing the size of our Total
40
data.
Table 12: Ratfall in Case - Neighbourhood during 01/09/94 to 12/10/94
Area
No of Rates seen Dead
Date
1
1
1
10/10/94
07/09/94
10/09/94
Choksi Mill, Udhna
Vijayanagar, Ved Road
Ramjinagar, Ved Road
Table 13: Addiction
Name of Addiction
Cases
Contois
Tobacco smoking
Tobacco chewing
Alcohol
Others
Any of the above
No Addiction
Total
9(22.5]
5(12.5]
5(12.5]
1(2.51
14
26
40
19(23.75]
15(18.75]
2(2.5]
—
31
49
80
206
RJH
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Vol JI: 4
1996
Table 14: Summary of Factors in Favour of and against Various Possibilities
Epidemiological Factors
Factors Against
Possible Disease
Factors in Favour
Plague
Heaps of garbage favouring the
rodent population
No evident case of bu
bonic Plague.
Flood must have forced wild
rodents to enter domestic areas.
No evidence of migra
tion of carrier from
Maharashtra
Ratfall may have gone unnoticed. No evident Ratfall
Mellidiosis
People were exposed to soil and
flood water.
Person to person spread
is unlikely
Hantan virus
Possibility of inhalation of dried
excreta of rodents.
Dengue fever
Spread by Mosquito.
Occur as isolated cases.
Person to person trans
mission does not take
place..
Attack rate is very high.
Possible Disease
In Favour
Plague
Fever +, Cough+,
Haemoptysis* Death, response
to specific treatment*,
No case of bubonic
plague seen
Mellidiosis
Fever*, Cough*, Haemoptysis*,
Death*,
No suppurative lesions
seen. Treatment needed
for 2-5 months for ob
taining cure.
Hantan virus
Fever*, Cough*,
Dengue fever
Fever*,
No hypotensive.
Oligouric, or polyuric
phase Antibiotics do not
help
No haemorrhagic menifestastion. Antibiotics do
not1 help
Possible Disease
In Favour
Plague
Gram-ve bacteria, consolidation
Mellidiosis
Gram-vc bacteria,
Consolidation.
Clinical Factors
Against
Laboratory Findings
Against
Hantan virus
Dengue fever
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1996
Culture and sensitivity re
sults not available
Serology not available.
Culture and serology not
done. No cavities/abcess.
Gram-ve bacteria.
Gram-ve bacteria.
207
Still the data is sufficient enough to give some clues and sets the
trend for further action regarding such epidemic in future. The study
design involved two controls for each case. This has given a good
amounts of confidence about our results. However, due to constraints
mentioned above it is not correct to apply satistical tests.
We have tried to draw provisional inferences by comparison be
tween cases and controls. The tables are quite self explanatory. In the
discussion that follows now, based on some available information
regarding the clinical profile of cases and present knowledge about
any other competing disease conditions (ofcourse, from medical
literature and books), we have tried to rule out some of the possibili
ties.
II
Was It Plague?
Epidemiological factors in favour of plague exit in Surat many
years. Especially the huge garbage heaps not cleared for a long time,
are convenient for rodent stay. Other factors like development of the
localities is haphazard, congested and dingy. This further makes it
convenient for the rodents to enter and be in the houses, recent history
of heavy floods in River Tapi could be one more factor. The flood
water mixed with sewage dirt entered into the peoples’ houses due to
low level housing and intricate open drainage system throughout the
city. In this case, due to absence of any substantial data to prove
otherwise, we may agree to the possibility of wild rodents entering
into peridomcstic areas.
Early labelling of the disease to be plague was done based on the
gram negative bacteria in sputum samples. They showed the bacilli
with bipolar staining. Also there is evidence of wild plague focus
around Surat.
There was no reporting of bubonic plague during our survey. Our
data clearly points out that there was no migration to or from the
families of the cases nor it was in their work places, secondly although
ratfall may have gone unnoticed, all the 40 cases and 80 controls our
sample do not remember to have noticed any ratfall. Looking to the
timespan of spread of plague in instances worldover, we find that it is
bit unusal that the disease was contained for a few days only with
much less mortality than one would have envisaged in Pneumonic
plague. Also from our data it is seen that the cases did have greater
congestion in their houses (Table 9) than the controls. Absence of any
related symptoms among contracts of the cases questions the disease
to be pneumonic plague. There is no firm information in literature
concerning efficiency of pneumonic plague cases in transmission of
208
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1996
disease by the aerosol produced while coughing. In some instances
many contacts become ill and in many others even without treatment
Ise family contacts remain healthy.
It shows that cither the attack rate was low (i e, low virulence of the
organism) or some previus immunity in family members (contacts).
Keeping in view the infectious nature of pneoumonic plague coupled
with congested living conditions of the cases it is difficult to explain the
absence of sdccondary cases.
It is observed that large number of cases and control were staying
in vicinity of garbage heaps and waterpools. Higher exposure to
animals points to possible sources of infection (Table 6). However it
is not possible to indicate the specific one. Alcohol addiction is higher
among the cases pointing to overall lower immuity. It favours intra
cellular organisms like viruses, pseudomonas pscudomelii, Y pestis,
etc. Overall the greater exposure of the cases to animals (Table 6),
congestion (Table 9) and less household belongings (Table 7 and 8)
indicate poor socio economic conditions, poor sanitation and un
healthy environment.
We may weigh the above discussions in light of other guesses regard
ing the disease (i e, whether it was Mellidiosis hantan virus infection, or
Dengue fever?)
The clinical signs and symptoms coupled with lab findings point out
that the epidemic was of bacterial origin. This is further proved by the fact
that the disease responded very well to the antibiotics. This rules out the
possibility of the disease having viral origin i e, Hanlan virus or of Dengue
fever. Also the epidemiological and other findings favour the above
conclusion.
Between Mellidiosis and plague, it is not very difficult to rule out
Mellidiosis. Although higher exposure of cases to flood water, near
ness to garbage heaps, puddles/open drainage would be possible risks
for development of Mellidiosis. There is lack of any other supportive
information in favour of Mellidiosis. Also, response to antibiotics
of short duration treatment (say one week) shows that it may not
be mellidiosis which usually requires treatment for lower spells
(2-5 months).
To conclude from all above and the patients’ response to tetra
cycline group of antibiotics give evidence in favour of plague. But as
already discussed and summarised in Table 15, there are many aspects
which have remained unexplained. So one cannot conclude for sure
that the epidemic was that of plague. It could be anyother gram
negative bacteria which is not identified by cultural, biochemical and
serological tests. Thus at the most, it may be apt to say that the
epidemic was that of ‘rapidly developing pneumonia’ of bacterial
origin.
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Ill
Issues of Concern
It is very crucial to document the unwillingness of the civic authority
and official medical professionals to come out and present the findings
of diagnostic tests to professionals, public forums, etc for information and
scrutiny. This unwillingness and secrecy has not only led to erosion of trust
in competence of government medical sector but left the problem of final
diagnosis unresolved. Of course, medical officers in Civil Hospital worked
very hard day and night is the only positive and bright side.
Another issue which came up is who should decide to give or suppress
information and to what extent. Should they be political authority, Medical
bureaucracy or any third forum? Looking to the kind of present day
political authority any party or a coalition it cannot be left to them. We
believe so because their decisons would not necessarily be guided by good
of the people but what may be al stake i e power, prestige, money, etc. On
the other hand medical bureaucracy being obedient servant to the power,
they would not dare to declare the facts even if people’s lives were at stake.
So we advocate the need to have an independent forum which should
have access and authority to examine all documents, samples, specimens,
etc. It should have authority even to order further investigations and
procure any diagnostic reagents from anywhere in a short time. Such a
body should lake people into confidence by telling the truth about
diagnosis and treatment. Even if in case the diagnosis cannot be decided
for definite, this forum would explain to the people in detail. Such an
authentic communication would lessen the fear, anxiety, and chaos
among the people. Il would avoid all the fallacious and contradictory
declarations by executive political wing and medical bureaucracy. This
forum should have regular communication with the people through
various media. Reports during epidemic, should be simultenously sub
mitted to public and to the government.
In the case of Surat epidemic, plague was thought of as possibility
on finding gram negative organisms in sputum microscopy. The next
logical and immediate step should have been to conduct following tests.
(1) Culture of sputum and blood (2) Postmortum histopathology &
culture (3) Animal Innoculation (4) Sensitivity to antibiotics
(5) Paired serological tests (6) Florescenl antibody microscopy
(7) Validation of primary serological tests by HI
One does not know whether these tests were done or not. If yes, when,
how and how many samples were tested is also not known. Secondly, the
results of all these tests should have been submitted comprchensiely to an
unbiased academic group.
Whether any sentinel serology was/is being done in various animals
and rodents is not known. If the government is sure the epidemic was
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plague then there should be a number of surveillance centres all over
Gujarat and Maharashtra. These centres would monitor the situation
among rodents, sentinel animals and human beings.
We recently obtained the report of WHO’s Investigative Team and the
interim report of the Technical Advisory Committee appointed by the
government of India regarding the Surat Epidemic.
The WHO Team reviewed (1) Laboratory and raiological findings of
51 seropositve (PHA) cases. (2) Epidemiological findings of non random
sample of 38 cases admitted before 23/09/94 and 23 cases admitted
between 8th to 17/10/94. (3) Record of clinical and epidemiological
features of 41 cases of suspected bubonic plague. WHO team also
conducted a case control study of 82 patients, of whom only 42 patients,
of whom only 42 patients could be traced.
The major observations were:
- 35 per cent cases of those admitted before September 23, and 97
per cent of those admitted between October 8 to 17 did not meet the case
definition.
- Only 3 out of 51 cases showed Leucocutosis.
- Clinical and epidemiological features of bubonic cases were incon
sistent with diagnosis of bubonic plague.
- In case control study 51 per cent of cases could not be traced
(non response).
- No greater risk was found in cases for occupation, exposure to ill
persons and participation in Ganesh Mahotsav. Only 4 cases and 1 control
(n-75) were seropositive with PHA and HI testing.
The WHO Team concluded:
Adequate documentation of signs, symptoms and laboratory diagnostic find
ings enabling the establishment of diagnosis of presumptive plague was
lacking in most of the patients’ records. It was clear that the most cases
hospitalised with a diagnsis of suspected plague did not have plague. It is
believed that other infectious diseases causing fever like Malaria, TB , Dengue
fever etc. were misclassified as suspected plague cases. However the WHO
added further:
Findings of specific seropositivity to Fl antigen in human and dogs in Surat
support occurance of plague. The observation, by NICD and WHO team, of
FA positive isolates in culture of clinical material from Surat, if confirmed by
biochemical reactions or phagetyping of Y Pestis in pure culture would
establish the diagnosis of pneumonic plague in Surat.
The TAC in its interim report concluded establishment of Y Pestis as
causative organism. TAC’s observations are:
- four subcultures out of 48 contaminated cultures were found to be positive
for Y Pestis based on a battery of tests like biochemical reactions, lysis
on specific bacteriophage and PCR.
- 13 sputum out of 20 specimens were positive by PCR.
- 23 serum samples out of 27 were positive by PHA and HI tests.
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- two out of five autopsy specimens showed Y Peslis genmi fragments by
PCR.
Both the above reports also raise many issues regarding the efficiency of
our regional and national academic institutions, some of them are inadequacy
in preserving and processing specimens, lack of safety equipment system and
to biosafety procedures anything a2bout results of animals innoculation.
Even if the TAC’s claim of establishment of Y Peslis as a causative
organism is accepted, disregarding WHO team’s observations and a number
of epidemiological gaps, only a liny fraction of the epidemic can be attributed
to be pneumonic plague.
The remaining large number of cases including deaths yet remains without
identification of specific causative organism/s.
In case it was plague the following things need urgent attention.
- Tracing the source - Identifying reservoir and its extent.
- Detecting geographic focci - Surveillance activities in human, rodents
and sentinel animals - Organising mechanism and structure for such epidemi
management - Assuring quality of preventive and control measures.
[We arc thankful to the following persons and institutions for their help in the Gujarat
Voluntary Health Association (GVHA) study. Prakash Kotecha. Jagdosj Dawda and study
team members, Bharat Champaneria of Kaka Ba Kala Budh Hospital Hansot, Utkarsh
Kikani, Baroda; Bhaskar Acharya and his friends. Surat; Sharifa Vijliwala and her student
volunteers. Surat; Sr Candida of Parvatibai Leprosy Hospital, Surat and above all the
people (interviewees and their families) for having given full cooperation and answering
the long questionnaire We are thankful to the following for contributing their time and
effort for the symposium: K K Datta, Director, NICD, New Delhi; N S Deodhar, Pune,
J C Gandhi, Additional Director Health (Epidemic Cell); N R Mehta, Surat; Ghanshyam
Shah, Surat; Dileep Mavlankar, Ahmedabad; Prakash Kotecha, Baroda and all participants
from Baroda and especially those participants from outside Baroda. We are also thankful
to VHAI for the financial contribution and other support and Kirti Parikh and Darshana
Vadnerkar of TRU, Baroda for secretarial help.]
References
Acha, P N and Szyfres, B (1987): ‘Zoenoses and Communicable Diseases Common to man
and Animals’. Pan American Health Organization, Washington
Bahmanyar, M et al (1976): Plague Manual. World Health Organization, Geneva.
Braunwald, E. et al (1987): Harrison's Principals of Internal Medicine, Me Graw-Hill,
New York.
Christie, A B (1980): Infectious Diseases: Epidemiology and Clinica Practice, Churchill
Livigstonc, Edinburgh.
Evans, A S and Feldman, H A (1982): Bacterial Infections of Humans: Epidemiology and
Control, Plenum Medical Book Company, New York.
Park, J E and Park K 91985): Textbook of Preventive and Social Medicine, Banarasidas
Bhanot, Jabalpur.
Robinson, D (1985): Epidemiology and the Community Control of Disease in Warm
Climate Countries. Churchill Livingstone, Edinburgh.
Nimitta Bhatt
Gujarat Voluntary Health Association
Vadodara
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Bio-social Determinants of Abortion
Among Indian Women
U S Mishra
Arvind Pandey
S Irudaya Rajan
It is claimed that widespread practice of abortion in the developing
world has led tofrequent reproductive health problems among women
and in some circumstances, unsafe abortions practices have been
the cause for maternal deaths too. The recently conducted National
Family Health Survey (NFHS) provides an opportunity to analyse
the abortion practices among Indian women. Despite all the handicaps
regarding the information an effort is made here to conceptualise
a bio-social model to understand abortion practices. This exploratory
exercise on determinants of abortions indicates that while induced
abortions are more often misreported as spontaneous.
I
Introduction
ABORTIONS are considered to be an important fertility inhibiting
component especially when induced abortion accounts for a large propor
tion of total abortions. On the other hand, spontaneous and induced
abortions form an integral aspect of women’s health. It is said that, while
the improvement in the nutritional conditions and maternal health ser
vices has brought down the incidence of spontaneous abortion, the
practice of induced abortion has been in vogue for its being used as a
contraceptive by many. In the recent past, researchers have accelerated
their interest in the field of research on abortion in the wake of increasing
maternal deaths arising out of the unsafe abortion practices in the
developing world [Dixon-Muller 1990; Royston 1991 and Royston and
Armstrong 1989; Mari Bhat, et al 1995]. In India too, a large proportion
of maternal deaths are claimed to be the ouctome of clandestine abortion
practices or post-abortion complications [Chhabra and Nuna 1993].
Accordingly, they have been the concern of health planners and policy
makers during this era of shifting emphasis from just maternal health to
reproductive health of women. Earlier, the success of the maternal and
child health programme was expected to bring about a reduction in the
extent of spontaneous abortions, whereas the present concern of re
productive health has a broader perspective - healthy sex and safe
motherhood along with the better nutritional conditions and care during
maternity.
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Existing studies have either forwarded the assessment of inhibiting
effects of abortion especially the induced on the reproudclive behaviour
of women or analysed the characteristics of the abortion users [Das 1989;
Irudaya Rajan et al 1996, Talwar 1989]. Apparently they do not provide
any clue regarding the facts and factors explaining the incidence of
abortion in a population. Hence, they fail to provide any policy implica
tions on the ground that they are envisaged neither from the entire
population base nor from any conceptual framework. However, if we
consider abortion as a phenomenon which is rare in nature, we can explore
the occurrence of such events in a population by conceptualising a model
which is bio-social in nature. Also, since there have been no large scale
surveys focused on abortion at least in the Indian situation, the recently
conducted National Family Health Survey may be considered the first one
to facilitate such analyses. Despite the possibility that the information on
abortion collected in such surveys may suffer from the problems of
reporting error in the form of the induced abortions being reported as
spontaneous [World Health Organisation 1978], it may be worth while to
examine the increasing incidence of abortion in India in relation to a
hypothesised set of bio-social factors. Given the situation, an attempt has
been made in this paper, to analyse the phenomenon of abortion (both
induced and spontaneous) in India by various bio-social characteristics of
women based on the data collected in the National Family Health Survey,
1992-93 [International Institute for Population Sciences 1995]. Applying
a multi-variate model, we have also derived the factors leading to abortion
(both spontaneous as well as induced), which are bio-social in nature.
The National Family Health Survey India is an ever conducted large
scale in the world covering about 90,000 households and about same
number of ever married couples from different states of all over the
country. The field work of data collection was carried out during 199293 by various state population research centres, consulting organisations
under the supervision of the International Institute of Population Sci
ences, Bombay, in joint collaboration with East-West Center, Hawaii and
the Macro International, Washington DC, under the sponsorship of the
government of India, ministry of health and family welfare, New Delhi.
Households being the primary sampling unit, were so selected that they
could be weighted with respect to the sampling design at the stale as well
as at the all India level. Further, though the survey was designed to study
feritility, mortality and family planning in the country, data on the
experience of abortion including induced and spontaneous were also
gathered in the survey. We select four slates of India merely on the ground
that the phenomenon of abortion may be linked with high fertility and
mortality situations - two states from the southern region namely, Tamil
Nadu and Kerala representing low levels of fertility and mortality and
two stales, one from northern and another from the north-eastern region
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i c, Bihar and Orissa having high levels of fertility and mortality espe
cially infant mortality in the country. Questions regarding the experience
of abortion were systematically asked in the survey as whether the woman
ever had an abortion in her life time. The women were further probed to
recall the type of abortion, viz induced or spontaneous they had, together
with the number of such abortions. Here we plan to utilise the former
information, i e, the experience of abortion rather than study it contextu
ally with a number of host variables which are bio-social in nature. A
logistic regression model is employed to explore the possible affects of
the selected variables to explain the phenomenon of abortion. In the
model, we control the demographic effect of age while determining the
individual impact of each of the components affecting abortion (sponta
neous as well as induced).
II
Bio-Social Model: Selection of Variables
As mentioned above, the dependent variable for our analysis is
dichotomous in nature defined as either the woman experiences the event
or does not experience the event where the event in question is the
experience of abortion, induced or spontaneous.
We have selected biological and social variables to study the phenom
enon. Among the biological variables the consanguineous marriages
have been considered as one of the important genetical variable as Bitties
et al (1992) have found that there is a positive association between
consanguinity and fertility in 19 out of 22 populations. We hypothesise
that the women who are from consanguineous marriages may have higher
risk of abortions spontaneous abortions than those who are not. Although
this variable has greater link with socio-economic factors, this analysis
will try to control the effect of other intervening variable. This kind of
marriage has been common in most parts of this country as 14 per cent of
marriages are consagueous in nature at the national level [International
Institute for Population Sciences 1995]. The next important biological
variable considered is the age at which women consummate marriage. It
is hypothesised that the women who consummate at an early age may
have higher chances of having had an abortion, particularly spontaneous
abortions. Education, considered in most studies as an important social
variable for its bearing on fertility and mortality situation, is taken as
another variable. Residence on the other hand, defined in terms of rural
and urban type, is taken as a development variable which by and large
depicts the demographic differentials within any population. With chil
dren ever born (CEB) as a fertility variable, in addition, a programme
variable is envisaged here to assess the impact of the attitude of couples
with unmet need, in including abortion.
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The experience of abortion among women is analysed separately for
rural and urban areas. It is found that both in rural and urban areas, the rale
of abortion is highest in the state of Tamil Nadu followed by Kerala. In
rural Tamil Nadu, more than 27 per cent women ever experienced an
abortion, whereas in rural Kerala, about 19 per cent women experienced
such event. On the other hand, in rural area of high fertility states viz,
Orissa and Bihar the percentage of women experiencing abortion of any
kind is about 13 per cent (see Table 1). In urban areas, the differential
pattern in the phenomenon across states although same is more pro
nounced. While the incidence of spontaneous abortion in Tamil Nadu and
Kerala ranges between about 16 and 18 per cent in rural areas and is
almost same as about 18 the pereent in the urban areas, is about 12 per cent
in Orissa and Bihar (see Table 2). The incidence of induced abortion is
consistently higher in urban areas than in rural areas and similar pattern
emerges for abortion in general across the stales, as it is maximum in
Tamil Nadu with 10.2 per cent of women in rural areas and 13 per cent of
women in urban rural reported to have experienced at least one induced
abortion. In Kerala, about 3 percent which is respectively 2.2 percent and
5.5 per cent in Orissa. The incidence of induced abortion is less than 1 per
cent in rural Bihar and it is about 3 per cent in the urban areas of the stale
(see Table 30). The experience of abortion, spontaneous as well as
induced, is further differentiated across categories of the selected ex
planatory variables, separately for rural and urban areas of the study
Table 1: Abortion Prevalence by some Associated Characteristics and
Residential Background, NFHS, 1992-93
Orissa
R
U
R
U
R
U
Tamil Nadu
R
U
Total
12.9
RMG Yes
15.9
No
12.6
CEB <2
11.5
>3
13.5
ACB <15
12.5
16-18 13.3
19+
13.1
NDNUO
11.9
1
14.2
EDU Illlerate 13.0
Literate
12.0
16.2
23.8
15.9
13.0
18.2
16.8
18.1
12.8
15.7
17.3
17.3
15.4
18.9
18.2
19.0
19.8
17.9
16.5
17.5
20.5
19.2
17.4
18.8
19.0
23.0
25.5
22.7
22.8
23.2
23.2
20.0
24.7
22.4
26.3
19.4
23.5
13.2
17.8
12.8
11.5
14.2
12.5
12.6
16.2
13.0
13.4
11.5
17.3
16.6
16.7
16.6
15.4
17.3
11.1
16.7
22.2
17.3
14.9
14.0
18.5
27.4
28.3
26.4
27.5
27.3
26.6
27.4
28.1
28.6
23.9
25.8
30.0
Kerala
Bihar
Characteristics
30.2
30.4
30.0
28.3
32.2
33.5
31.5
27.9
30.6
28.7
29.2
30.5
Note: RMG refers lo marriage within blood relatives, CEB denotes children
ever bom, ACB denotes age at cohabitation, NDNU = 1 categorises couples
with no desire for additional children as well as without current use of
contraception.
216
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population. Consanguineous marriages account for a significantly higher
proportion of abortion than those who do not have such marriages, both
in rural and urban areas across all the four states. The difference is,
however, not very pronounced in urban areas possibly due the availability
of belter maternal care and utilisation of health services in urban areas.
The age at cohabitation does not reflect any strict pattern in relation to
the extent of abortion experience possibly due to the reporting error in the
age at cohabitation itself. The chance of a conception resulting in a
spontaneous abortion is expected more in case of lower age at cohabita
tion because of biological immaturity among women at the beginning of
reproductive life to cany the pregnancy to full-term, whereas the couples
initiating cohabitation at later ages may be more prone to induced
abortions. This reasoning appeared to be supported by the finding that the
abortion experience decreases with the increase in age at cohabitation in
rural areas which, on the other hand, increases with increasing age at
cohabitation in urban areas and such contrary experience among urban
women may perhaps be explained in terms of a greater extent of induced
abortions among urban couples.
The incidence of abortion among two categories of women with
respect to children even born, i e, (i) those women who bear al most two
children, and (ii) those who bear three or more children, it is found that
the women of latter category have more abortion, than the former. This
obviously indicates that greater the exposure to reproduction, greater is
the chance of experiencing an abortion. This differential seem to be
minimal among urban women which may be due to the higher use of
contraception and thereby lower fertility levels among them.
Table 2: Spontaneous Abortion Prevalence by some Associated
Characteristics and Residential Background, NFHS, 1992-93
Characteristic s
U
R
U
R
U
Tamil Nadu
R
U
Total
12.3
15.2
RMG Yes
No
12.1
CEB <2
11.2
>3
12.9
ACB <15
11.9
16-18 12.9
19+
12.1
NDNUO
11.4
1
13.6
EDU Illiterate 12.5
Literate
11.4
14.1
21.4
13.8
11.2
16.0
15.2
15.5
11.0
13.2
16.3
15.7
12.8
15.6
14.2
15.8
15.5
15.7
16.3
14.8
15.9
15.8
14.6
17.7
15.2
18.6
20.4
18.4
18.1
19.2
20.2
16.3
19.7
18.2
21.1
17.7
18.7
11.3
14.4
11.1
9.6
12.4
11.2
12.8
11.3
11.3
11.3
10.7
12.9
11.7
13.1
11.6
10.9
12.2
8.3
12.3
14.2
12.3
10.4
11.6
11.8
18.4
19.3
17.5
20.0
17.3
17.2
18.1
20.2
18.9
17.0
17.9
19.3
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1996
Orissa
Kerala
Bihar
R
18.5
20.9
16.9
18.8
18.1
19.8
19.8
17.0
18.2
18.2
19.9
18.0
Note: Same as Table 1.
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217
Abortion experiences especially induced abortion seem to be more
frequent among educated women. Further, this differential is more in
urban areas where induced abortions are a larger share of total abortions.
Finally, the variable describing the attitude of couples with unmet need
(i e those not desiring any additional children and at the same time not
using any contraception too) shows a reasonable differential in abortion
prevalence except some contradictions in rural Kerala, Urban Orissa and
Tamil Nadu as a whole.
While analysing, specifically the intensity of spontaneous abortion by
the set of explanatory variables as mentioned above, it is found that
marriage within blood relatives seem to be prominent by depicting a
strong differential in prevalence of abortion. This differential is clearly
indicated in the rural areas as such marriage may have less affect in view
of good health of mothers and belter maternal care in the urban areas. The
other biological variable i e. the age at cohabitation does not reflect the
hypotehsised pattern of negative association between the intensity of
spontaneous abortion and the age at cohabitation. Once again, this may be
due to ill reporting of age at cohabitation by rural women. Further, in
relation to the education as well as parity of women, an expected pattern
of abortion prevalence emerges with the women of higher parity having
more spontaneous abortions and the educated have a lesser risk of
spontaneous abortion compared to their uneducated counterparts.
As far as abortion induced is concerned, the said characteislics do not
reflect the expected nature of association mostly because of induced
abortions being reported as spontaneous. As a result, induced abortion
incidence seem to be quite low in Bihar, Orissa and Kerala and thereby its
Table 3: Induced Abortion Prevalence by some Associated Characteristics
and Residential Background, NFHS, 1992-93
R
U
R
U
R
U
Tamil Nadu
R
U
Total
0.8
RMG Yes
0.2
0.7
No
CEB <2
0.6
0.9
>3
0.7
ACB <15
16-18 0.6
19+
1.5
0.7
NDNUO
1
0.9
EDU Illiterate 0.6
Literate
0.9
2.7
2.4
2.7
2.8
2.7
? 5
5.5
1.8
3.2
1.5
2.8
2.7
3.9
4.5
3.8
4.9
2.7
0.8
3.2
5.1
4.0
2.8
1.8
4.3
5.5
6.1
5.4
5.8
5.1
3.0
4.9
6.2
5.4
5.9
3.2
5.8
2.2
3.3
2.1
1.9
2.4
2.0
1.9
3.6
2.1
2.4
1.0
5.2
5.5
3.6
5.6
5.1
5.7
3.4
4.8
8.7
5.9
4.5
2.7
7.6
10.2
10.4
10.1
8.6
11.4
9.8
10.4
20.4
11.1
7.7
8.9
12.4
Bihar
Characteristic:s
Kerala
Orissa
13.0
11.3
14.1
10.6
15.8
14.7
13.6
12.0
13.5
11.6
10.2
14.1
Note\ Same as Table 1.
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differentials across the said characteristics are not distinct. Also, the
expected direction of association between the incidence of induced abor
tion and the set of bio-social characteristics does not hold good except for
education. It reflects that educated women experience more abortions of
induced nature and the differential is prominent in urban areas as well.
Multi-variate Model
A logit regression model is applied to describe the phenomenon of
abortion in general and induced and spontaneous abortions in particular
as a function of the set of bio-social characteristics (see Table 4). In this
effort, current age of women is taken as a control variable to adjust for the
effect of age on abortion. As revealed from the bi-variate analysis women
aspiring for a small family may also have higher rate of induced abortion,
rural women with higher family size aspiration may experience frequent
spontaneous abortions as a result of higher reproductive exposure, in the
multi-variate set-up we have excluded the variables CEB on the ground
that its effect may be confounded while controlling for age.
Though age has been taken as a control variable but its regression
coefficient provide some interesting observations. In all the states, the
relative odd of experiencing reproductive loss due to abortion decreases
significantly with the age of women. However, the regression coefficient
for age in case of induced abortions as well as spontaneous abortions is
positive depicting that the incidence of induced abortion rises with the
increase in age i e, the reproductive exposure (see Table 4).
There regression coefficient for age being positive in the case of
spontaneous abortion seems puzzling and this may be due to aforesaid
fertility and reproductive loss relationship. We also find that the relative
Table 4: Determinants of Abortion: Exponent of Odd Ratios based on the
Logit Regression Model
Variables
Bihar
Kerala
Orissa
Tamil Nadu
Age
Edu
RMG
ACB
RES
NDNU
0.9723**
1.0505
0.7126*
1.0977
0.7544
0.9833
0.9879*
0.9239
0.9498
0.8175*
0.8023*
1.0204
0.9736**
0.6522**
0.6732*
0.7511*
0.9086
1.0689
0.9796**
0.8095*
0.9349
1.1064
0.9133
1.3185**
Note-. Age refers to the current age of women; Edu is considered in two categories
literate and illiterate; RMG refers to marriage within blood relatives; ACB
denotes age at cohabitation; RES denotes place of residence; NDNU = 1
categorises couples with no desire for additional children a well as without
current use of contraception.
** & * indicate significance respectively at 1 per cent and 5 per cent level of
significance.
RJH
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219
odds of experiencing an abortion increase with increasing level of
education in the slate of Bihar, whereas it is other way true in case of
Kerala, Orissa and Tamil Nadu that the relative odd of experiencing a
reproductive loss decreases with education and they must be mostly
spontaneous in nature. Of course, the effect is not significant in case of
Kerala possibly because of the contrast in educational composition of
women in the state. As expected, the odd of experiencing induced
abortion increases substantially with the increase in education in all the
states excepting Bihar (see Table 5). Though not reported here, we also
tried to assess the affect of work status of women on the onset of abortion
and found that the work status does not provide any clear indication
because of limited sample, size, definitional problems and concentration
of women in non-w'orking category.
Ill
Concluding Remarks
The foregoing analysis has shown that the reproductive loss in terms
of abortion varies across the selected states, both in rural and urban areas
representing the different stages of demographic transition. Tamil Nadu
which has witnessed a recent dramatic transition in fertility levels,
reported a high level of abortion compared with other Indian slates.
Table 5: Determinants of Spontaneous Abortion: Exponent of Odd
Ratios based on the Logit Regression Model
Variables
Bihar
Kerala
Orissa
Tamil Nadu
Age
Edu
RMG
ACB
RES
NDNU
1.0282**
0.9266
1.3988*
0.8925
1.2034
1.0398
1.0112*
0.9102
0.9686
1.0904
1.2221*
0.9707
1.0283**
1.1728
1.3874
1.2310
0.9433
0.8950
1.0053
1.0293
1.1915*
1.0473
1.0044
0.8840
Note\ Same as Table 4.
Table 6: Determinants of Induced Abortion: Exponent of Odd
Ratios based on the Logit Regression Model
Variables
Bihar
Kerala .
Orissa
Tamil Nadu
Age
Edu
RMG
ACB
RES
NDNU
1.0186
1.0815
1.4734
1.2176
3.2446**
0.9065
1.0147
2.1392*
1.3264
1.6871*
1.3491
0.8619
1.0170
4.6974**
1.4711
1.4052
1.6381*
1/0629
1.0415**
1.5709**
0.9186
0.8192
1.1665
0.6222**
Note-. Same as Table 4.
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These were predominantly of induced nature of avoiding unwanted
pregnancies. High level spontaneous abortions in this state may be
explained in terms of a large number of induced abortions being reported
as spontaneous. Kerala having lower levels of fertility and mortality
compared to Tamil Nadu, has the lower level of abortion too. In contrast
to Tamil Nadu, women from urban areas in Kerala have greater abortion
incidence (han their rural counterparts. Similarly while Oriya women do
not vary by residence in terms of the extent of abortion, urban Bihari
women are found to have had more abortions than rural women.
The most interesting finding could be that abortion has a strong
bearing with consanguinous marriages. Its effect is reduced in the urban
setup due to improved maternal care services. However, its effect on
induced as well as spontaneous abortions as obtained from the analysis
clearly establishes the misreporting of the type of abortions.
The effect of safe and systematic induced abortion services can be seen
in terms of the odds of abortion by the residence. Moreover, among Indian
women seems to be more of induced nature which are reported as
spontaneous. Education and urban residence are strong correlates of
induced abortion whereas spontaneous abortion is explained more in
terms of biological variables such as consanguineous marriage and age at
cohabitation. This exploratory exercise provides a further clue on the
incidence of induce abortions. There are a large number of induced
abortions which are reported as spontaneous abortion resulting out of the
extent of unmet need for contraception among Indian women.
References
Bitties Alan H, W M Mason, J Greene and N Appaji Rao (1991): ‘Reproductive
Behaviour and Health and Consanguineous Marriages,’ Science, Vol 252,
pp 789-794.
Chhabra, R and Sheel C Nuna (1993): Abortion in India: An Overview, Delhi.
Das, N P (1989): ‘The Impact of Contraception and Induced Abortion on
Fertility in India’ Journal of Family Welfare, Vol 35(5), pp 14-25.
Dixon-Muller, Ruth (1990); ‘Abortion Policy and Women’s Health in Deve
loping Countries’, International Journal of Health Services, Vol 20(3),
pp 297-314.
International Institute for Population Sciences (UPS), (1995): National Family
Health Survey (MCH and Family Planning), India 1992-93, UPS, Bombay.
Irudaya Rajan, S,US Mishra and T K Vimala (1996): ‘Role of Abortion in the
Fertility Transition in Kerala’. Paper Presented at the Seminar on SocioCultural and Political Aspects ofAbortion from an Anthropological Perspec
tive, organised by (he International Union for the Scientific Study of
Population, held at Trivandrum, India, March 25-28.
Mari Bhat, PN, K Navaneetham and S Irudaya Rajan (1995): Maternal Mortality
in India: Estimates from a Regression Model. Studies in Family Planning,
Volume 26, number 4, July/August, pp 217-232.
Royston E (1991): ‘Estimating the Number of Abortion Death’ in Methdological
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„nruMENTA.TION
j
/l
Issues in Abortion Research, Francine Coeytaux, Ann Leonars and Erica
Royston (Eds), Proceeding of a Seminar Presented Under the Auspices of
The Population Council’s Robert H Ebert Programme on Critical Issues in
reproductive Health, New York, December 12-13, 1989.
Royston E and Sue Armstrong (1989): ‘Death from Abortion’ in Preventing
Maternal Deaths, WHO, Geneva, pp 107-136.
Tai war, P P (1989): ‘Impact of Induced Pregnancy Termination on Birth rate in
India’ in Singh et al (eds) Population Transition in India, Vol 1, B R
Publishing Corporation, New Delhi, pp 411-420.
WHO (1978): Spontaneous and Induced Abortion, WHO Technical Report
Series No 461.
U S Mishra
Centre for Development Studies
Ulloor, Thiruvananthapuram
Issues in
MEDICAL ETHICS
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Branded Health Care
K S Sebastian
The current proliferation offive star hospitals is the culmination
of the process of commodification of health care. And as in the
case of any branded goods, only a comparative few can afford it.
A REPORT on the opening of a ‘five star hospital’ in Delhi goes as
follows: “Realising the need to market and commodity hospital services,
to build a brand name and ensure brand loyalty” the ‘xyz’ hospital
launched a full-fledged marketing department. The same report quotes
the chairman of the hospital as saying “the accountability to the share
holders and responsibilities towards the foreign partner created the need
for marketing”. Thus followed by the process of commodification of
health and health care, we are entering the era of purchasing health care
exactly the way we could buy a Levi jeans or YSL perfumes.
Commodification of health is an ongoing phenomenon which started
sometime in the first half of this century followed by the advent of ‘germ
theory’ which disregarded the overwhelming influences of epidemiologi
cal and social factors in the aetiology of diseases and attributed the causes
of illness to micro-organisms. Transnational pharmaceutical companies
(TNCs) could establish a hegemony of this paradigm, by inventing
antibiotics, sulpha drugs and vaccines and various technical devices to
apply these products in to human beings. The impression created was that
a systematic use of their products (vaccines, tablets, tonics etc) could
take care of human health world over.
When the government of India undertook various campaigns for
’immunisation’ and ‘eradication’ with the help of ‘expert advice’ from
international agencies and bilateral aid organisations, it underlined the
above paradigm in which ‘products’ and ‘technology’ sidelined social
and epidemiological factors. Today if we want to avoid AIDS we may use
‘condoms’ disposable syringes and needles; if we want to have a happy
family or safe motherhood we may use ‘contraceptives’; to get rid of
diarrhoea we must use ORS packets. Thus we have a specific product to
purchase to ensure health and well-being. Today, commodification of
health care has taken firm roots and TNCs could rightly think of launching
this commodity under various brand names.
Market experiences in India and elsewhere proved beyond doubt that
once you create a brand name, those who have the purchasing power
would not care for the price. It is the brand name which matters. When
Indian cotton, processed in Indian factories get the label of an established
foreign brand people are ready to pay any amount for it. Brand makers of
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health care are expecting the same thing in the emerging market of health
care in India.
This commodification and branding of health care has got alarming
implications on the public heah scenario and development of this country.
In the 1970s when there was a furious campaign against Coca-Cola, the
campaigners argued that government’s priority should be to ensure
drinking water in every' village before any foreign soft drinks company is
allowed to launch their products in India. Today we get either Coke or
Pepsi in every' comer of India. This happened at the cost of the provision
of potable drinking water to the villages. There is nothing against
believing that a similar situation would exist in India, when we enter the
next century - a situation in which there is branded health care for a few,
rather than health for all.
The arguments offered by those who support branding and marketing
of health care are as follows:
(i) These types of initiatives are mainly or wholly by private invest
ment and target only those who otherwise go abroad in search of such
facilities. Thus considerable saving in foreign exchange can be made.
(ii) By employing doctors on par with international perks we could
prevent loss of talented physicisns to foreign countries. An opportunity to
work with foreign experts would improve the skills of our own physi
cians. Moreover, a large number of experts who are working abroad are
willing to come back if international working conditions and perks are
available.
(iii) By way of R and D we improve our facilities by bringing
sophistication to the obsolete health care technology as existing today in
India.
(iv) Leaving the health care of those who have purchasing power to
private hands will give the government more opportunities to allocate
resources for the deprived sections. State and non-semi governmental
sector can now consolidate their efforts to attack illness and poverty.
These arguments appear very logical. But a careful examination with
empirical evidences and experience of various countries reveal the
absurdity and dangers inherent in these arguments.
The first argument is essentially an argument which is going on in
public health circles for quite a long time viz whether public sector or
private sector should be given primacy in health care delivery. Those who
stand by the private sector point out its ‘proven efficiency’, ‘cost effec
tiveness’ and their ‘track record of executing anything successfully’.
They discredit the public sector health services pointing their ‘poor
services’. These conclusions are not based on any empirical facts.
Moreover, we could not forget incidents of subjecting poor patients to
several unnecessary tests and operations and prescribing unnecessary
medicines to earn profit by private hospitals, which may cause immediate
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and permanent damage to human organs. The greed for profits and
commissions by the private sector often ends up in criminal malpractices
such as aborting female foetus. The effect of proliferation of private brand
hospitals will not be confined only to those who have purchasing power
and rush to foreign countries for health care. Its ‘demonstration effect’
can change the practice and the theoretical framework upon which the
entire health care delivery system in India is built up today.
The second argument cited above should be approached from two
angles. The first angle is the presumption of the superiority of the
‘international model of healthcare’ which for all practical purposes is the
model advocated by the west. The west moulded the thinking pattern of
the third world countries like India in many ways. It provided liberal
scholarships and short-term research assignments to the elite students of
the third world to study or work in their institutions. When these elite
students returned and became decision-makers of their respective coun
tries. they acted within the theoretical framework and world view offered
by their alma mater. The developed countries of the west undertook
various demonstration projects of health care for the benefit of the newly
emerged decolonised nations, offered expert advice and consultancy and
infiltrated the policy-making bodies. Therefore by giving more opportu
nities to those who could not go for overseas assignments will be, in
reality, further encouraging a model which destabilised and discredited
indigenous health care models.
It is also to be noticed that this role model which we are looking up to
is presently suffering from various contradictions. The public health
services in the US is in doldrums and measures like ‘health insurance’ lost
their credibility and people are running towards ‘faith healers' and
alternate medical practitioners.
Another angle from which the second argument is to be looked at is the
absorption of the best talents in to the brand sector and the consequent loss
of personnel to the governmental sector. There is no doubt that the best
talents would join the lucrative brand hospitals, especially when more and
more people started subscribing materialistic and consumeristic values.
This, along with the already existing regional imbalances in the health
care resources, would aggravate the problem of public health in India.
The next argument regarding R and D underlines the increased use of
technology in health care and thus underscores the need for intersectoral
linkages and social determinants one has to keep in mind during health
planning. The blind faith in the scope of technology forces us even to
import outdated and cumbersome technology which are discarded in
western hospitals. Above all, the research these institutions would under
take come wholly in the realm of advanced technology required to tackle
the health problems of those who could afford purchasing brand services.
In fact, today there is not much government-sponsored research taking
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place in areas of TB, leprosy and other diseases which affect the common
man. It is indeed unrealistic to expect cither profit-orienicd private sector
which is “accountable to share holders and foreign partners” or that aid
dependent NGOs would undertake serious research in these areas.
As in every market, the position of those who are having purchasing
power is always secured and protected. The precarious situation of those
who are outside the market calls for state intervention to ensure that the
pressure of market forces will not leave them helpless and stranded. In
reality, this is only a ‘reactive situation’ (in which the slate acts only as
an agent to alleviate the dysfunctions caused by the market, exactly the
way World Bank and IMF expect states to behave in post liberalisation
period); not an ‘active situation’ in which the state lakes a more positive
initiative to ensure health as a right of its citizens. But even to act in the
former position is impossible as branded health care would swallow
government resources in many ways. The brand makers by monopolising
and controlling pharmaceutical manufacturing and health care suited to
their profitability could strain the government resources by forcing it to
import essential drugs. They could create scarcity of health personnel by
recruiting the medicos who are trained by the state exchequer. While the
government’s health cae infrastructure is vigorously forced to undertake
population control programmes and AIDS awareness campaigns, they
can further lighten their grip on the profitable health care sector.
The case of the role of NGOs is often misconceived. Barring a few
committed NGOs started by philanthropic individuals or groups, most arc
perpetuators of ill health and underdevelopment, knowingly or unknow
ingly. The health action of NGOs stems from their dependence on non
local processes and decisions which lie beyond their small scale project
focus. Theirexclusion from the definition of polices, limited research and
dissemination capacities and localised nature rarely enables them to
address wider structural factors that underlie poverty and ill health in
India. Their inability to finance infrastructure makes them further depen
dent on donors and the government. They are quite often pre-occupied
with the delivery of programme packages assigned to them by donors.
Their critique on health policy mailers is mostly on technical inadequa
cies of government programmes rather than the distributional bias and
priorities involved in the policies. Their rhetoric of ‘people’s participa
tion’ often exceeds reality as they have self-appointed rather than elected
bodies to control institutional resources from within. These ‘yuppie’
organisations staffed by middle class professionals, administered through
formal bureaucratic procedures cannot attack ill-health and poverty as
their socio-ultural origins lie more in the dominant than dominated groups
in society.
When emphasis is laid on NGOs and their charity programmes, health
and development are misinterpreted as an offshoot of charity of certain
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philanthrophists or as gifts offered by some foreign benevolent donors
rather than a matter of right to be obtained from a democratic state. This
would further emphasise dependency relations and feudal values.
As early as in 1978, there was a global consensus to concentrate on
primary health care which was articulated at the International Conference
on Primary Health Care held at Alma Ata, attended by decision-makers
of 134 countries across the world. A very important declaration made at
the end of this conference assigned new values to health, based on equity
and social justice. The new dimension of health which is a state of ‘well
being’ and not just the availability of health services, calls for the removal
ofobstaclcs for health which go beyond medical interventions. Recognising
the fact that many primary causes of ill health are based on factors such
as poverty, deprivation and environmental abuse, it underlined the need
for total health systems designed around the life patterns of population,
to support the needs of periphery on the principle of equity and active
participation of local population.
But the developments which followed Alma Ata declaration is quite
frustrating. Unfortunately, in the struggle between an elite oriented health
model and a people oriented health model, the global agencies including
WHO took the side of the former. The inability of these agencies to act as
catalysts of health of the masses while the commercial interests defined
the ecological and epidemiological determinants, the choice of technol
ogy and the targets to be attained in the health system is well documented
in recent research studies.
The inability of programmes devised by international agencies, of
policies formulated by government and of action undertaken by NGOs in
transforming the health sector is mainly due to the congruence of interests
of TNC functionaries, policy makers and technocrats. These affluent,
educated and established groups while taking initiatives to ‘transform
health sector’ cannot take actions that may harm their own position,
power, prestige and privileges. If at all they draw some plan of action on
paper, it will just not take off as happened in the case of ‘land reforms’ in
India. The only way out, probably, is to strengthen the grassroots level
activists groups and people’s science movements to form a frontline
through which they could resist the onslaught of ‘brand makers’ of health
care and to defend people’s health by ensuring equity and justice.
K S Sebastian,
Centre of Social Medicine and Community Health,
JNU,
New Delhi.
Please renew your subscription to RJH for 1997
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Educating Women Doctors
An Experiment in Sudan
Ahfad University for Women's aim to educate women and raise
their capabilities to improve and development the women status
in the Sudanese community as a whole and particularly in the rural
societies. With this in mind Ahfad established the School of Medicine
in 1990 adopting the philosophy that women doctors have a better
opportunity' than men to affect the women doctors have a better
opportunity' than men to affect the women’s health and improve
it as they have an easy access to Sudanese families. Therefore
it adopted an innovative approach to the curriculum which is community
oriented with problem solving approach. The curriculum is integrated
both horizontally and vertically with a holistic approach. It has
three phases and phase 111 is concerned with the management of
the patients', the family and the community' health problems. The
objective of the paper is to introduce to the reader the setup at
the Ahfad School of Medicine.
[Reprinted from Ahfad Journal Vol II. No 2, December 1994].
IT is difficult to define the word professional but an agreeable definition
has been given by Friedson, (1973) which states that “professionalism is
a process by which an organised occupation, usually but not always, by
making a claim to a special esoteric competence and to concern for the
quality of its work and its benefits to the society obtains the exclusive right
to perform a particular kind of work, control training for and access to it
and control the right of determining and evaluating the way the work is
performed”.
This applies to medicine, law and engineering. Education in some of
those professions has been different from that in other disciplines. The
training in medicine has been built on apprenticeship and the responsibil
ity of licensing and qualifying has been left to the professional bodies
rather than the academic institutions. This situation still exists in many
countries including the UK and the USA. In these countries the profes
sional associations or similar bodies have enjoyed a much firmer control
over hte form and content of training than has been the case elsewhere. In
such situations traditions are hard to die or change and as a result there has
been a little chance for innovations. Several attempts have been tried in
the established schools without bringing about any fruitful change.
Systems of apprenticeship survived for a long period and educational
institutions have been relatively weak and less influential in establishing
the forms of vocational training.
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Over the past century the objective of medical institutions was to
qualify a general duty doctor who is able to give a hand in any branch of
medicine. For this reason the duration of the study was six years in most
countries to which a pre-regislration year spent under supervision was
added. As the years passed it was recognised that changes in education
and (raining as well as in the general philosophy of the educational
process arc long overdue. The aim of medical education was then
recognised to change and hie proposed aim would be to produce an
educated person who would be qualified by postgraduate training. So the
medical student will have to know how to learn first and secondly how to
go on learning.
Why The Change?
A strange cause that will bring a change in medical education is
derived from the international agreement reached in 1978 at Alma-Ata,
in the previous USSR. There, all countries of the United Nations adopted
a resolution at the 34th World Health Assembly in 1979 proposing health
for all by the year 2000. The method proposed to promote this goal is the
new concept of primary health care (PHC) which calls for promotion of
health through health education, emphasis on preventive aspects of
disease, proper nutrition, provision of safe water supply, good attention
to motehr and child health and family planning and attention to treatment
of endemic diseases.
This high level of control over the professional education achieved
by the associations is still with us today in many countries to the extent
that many argue that the possibilities of innovation and rationalisation
in professional education are limited. In some of these countries it has
been suggested that a narrow pragmatic view of education has been
sustained despite mounting evidence that the consequences are unde
sirable in a number of respects. To give an example it has been realised
in medicine for decades that training in the field of prevention is
crucial for the improvement of modern systems of such a function in
the practising profession, medical education has failed to respond to
such needs.
Inspite of what has been happening in some countries changes have
occurred in several places. Teaching is part of learning and innovative
teaching can lead to innovation in the learning process.
The dilemma of medical education is that facing science in general:
how to keep abreast of the exponential growth in knowledge.
If this concept Primary Health care (PHC) is to become a reality a
major change will be demanded of the medical schools. Delivery of health
care will have to be modified and new teaching and learning strategies
will have to be adopted. The World Health Organisation (WHO) is
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helping medical schools to bring about this change in medical education
and for obvious reasons emphasis is placed on newly established medical
schools.
The curricula of these new medical school are based on new innova
tions. How the many different basic science and medical subjects should
be selected, pul together, taught, learned, evaluated, monitored and
students assessed are important issues to be addressed. The new ap
proaches pul emphasis on the learning objectives of each leaching module
or unit.
Another area of innovation is the use of small group leaching thus
abandoning the lecturing techniques and thus they implement the phi
losophy that the student is the centre of the educational process ralehr than
the lecturer who is now a mere facilitator.
The traditional medical schools have different departments respon
sible for teaching different disciplines and in this way the student does not
learn the human body as one unit but in a dis-integrated manner. The new
concept asks for integration of learning both in the horizontal and vertical
dimensions. In this respect difficulty has been encountered^ implement
ing horizontal integration.
Vertical integration is also important because illnesses and their
management increasingly transcend any disciplinary or departmental
boundary. There is also much evidence that it is educationally wrong to
confine a learner’s attention artificially, by department fragmentation, to
one sphere when comprehension requires mullidescriplinarily, (Mustard
et al, 1982).
Another change brought about is teh adoption of problem-based
learning. The notion of using problems or cases as the basis of profes
sional education is not new. Since the very early days glimpses of it can
be detected in teh writings of great teachers of medicine through the ages.
The “case methods’’ pioneered at the Harvard Business School is an
example of the concept expressed in basic curricular form.
The theoretical basis for.problem-based approach in medical educa
tion is to be derived from the writings and research in the general
educational literature which supporters the concept. In addition there has
been insight into the clinical reasoning process which was derived from
research.
The general rationale assumes that the task of the medical doctor is to
identify, investigate and manage the medical problems of their patients in
an effective and efficient way. According to acquire and use information
in the context of problem analysis and solution, thus increasing the
likelihood of retention. There is potentially a higher level of intrinsic
motivation and interest as students see themselves engaged in relevant
learning tasks, discovering the knowledge they need to analyse and solve
the problem al hand, (Knowles, 1975).
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The MD programme at McMaster University has established a prob
lem-oriented method as its fundamental educational approach so that the
student will be equipped to cope with changes in medical knowledge in
future practice. Since its inception in 1969 this programme has pioneered
certain innovations in its education approach. Key features are the
analysis of problems as the principal method of acquiring and applying
information, the fostering of independent reading and the use of small
groups as the main educational forum. The duration of the programme is
thirty three months, and consists of a series of interdisciplinary curricular
units, several elective blocks and one year of clerkship. But it is essential
to mention that the programme requires careful selection of mature
students whose learning habits arc compatible with the style of the
programme and who demonstrate both academic ability, and desirable
personal qualities, (Farrier, 1978). The major challenge here is for the
professional educator to create an efficient and comprehensive curricu
lum that will prepare the future practising physician for a career of
lifelong learning. HarmenTiddens, a founder of Mastrich Medical School
in the Netherlands quotes;
That evidence is accumulating that a curriculum based on the concept of
problem-based learning offers the best solution to the major obstacles medical
education is facing today” (Mustrard et al, 1982),
Another change associated with hie new health issues are not only the
teaching and learning techniques but in the health sellings where learning
lakes place. Medical education is thought to be relevant to take place
where the patients present their problems initially rather than in sophis
ticated hospitals when a lot of sorting out as to where the patient is to be
sent has already taken place. The implication clearly is that the proper
training setting is the community, with its homes, factories, schools,
health care centres and all primary medical care setting like general
practices and outpatient departments.
This has commonly been referred to as community based learning.
Here there is a problem because some of these health care setting are not
prepared for these purposes. Before practical leaching can be moved out
into the community potential teachers based there have to be adequate by
trained in the learning environment.
Ahfad University is the only University in the Sudan for Women only.
Il comprises of five schools, the newest is the school of medicine
established in 1990 adopting a holistic approach to medicine within the
concept of health promotion, desease prevention, cure and rehabilitation.
As the Ahfad graduates are females they are expected to have easy access
to Sudanese families specially mothers and children who constitute about
70 per cent of the population in the Sudan especially in the rural areas
where the majority of the population reside.
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The curriculum of the School of Medicine is Community orientated,
integrated both horizontally and vertically, as well as following problem
solving approach.
The students are exposed to the community since the first year which
is called phase I. Here they do a programme called family attachment and
they follow that family for the rest of the six years continuously reporting
on the state of health of that family and also giving health advise to
pertinent mothers within theirdomain of knowledge. During the mid year
vacation the students of first year go to the rural villages together with
their peers from other schools in small group to perform supervised
surveys and give all possible health education, lectures on all women
development issues as well advise or harmful traditional practices.
During that lime the students have a better of mixing with each other and
do team work which they report on after their return in the form of
assignments. Thus they develop the ability and skill of integraded team
approach for the development of women in rural areas of the Sudan.
In phase II of the curriculum they learn the function and abnormality
of the human body in an integrated pattern system-wise. This learning
process is divided into eleven modules and each module comprises all
major problems in that system including the individual, family and
community problems. During the vacation of phase II the students do
field work in the rural areas studying the health problems and their
impact on the individuals and community. Again this is done in an
integrated inter-sectoral activity involving the community as an inter
ested party.
Strategies of the educational programme are based or systems and
methods that are compatible with programmes in the Sudan. Again a
student centred approach is followed.
In phase III the stduents spends a twelve weeks at first in primary care
setting both in the urban and rural areas. This period is followed by a
longitudinal one day throughout the duration of phase III to be spent in
community field activities supervised by the various disciplines.
The rest of the period is spent in a scheduled programme of clerkship
covering aspects of the undergraduate medical curriculum as decided by
the phase committee.
The total duration of the study in the School of Medicine is six years
divided among the three phases.
The curriculum also includes a programme of women studies and rural
extension. This is a requirement to be fulfilled by all the graduates of
Ahfad University for Women.
The aim is to graduate a female doctor who will be recognised by
international standards and who will assist in the development of women
issues as well as the community as a whole and be prepared to work in the
rural areas of the Sudan.
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Conclusion
Ahfad University College has established the School of Medicine with
the aim of fulfilling the requirements of its philosophy of promoting
women education in priority areas. It has also followed its adopted
strategy of taking care of the community needs and therefore the medical
curriculum is community oriented. Another strategy followed is the
introduction of recent innovations in medical education, ie Problem
Based Learning (PBL). Thus Ahfad is promoting women’s development
following the most recent international scientific strategies.
References
Alma-Alta Declaration - World Health Organisation 1978
Friedson, E(ed) (1973): The Professionals and their Prospects Beverly Hills and
London, Sage.
Knowles, M (1975): Self-directed Learning: A Guide to Learners and Teachers,
New York, Association Press.
Miller, G E (1978): The Contribution if Research in the Learning Process,
Medical Education 12, (5) 28.
Mustard, J F, Neufield, V R, Walsh, W I and Cochran, J (ed) (1982): New Trends
in Health Sciences, Education and Services, The McMaster Experience, New
Yoark, Praeger Publisher.
Ahfad University for Women
P O Box 167
Omdurman
Sudan
Note to Advertisers
The RADICAL JOURNAL OF HEALTH is a multi
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viding a rational, humane and critical perspective on these
topics. Our readership is made up of academics, activists,
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abroad. For information write to Sushma Jhaveri, RJH,
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Communications
Learning to Know Differently
Usefulness of Primary Data
The norm today is to decide on policy at a central level using
necessarily partial and false aggregate data. Its no wonder that
such policies are uniniplementable.
THE adage ‘knowledge is power’ has become a cliche in this age of
lhe information revolution. Gargantuan centralised systems often span
ning the entire globe obviously cannot function without efficient infor
mation management. Spurred on by computers and satellite communi
cation vast volumes of data are being generated and analysed to aid human
beings in fulfilling their urge to control all aspects of nature and society.
So much so that it has become a norm for even small projects these
days to undertake preliminary surveys oi all kinds to aid the planning
process. This voracious appetite for information has, however, led to
a disregard for the quality of data collected and the ethicality of eliciting
information. This is more so in the case of data on social parameters,
which are far more difficult to measure or collect and which often impinge
on the privacy of individuals, than for statistics of a physical or com
mercial nature. The conceptual, ethical and practical difficulties that are
being encountered in garnering information for improving the quality
of reproductive health (RH) services in a remote rural corner of India
are outlined below to give an idea of the kind of problems that are
normally glossed over by academic researchers and policy makers.
The northeastern comer of Khargone district of Madhya Pradesh is tucked
away between the hills of the Vindhya Range descending from the Malwa
plateau and the Nimad plains of the Narmada valley. Being populated mainly
by various subtribes of the Bhil tribe this area has been grossly neglected in
terms of modem development as compared to Malwa and Nimad. Especially
wanting are the quality and quantity of services provided by the government
in the education and health sectors. Due to a lack of allweather roads the
area remains isolated during the monsoons except for a central market
village called Katkut. The worst effects of this neglect and isolation are
manifested in the health of the people of the area. In 1995 an NGO, the
Kasturba Gandhi National Memorial Trust (KGNMT), began work in the
area in an attempt to improve lhe state of affairs in the health sphere.
Normally the KGNMT starts work in a new area in the standard
Gandhian way by holding meetings of the people to ascertain their
problems. This time, however, they were implementing a PVCH II
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scheme of the government funded by USAID and being monitored by the
Mahatma Gandhi Institute of Medical Sciences (MGIMS), Wardha. So a
preliminary health status survey was foisted on them. The questionnaire
covered the whole gamut from socio-economic to maternal and child
health indicators. The workers found that the people were quite indiffer
ent to the survey and some were openly sceptical. Some people com
plained of survey fatigue what with some government official or other
coming along every now and then to elicit some information or other. The
biggest difficulty was that the length of the questionnaire and the
complexity of some of the questions meant that it would have taken at
least two hours to fill it in correctly. Obviously neither the workers nor the
people had so much lime and patience and so the survey was fudged. In
an area having about 3000 families as many as 472 were surveyed and so
the sample was a fairly large one. Yet the data generated could not be said
to be an accurate representation of reality. A general idea of the socio
economic and health status of the people only could be gained.
The project envisaged that the K.GNMT would complement and not
duplicate the services being provided by the governmel. So an appraisal
of services being provided by the government staff under the direction of
the PHC in Barwah had to be undertaken. The advisors from the MGIMS
suggested that the records of the PHC could be consulted for this purpose.
A perusal of these records revealed that between 80 and 100 per cent of
the people were being covered and being fully provided with all kinds of
services ranging from immunisation, prevention of malaria and tubercu
losis to maternal and child health. Thus on paper there was no need for the
KGNMT to work in the area at all. This reported efficiency went so much
against the visible lack of services in the area that the workers of the Trust
decided to investigate the reasons for this anomaly. It was found that the
village level health functionaries like the ANMs and the MPHWs were
submitting false monthly reports of the work done by them. These latter
brazenly admitted that they could not possibly go around to each and
every household to provide services and anyway they did not have enough
medicines with them. These workers were even falsifying the reports of
births and maternal and infant deaths!
Finally when it came to the KGNMT’s own reporting time it was found
that its village level workers who were only just literate had not kept
proper records of the work they had done and also of various important
health indicators. Most of them complained that people just do not want
to give the information being asked of them and sometimes even know
ingly furnish false information. This kind of explanation would not do
with the MGIMS, however, and so registers had to be cooked up and data
collated from them to make up a meaty report. These data were then
crunched in the MGIMS computers and presented stylishly in the form of
graphs and charts accompanied by a slick write-up as a record of the
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achievements of the KGNMT to USAID. Much in the same way the false
government health data are analysed to get a picture of the health scene
in this country which is far removed from the reality that actually prevails.
The KGNMT workers had earlier found on attending the monthly
meetings of the Barwah PHC that the concern was about presenting good
performance reports and not with providing adequate health services to
the people. They now realised that the system of reporting itself was
responsible for introducing its distortion.
A Gandhian institution to the core the KGNMT decided to review its
methodology of work midway in 1996 to do away with the need for such
false reporting. Such reporting was not only unethical but also took up a lol
of lime that could otherwise have been devoted to grassroots work. Instead
of going to the people with a preset agenda it was ecided to ask the people
about what they felt their health needs were. The Trust had been formed with
the express purpose of alleviating the lot of poor rural women and so it was
decided lb concentrate on the health problems of women instead of dis
sipating energy and resources on providing broadbased health care. This
was also in tune with current thinking which stresses the importance of
providing adequate RH services to women and working towards giving
them control over their own bodies and the right to enjoy their sexuality.
The floodgates were opened. The workers of the Trust were shaken.
Women had to be initially literally dragged to the exclusive meetings that
were held with them. But once one of the workers talked about how she
herself had suffered from a particularly painful reproductive tract infec
tion (RTI) in silence and only recovered after proper medical attention, in
meeting after meeting, most of the women talked openly of their own
problems. All women had sufferred at some time or other from RTIs and
on an average 70 per cent of the women in a village were currently
affected. The women also complained bitterly about the insensitivity of
their men who wanted to satisfy their lust even during the menstruation
period. The women said that unless the men too understood their prob
lems they alone could not ensure their own health.
These revelations from just a few meetings have been much more
worthwhile than all the false information garnered from the surveys and
reports done previously by the Trust and the government. To tackle this
problem of the disastrous RH status of the women the Trust has launched
a programme of special gynaecological checkup clinics in which doctors
from Indore provide their services free of charge. These are then followed
up and awareness workshops are held. This is not without problems as
women are reluctant to let themselves be examined. The general belief
that injections of antibiotics are the best solution for any disease also acts
as a barrier as women often resist the administration of vaginal tablets for
leucorrhea or the idea that regular intake of folic acid, iron and calcium
tablets can mitigate most of the excruciating pains being sufferred by
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them. Then there are the omnipresent problems of poverty due to a lack
of livelihood opportunities and overwork due to patriarchal relations.
Often men forbid the women to go for checkups or attend meetings.
Nevertheless start has been made in the right direction.
Characteristically despite repeated invitations the government health
workers have not shown any interest in these camps apart from a lone
pathologist who is also in charge of the tuberculosis programme. The
trust has given his three TB case who were getting themselves treated
privately totally unaware of the free services being provided by the
government. The day of the second instalment of the Pulse Polio
programme, January 18, a woman in Rajna village was in trouble with the
delayed delivery of the second twin baby while the first was desparately
fighting the cold to survive after delivery. A worker of the Trust had gone
there on being called and was desperately trying to arrange for a vehicle
to take the women to Barwah. Just then a doctor from the PHC at Barwah
happened to come along in a jeep. When the doctor was asked to take the
woman to Barwah he declined saying that he had to oversee the Pulse
Polio programme which involved the health of thousands of children of
the area and so he could not a attend to the needs of just one child and
mother. Eventually a private jeep had to be arranged but the twins died in
Barwah. The particular worker remained distraught for a whole day.
Bringing about social change is a complicated process and demands
human interaction between the change agents and the people who are to
bring about the change. Such a process is heavily dependent on a correct
evaluation of local conditions. Thus informal meetings which encourage
people to articulate their needs and feelings are the most effective way of
determining a plan of action. Instead of this the norm today is to decide
on policy at a central level based on necessarily partial and false aggre
gated data for sometimes as vast an area as the whole country or even the
whole world and then go down to the village level with these predeter
mined prgrammes couched in populist rhetoric expecting the people to
participate in them wholeheartedly. Naturally people resist if not openly
then by silent non-cooperation. Such a process while providing jobs to
statstisticians, academic researches and policy planners at the same time
ensure that no real social change does indeed take place and threaten
increasingly global exploitative interests.
The latest example of such spurious populism is the introduction by the
government of the ‘Target Free Approach’ (TFA) in the Family Wefare
Programme from April 1996. Achievement of sterilisation targets has
been done away with and instead a comprehensive RH package is to be
provided and the health services are going to be made more client
sensitive. This is in accordance with the current thinking on RH referred
to above which gained international recognition al the International
Conference on Population and Development held in Cairo in 1994. Even
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though the manual that has been designed for the purpose has a number
of laudable provisions significantly it is not free of the government’s
obsession with reporting and monitoring of achievements. Thus a lowly
ANM has been prescribed as many as 23 activities including providing
regular ante-natal care of high quality to pregnant women of which she
has to submit monthlly written exports to the PHC. This is repeated right
upto the PHC level and the proorma for these reports take up a lion’s share
of the mannual. NGOs which take funds from government or interna
tional donors like UNICEF, USAID and WHO will also have to comply
with these reporting requirements. Going by previous experience of the
work of the government and the KGNMT described above one can safely
predict that the TFA too will end up as a collation of false data without
bringing about any substantial change in the health status of women.
Since the European enlightenment the Cartesian knowledge system
has been given pride of place over all other knowledge systems. The
science and technology it has spawned has given modern man a hubris
that he can dominate nature at will. Modern medicine and health care too
have been affected by this arrogance. Even though great benefits have
ensued to mankind as a consequence of this simultaneously there are
serious shortcomings which are becoming more and more evident. The
biggest problem is that pharmaceutical research and hightech health care
have become so expensive that today commercial profits rather, than
health concerns drive the drug and healthcare industries. International
organisations and national governments too serve these commercial
interests. Under the circumstances it is unlikely that local knowledge
systems which have a more reverential attitude towards nature will be
promoted in any worthwhile manner by the establishment and we stand
to lose valuable information that is available with these.
Indian villagers still hold nature in reverence despite half a century of
government attempts to spread the half baked Nehruvian scientific temper
among the masses. The challenge today before rural health activists is to
synthesise local knowledge systems and modem medicine with the active
involvement of the people and especially women. Statistical jugglery of
untrustworthy primary data will only provide knowledge and power to MNCs
while ensuring that the masses continue in a state of powerlessness. For the
masses to become powerful they must construct their own knowledge. That
is they must learn to know differently from the way being foisted on them. The
KGNMT is trying to initiate such a process in a small comer of this country.
-Subhadra
Rahul
Sarvoday Shikshan Samity
Villxpo Machla
Viakasturbagram, Indore 452 020
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Reviews
Genome Research and Justice
Justice and the Human Genome Project edited by Timothy R Murphy
and Marc A Lappe; University of California Press, Berkeley, Los Angeles
London; 1994, pp 178+xii
THE essays in this volume address the theoretical and practical aspects
of justice and the human genome project. Murphy raises many questions
about the moral aspects of the genome project. He asks ‘Will the genomic
project cast a hermeneutic of suspicion over all people and especially
children...How many tests will a child have to pass to be wanted, bom,
and loved?” Cautioning against the potential possibility of differences
unravelled by genetic mapping being used as a pretext for vilification,
he argues that we should continue to value differences among individuals.
Daniel J Kelves traces the origins of eugenics and provides a brief history
of eugenics. He discusses the eugenic prospects in these times and
highlights the factors that would work as bulwark against revival of
negative eugenics. Although he optimistically writes that flow of history
compels us to think and act differently, trends like revival of neo-nazi
groups in Europe, ethnic cleansing and the menace of nationalist/racist
violence do not offer much hope or confidence. Arthur L Caplan cautions
that the genetic information based on genome might be used for various
purposes, ranging from determining whether one belongs to a particular
race to prescribe good mating behaviour. Using six imaginative ex
amples, he discusses the potential (ab)uses of genetic information and
ethnical issues in developing human systematics. For example, will
biological knowledge supplement or override the cultural and political
definition of race and ethnicity. According to him, to use this information,
when biology and notions of equal opportunity and fairness provide very
different questions, will be a challenge to the society tomorrow. Lori
B Andrews discusses the various aspects of genetic testing and the issues
relating to uses and abuses such testing. He observes “The dichotomy
between public choices and private choices is not as clear as we might
like”. Hence private choices about genetic testing should be provided
with additional protections. George J Annas discusses the current law
relating to medical records in the context of protecting privacy and DNA
profiling. The need to evolve appropriate rules for medical information
systems when DNA is considered as a ‘future diary’ is highlighted by
Annas. He provides a set of preliminary rules for protection of individual
privacy and liberty, without denying reasonable medical research and
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treatment. Of course the privacy he refers to includes the privacy after
death as genetic information about a person once stored, can be studied
and discussed after his/her death also.
Robert J Pokorski discusses the use of genetic information by the
private insurance industry. According to him genetic information “will
not significantly affect the availability and affordability of private insur
ance coverage”. He argues that use of genetic information by insurers is
nothing new, and from the track record of the insurers on the confidenti
ality of genetic data one can hope that in future also such data will be used
with utmost confidentiality. While most of his arguments arc based on
past conduct of the industry can one be so sure about the future as more
and more genetic data will be available, which might be used to reclassify
diseases and disorders, to evaluate the risk and premia? Norman Daniels
describes the various issues relating to providing health care in the context
of information on individual variation made available by genome map
ping. He argues that using this information to the disadvantage of
individuals who are prone to certain diseases would be unfair. Although
new information may provide a better understanding of genetic factors,
priority should be given to treatment than enhancement. We should strive
to create just institutions lest the information from genome project be put
to unjust purposes. In this context it is worth noting that as many as
thirteen states in the US have passed laws to ensure that insurers do not
discriminate on the basis of ‘predictive’ genetic information and five bills
are pending before the US Congress on this issue [Dotsey 1996].
Leonard M Fleck argues that there are “unique moral contours to the
problems ofjustice that will be posed by emerging genetic technologies”.
Although principles of justice used in other contexts will not be of much
use. According to Fleck “...these technologies undercut one of the
bedrock factual assumptions on which our usual concept of justice rest,
namely, that our genetic heritage (and the burden and opportunities it
might represent) is a given”. He points out that the possibilities offered by
emerging genetic technologies challenge the compatibility of liberalism
and genetic justice. Fleck provides examples of development and dis
semination of totally implantable artifical hearts, developing germ-line
genetic engineering techniques that would help in determing whether an
embryo should be permitted to develop and born or destroyed if it
contained flawed genetic structure and discusses the applicability of ideas
relating to health care justice. According to him it will be difficult to
maintain our commitment to liberalism and justice, in the development
and application of genetic technologies. Marc A Lappe discusses issues
relating access to health in the context of information provided by
mapping on data relating to genetic predisposition to disease. With
development of genetic mapping it is possible to discover genetic predis
position to a range of traits and disorders. The increasing exaplanatory
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power of genetic knowledge relating to existence of group-specific
differences in ‘key human attributes’ can be abused to the disadvantage
of minorities and socially disadvantaged groups. Using new genetic data
on issues relating to social policy without compromising on values of
justice and fairplay is the “largest and long term challenge posed by the
genome project”.
The essays in this volume raise many important questions relating to
use of genetic data and justice. These questions cannot be wished away
nor can we expect science to provide us all the answers. While the genome
project will provide us an unprecedented body of knowledge about
human genetics, it does pose a challenge to humankind.
According to E F Keller (1991) “Genetics asks certain kinds of
questions and it doesn’t ask other kinds of questions. Genetics is a tool for
understanding what goes wrong, a tool for understanding aberration,
abnormality, mutation. Genetics is not necessarily such a good tool for
understanding normal development.” Passive acceptance of genome
research without questioning it’s hidden assumptions and claims and the
implications of such research will result in the development uncritical
faith in the applications of genome research. To probe the implications of
genome research for justice and policy this book will be very relevant and
for that reason it is an essential reading for those interested in social,
ethical and legal issues relating to genome research and its applications.
References
Dotsey, Jennifer (1996): ‘Lawmakers Crack Down on Genetic Discrimination’,
Gene Watch, Vol 10, No 1, August.
Keller, E F (1991): ‘Decoding the Human Genome Project: An Interview with
EF Keller’ (Interviewed by Larry Casalino) Socialist Review, Vol 21,
No 2, 111-128.
-K Ravi Srinivas
We invite reports on current developments field surveys,
conferences and seminars for the ‘communications’
section. The ideal length would be about five pages
of the RJH including tables and references. Please keep
references and tables to a minimum. We would
appreciate the material in a wordprocessed format
with a floppy.
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Document
Statement on National Population Policy
[This document is awaiting cabinet approval before being presented to
Parliament]
1
Towards a National Population Policy
1.1 IN 1951, India launched the first official Family Planning Programme
in the world, with the objective of “reducing the birth rale to the extent
necessary to stabilise the population at a level consistent with the
requirement of the national economy.” A Statement on National Popula
tion Policy was made in 1976, and a Policy Statement on the Family
Welfare Programme was made in 1977. The National Health Policy of
1983 emphasised the need for “securing the small family norm, through
voluntary efforts, and moving towards the goal of population stabilisation”
The National Health Policy stated the need for a separate National
Population Policy. The National Development Council (NDC) appointed
a Committee of the NDC on Population in 1991. The report of this
Committee, endorsed by the NDC in 1993, recommended that “aNational
Policy on Population should be formulated by the government and
adopted by the Parliament”. A Group of Experts was set up to prepare a
preliminary draft of the Population Policy. This group has made some
valuable suggestions. This Statement on National Population Policy is a
culmination of the exercise initiated with the NDC’s Committee on
Population.
2
Population in India’s Planning Process
2.1 Improving the quality of human life based on the principles of
self-reliance, social justice and harmony between human population
and nature has been a cornerstone of India’s development policies and
strategies since the beginning of the First Five Year Plan in 1950-51.
India has been one of the first countries in the post World War II era
to attend seriously to population issues. This has led to substantial
achievements. However, the growth rate of population continues to
be high.
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3
Variations between States
3.1 Uneven progress among States in population stabilisation has been
one of the factors responsible for a high national growth rate. Thus, while
for the country as a whole the Total Fertility Rate (TFR) was 3.5 in 1993,
it was 5.2 in Uttar Pradesh, 4.2 in madhya Pradesh, 4.5 in Rajasthan and
4.6 in Bihar. On the other hand, the TFR was 1.7 in Kerala and 2.1 in Tamil
Nadu, the two major States which have already reached below replace
ment level of fertility. The four large states contributed 42 per cent of the
net increase in India’s population during 1981-91. Il is thus evident that
population stabilisation strategies will have to keep in view the diversity
prevailing among States in total fertility rate, death rate and infant
mortality rate. Policies and programmes will have to be tailored to suit the
particular socio-cultural and socio-economic factors prevailing in each
area. Recent developments provide an excellent opportunity for promot
ing the concept of Unity in national population goal but diversity in
implementation strategies. With the Panchayat Raj Acts coming into
force in all States and Union Territories consequent on the 73rd Amend
ment to the Constitution of India, there is a real opportunity for planning
al grassroot level. Hence, this Population Policy is structured on the basic
premise: think, plan and act locally and support nationally. Such a shift
in approach is fundamental to achieving a population policy driven by
peoples’ perceived needs. Based on the national population policy frame
work, each panchayat and nagarpalika can develop a blue print for action
based on integrated attention to health, education and environment with
sensitivity to gender and poverty issues.
4
Population and Poverty
4.1 The World Health Organisation (WHO) defines health as “a state
of complete, physical, menial and social well being and not merely
absence of disease or infirmity”. To achieve this, it is necessary not only
to adopt a holistic approach to health but also to recognise the need for
giving priority to effective implementation of our policies and pro
grammes designed to ensure poverty eradication, environmental protec
tion and gender equity. The current global development pathways are
leading to a continuous increase in the gap between the incomes of the
poor and the rich, besides damaging basic life support systems of land,
water, flora, fauna and the atmosphere. Development which is not
equitable will not be sustainable in the long run. Programmes for gener
ating an enabling environment where all people can experience a healthy
and productive life will call for speedy and effective implementation of
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the Minimum Needs Programme and in particular, for according the
highest priority to (a) safe drinking water and good sanitation, (b)
ensuring the health of families, (c) providing opportunities to plan the size
of one’s family, (d) education of children, with particular attention to the
girl child, (e) provision of creches and child care services to support
working mothers, and (f) increasing the income earning capacity for both
men and women.
5
Population and the Environment
5.1 Gandhiji said “We have enough for everyone’s need, but not for
everyone’s gree.” The consequences of our failure to achieve a continu
ous improvement in the quality of life of all in harmony with nature arc
grave. Prime farm and is getting diverted at a rapid rtae for non farm uses.
Per Capita land and water availability is declining to levels where both
national food and drinking water security are at grave risk. Nearly 50 per
cent of the irrigation water now comes from ground water and increas
ingly, the static component of ground water (which is not annually
replenished by rainfall) is being exploited. Precious biological diversity
is getting lost due to the destruction of coastal, mountain and forest
habitats rich in genetic diversity. Pollution by non biodegradable and
toxic wastes is also growing. The unsustainable life styles of both wealthy
nations and wealthy people everywhere are posing threat to climate,
particularly precipitation and are contributing to a potential rise in sea
levels and ultraviolent B radiation. Under such circumstances the loss of
every gene or species limits our capacity to adapt to new situations. It is
high time the limits to the human carrying capacity of the supporting eco
systems are recognised.
6
Gender Equity and Gender Balance
6.1 The emergence of grassrool level democratic structures provides
opportunities for correcting the prevailing gender imbalance in the
acceptance of contraception. The neglect of the girl child, the higher
levels of child mortality of females as compared to males, persistence of
female child labour, low literacy rates for women, the high drop-out rates
for girls, the low age at marriage, the high proportion of teenage high risk
mothers and low birth weight babies, the high maternal and infant
mortality rates and increasing violence against women are all areas where
urgent remedial action is called for. The decline is sex ratio is a warning
signal. The sex ratio for the country of 927 females per 1,000 males
observed in the 1991 census is indicative of extensive discrimination
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against women. Only Kerala has a sex ratio exceeding unity. Women’s
participation is formal groups such as panchayats or informal groups such
as Mahila Mandals, Mahila Swasthya Sanghs and voluntar organisations
are the most effective and sensitive vclricles for rectifying gender
imbalances and promoting the interests of women. Nearly one million
reserved seats will be available for women in panchayats in the country
as a whole. Such political and social empowerment, if supported by steps
designed to strengthen the capability of women in decision-making
processes, should help us to make a new beginning in integrating gender
equity in plans for health and family welfare and also help to arrest and
reverse the declining sex ratio.
6.2 Men have aften misused their power to satisfy their greed for more
and more and have resorted to unsustainable and irreversible exploitation
of natural resources to the deteriment of the less powerful segments of
society whose primary needs cannot be met because of the greed of the
high and mighty. Observance of Panchshcel of gender relations would
emancipate men from their mindset of greed, encourage women to rise to
their full potential, achieve gender equity and eliminate gender conflicts.
Panchsheel for Gender Relations
(i) Equality of Status
(ii) Respect for the views and independence of the other even in
situations of interdependence.
(iii) Gentle courtesy in personal and social relations.
(iv) Extending maximum assistance to the other to achieve full
potential.
(v) Abjuring possessiveness.
7
Enablement and Empowerment for
Population Stabilisation
7.1 Annually more people are added to the population of India than any
other country in the world. Even now, those living below the poverty line
are numerically as many as the total population of India at the beginning
of the First Five Year Plan, i e, about 360 million. Population, poverty and
environmental degradation have close linkages and quest for food,
education, health and work for all will remain illusory unless success is
achieved in limiting the growth of population. It must be recognised that
given India’s age structure and the current levels of fertility and mortality,
the population has an inbuilt momentum for continue to grow for the next
few decades in spite of continuing decline in the birth rate. By the year
2000, a population of over 1000 million seems inevitable. In terms of
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employment, this would mean that nearly 100 million new jobs will have
to be created by the end of this century. An enabling environment and
empowerment mechanisms are needed to accelerate the march towards
the goal of population stabilisation by achieving a Total Fertility Rate
(TFR) of 2.1 by'lhe year 2010.
8
Empowerment Mechanisms and Policy Initiatives
8.1 There is need to achieve a proper match between steps to promote
an enabling environment and those designed to empower governments,
communities and families in achieving the family welfare goals. The
proposed empowerment mechanisms are enumerated below:
8.1.1 Family: The tendency to shift the entire responsibility for
family limitation to women will be checked and the culture of joint
responsibility of the couple in all matters relating to the family will be
nurtured through various steps including the removal of gender bias in
textbooks, media and public services. The contraceptive services
provided to the family will be based on informed choice and decisions
will rest with the users.
8.1.2 Panchayati Raj and Nagarpalika Institutions: Each panchayat
and nagarpalika will be encouraged to prepare a socio-demographic
charier for the respective village, town or city. The village/town/cily
level charier will have specific goals for population stabilisation
developed after discussion among the people of the area. The charter
will pay particular attention to achieving a balance between human
population and resources available to the community. In addition, the
charier will indicate the steps which the local community plans to
initiate for ending social evils like dowry, child marriage, female
foeticide and infanticide and female and male illiteracy. Il will also
develop guidelines for improving the quality of life. Such a charter
will include a blue print for action, which will spell out the financial
and technical support needed.
8.1.3 District: Al the district level a broad-based administrative
mechanism will be formed by networking of existing departmental
and elected bodies with NGOs, social workers, etc. This mechanism
will monitor progress in implementing the village and town socio
demographic charters and ensure their success. An important respon
sibility of this arrangement would be to achieve convergence and
synergy among all ongoing governmental and non-governmental
programmes in the areas of population containment and social devel
opment programmes in the areas of population containment and social
development. The structure of this district level mechanism may vary
from state to stale and existing bodies may be entrusted this task.
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Central funds under the Family Welfare Programme and various other
social sector programmes may be granted directly to the district level.
8.1.4 State'. A major role of slate governments will be the promotion
of integrated quality of life improvement measures, with a focus on
education and population limitation methods. The quality and adequacy
of the health care and contraceptive delivery systems will need particular
attention. Effective and safe contraceptive methods, chosen on the basis
of informed choice, should be available to all who want to use them.
8.1.5 National Level'. A Cabinet Committee on Population and Devel
opment will monitor' the implementation of the National Population
Policy, besides providing political and policy guidance. It will be chaired
by the prime minister and will consist of the ministers incharge of Health
and Family Welfre, Finance, HRD, Welfare, I&B, Rural Development,
Urban Development, Environment and Deputy Chairman, Planning Com
mission and others as decided by the prime minister.
9
Freezing of Seats in Parliament and State Legislatures
9.1 To ensure strong political commitment, legislation will be under
taken to prospectively debar persons who do, not adopt the small family
norm from all elective office. Political leaders at all levels will be
encouraged to refer to family planning and family welfare in all their
public communications, in any forum whatsoever.
9.2 As of now, the seats in parliament and state legislatures are frozen
till the year 2001. Consistent with the goals of this policy, it is proposed
to extend the period of freezing of seats up to the year 2011.
10
International and Internal Migration
10.1 The problems of migration will be addressed in all its aspects
including the proliferation of urban slums.
10.2 Documented international migrants will be accorded rights and
responsibilities according to the national law.
10.3 Potential international migrants will be made aware of the
conditions for entry, stay and employment so as to deter undocu
mented migration. Legal action will be taken against those who
organise undocumented migration and exploit such migrants. The
return of undocumented migrants to their countries of origin will be
encouraged and facilitated.
10.4 In view of the rapid urbanisation and resultant pressures on
civic amenities and the environment, a balanced spatial distribution of the
population will be fostered. This will take into account the role of
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economic and environmental policies, sectoral priorities, infrastructure
investment and balance of resources among central, state and local
authorities.
11
Goals
11.1 The following goals, incorporating the goals adopted by the
International Conference on Population and Development (ICPD),
1994, are set:
(i) Universal primary education by the year
AD and universal
female literacy by the year...... AD.
(ii) Infant Mortality Rate (IMR) of below 35 per 1,000 live births
by the year 2015 AD;
(iii) Under 5 Child Mortality Rate (CMR) of below 45 per 1,000
population in the age group, by the year 2015 AD;
(iv) Maternal Mortality Rate (MMR) below 75 per 1,00,000 live
births by the year 2015 AD;
(v) A life expectancy at birth greater than 70 years, both for men
and women, by the year 2015 AD; reduction of morbidity and mortal
ity differentials between males and females, as well as between
geographical regions, social classes and ethnic groups;
(vi) Universal access to quality reproductive health care, through
the primary health care system, including both services and informa
tion, by the year 2015 AD;
(vii) Reduction in the incidence of marriage of girls below the legal
age of marriage to zero, by the year 2000 AD;
(viii) Increase in the percentage of deliveries conducted by trained
personnel to 100 per cent by the year 2000 AD;
(ix) Containment of HIV/AIDS and sexually transmitted diseases;
lx) Full civil registration of births and deaths by the year 2000 AD;
registration of marriages to be made compulsory by law.
(xi) Total Fertility Rate of 2.1 by the year 2010 AD.
11.2 States which have achieved these goals or achieve them before
the specified years should aim to achieve better socio-demographic
and reproductive health indicators.
11.3 This Population Policy, if implemented by individuals and
governments, irrespective of religion, caste or political affiliation,
will help to provide a better common present and future to all our
people. It is being introduced in a time of historic transition in the
evolution of political instruments capable of enabling people in
villages and towns to guide and shape their own destiny. If our
population policy goes wrong, nothing else will have a chance to go
right.
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12
Strategy for Implementation
12.1
Primary Health Care
12.1.1 A package of Reproductive Health Care will be delivered
through the primary health care systems and efforts will be made to
integrate the different components of health like MCH, reproductive and
sexual health, as also the national programmes for the control/eradication
of malaria, leprosy, tuberculosis, blindness, AIDS, etc.
12.1.2 A holistic and comprehensive approach to health would be
identified and implemented. This will mean that the programme will be.
reaching beyond maternal and child health care and family planning
services to cater to gynaecological and sexual problems, safe abortion
services and reproductive health education. The health package will
include attention to AIDS and reproductive tract infections. The emphasis
will be on quality services for prevention and cure.
12.1.3 Access to available, acceptable and affordable quality health
care services and information will be a strategy central to reducing
mortality and morbidity. Ensuring access to services and information to
women and disadvantaged sections of the population will be a priority
task;
12.2
Reproductive Helath Care
12.2.1 The service delivery mechanism for health and family welfare
services is already integrated through the primary health centres and sub
centres. The existing family planning and MCH services will be broad
ened to include other aspects of reproductive health care, at a pace
appropriate to the capacity in each State, ensuring the quality of services
rendered. Equipment and supplies required to provide the identified range
of services, ensuring quality of care, will be provided.
12.2.2 The system of setting method-wise contraceptive targets has
already been replaced by decentralised participatory planning at the
primary health centre level.
- 12.2.3 Maternal health services will be provided through the primary
health care system to reduce the maternal mortality rate. These would
include education on safe motherhood, safe and effective prenatal care,
assistance at delivery by trained personnel, emergency obstetric care,
referral services and post-natal care. Measures will be taken to prevent,
detect and manage high-risk pregnancies and births, particularly those to
adolescents and late parity women.
12.2.4 Another critical area deserving attention concerns the large
number of unsafe abortions conducted by unqualified persons which has
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led to high morbidity and mortality among women. Every effort will be
made to reduce such unsafe abortions. Primary heailh centres and com
munity health centres will be properly equipped to carry out safe abor
tions in accordance with the law. and such facilities will be made more
acessible.
12.3
Training of Staff
12.3.1 The service provides, namely the medical and paramedical
personnel will continue to provide sendees in the rural and urban areas
under state governments. However, there will be an effective programme
for induction, promotion, continuing education, training and orientation
at all levels. There is also need for reallocation of duties and above all a
change in attitude towards the whole programme. The Chief Medical
Officer in each district, who should have public health training and
orientation, will prepare a district morbidity, mortality and fertility
profile. This will help in prioritising various ongoing health programmes.
In this context, health management and skill formation will be key factors.
The provision of quality health services and in particular, screening and
aftercare services for all contraceptive acceptors are high priority issues.
The credibility of the programme can improve only through improving
the quality of services, efficient logistical support and better management
at the grassroots level. The training will be planned al the district level.
Training reserves will be cretaed to enable release of personnel for
training on regular basis. The content of the training input will be oriented
to the practical.
12.3.2 Reproductive and Child Health and Public Health will be
stressed in the medical education curricula.
12.4
Contraceptive Methods
12.4.1 The Indian Family Planning Programme in its earlier years
mainly offered barrier methods for women, until some leading medical
experts and administrators promoted the vasectomy operation for men as
a terminal method. Female sterilisation also soon became well known,
and as the programme spread from urban to rural areas, sterilisation
became prevalent as it was a safe, one time procedure, freed the acceptor
from further action, and limited the size of the family.
12.4.2 The balance between the numbers of vasectomies and
tubectomies has drastically altered in recent years, and today women form
the majority among acceptors of sterilisation operations. Il is necessary to
redress this. Men should come forward again for vasectory where family
limitations is desired, as also in adopting the condom method, thus
sharing the responsibility for family planning.
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12.4.3 Another crucial consideration lies in the fact that there should
be as wide a range as possible of methods available from which to choose.
Sterilisation still continues to be the leading method, but if it is resorted
to by older couples who already have three or more children, it does not
have the desired demographic impact. In view of the prevalence of early
marriage, methods which help to space births need to be easily accessible
with quality services for younger couples who, on completion of their
family, may choose sterilistion thereafter. Spacing of births undoubtedly
has a positive impact on the health of women, and will be promoted
accordingly.
12.4.4 Apart from the barrier methods, there now exist newer methods
which women can use for spacing. It is possible that bio-medical research
will yield non-terminal and reversible methods of contraception for men
also. It has to be recognised that no mediation, including that for
contraception, is completely free from side effects. But India has an
efficient scientific set up for testing for safety, efficacy, reliability, and
acceptability of contraceptive methods before introducing them into the
Family Welfare Programme. Although controversies are raised from time
to lime about various methods, there is no reason why a range of methods,
provided they are scientifically tested and approved, meet ethical stan
dards and are backed up by appropriate services, should not be made
available to men and women. In delivering services, it must be ensured
that all potential users can exercise a free choice, backed by full informa
tion and counselling about the safety, efficacy and possible side effects of
each method, and how they should be used. Changing methods when so
desired is also a part of informed, free choice.
12.4.5 Safe and effective methods, counselling, informed choice,
quality services, adequate supplies, and careful follow-up, are essential
requirements for promoting contraception.
12.5
Incentives
12.5.1 Incentives in cash or kind given by the Central and State
Governments for the acceptors of contraception as well as to motivators
and service providers will be discontinued in a time-bound manner.
Community incentives aimed at encouraging the community to undertake
activities resulting in reduction of birth rate, infantand maternal mortality
rates, increase in female literacy, increasing the age of girls at marriage,
etc, have been introduced. The possibility of introducing income tax
concessions, in the form of higher tax exemption limit or in other forms
will be examined. Innovative schemes specifically directed to improve
the status of the girl child and eliminating adverse sex ratio would be
developed. Special attention will be given to the areas and states having
a high TFR and IMR.
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12.6
Organised Sector
12.6.1 The employees of the central government, state governments,
municipalities, and employees of various public sector undertakings
must give the lead in adopting the two child norm. The service rules in
the central and state governments and their undertakings would be
suitably modified to ensure that the two child norm is adopted by their
employees. Similarly, all new entrants to the government who are
married before the legal age of marriage will be debarred from recruit
ment. Promotion policies should be such that the adoption of the two child
norm is encouraged. The entire organised sector (public as well as
private) must also take similar steps in order to crctae an environment
where the two child norm is adopted by these relatively better off classes
of society.
12.7
Health Insurance
12.7.1 The Life Insurance Corporation and private sector insurance
companies would be asked to draw up suitable schemes for group health
insurance for workers in the unorganised sector and their families. It will
be mandatory for the employers in the organised sector to provide for such
group health insurance.
12.8
Gender Code
12.8.1 Every effort will be made to eliminate all discrimination against
women. In this context the media and advertisement agencies must
develop a gender code which eliminates glorifying violence and vulgar
ity. Steps will be taken to provide special care for the girl child and the
adolescent girl through higher levels of school enrolment, skill formation
and income generating capacity. This will also be conducive to raising the
age at marriage and adoption of contraceptive methods based on informed
choice.
12.9
Population Programme as a People’s Programme
12.9.1 The government bears the primary responsibility for the poli
cies, planning and country wide promotion of programmes for population
and social development. At the same time, not only are its tasks made
easier, but it is a part of good governance to evoke the whole hearted
participation of the people in population stabilisation measures on the
basis of shaped perceptions and goals. Voluntary and non-governmental
organisations can be particularly effective in mobilising the community,
bringing about social change in attitudes and behaviour as in gender
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issues, fighting evil customs like dowry and increasing people’s partici
pation, through communication, management and marketing skills. They
can also help to promote the adoption of orphan children after a couple
have had a child of their own, so that children already born have a chance
to have a happy life. Voluntary organisations will be fully involved in
policy, planning and implementation of all programmes related to popu
lation stabilisation and social development. They will be given the
necessary authority and autonomy to be innovative in socially relevant
ideas, subject to financial accountability and ethical norms.
12.9.2 It is recognised that a large majority of the health functions can
be handled by the community with effective support from functionaries
of the health care system. This would involve transfer of knowledge
and skills from the health workers to the community. Helath woriers
and the community would be oriented in simple, inexpensive inter
ventions to ensure the survival and development of children. While
emphasis would be on prevention and management of common childhood
diseases, recognition of dnger signs when the child needs to be managed
in a health facility would be taught to health workers and mothers. To
provide effective referral support, a network of first referral units would
be set up.
12.10
Information, Education and Communication (IEC)
12.10.1 Information, Education and Communication (IEC) efforts are
vital for the successful implementation of the population policy. How
ever, the infrastructure for implementing IEC measures, both at the centre
and in the states, remains inadequate. The IEC strategy tends to be
centralised and the arrangements confined by and large to official
sources.
12.10.2 The state governments will take up the task of formulating
state-specific strategies on IEC. Panchayats, zilla parishads,
ncgarpalikas and NGOs will be involved in implementation and follow
up. IEC will be an integral part of the population planning process at all
these levels.
12.10.3 All IEC efforts will be such that informed choices of all issues
are facilitated, educational efforts both formal and non-formal are sensi
tive to population issues and the process of communication in belistic and
focussed, keeping the diversities and imbalances in the country in view.
The role of inter personal communication is voted and therefore health
provider should be suitably, trained.
12.10.4 The media as well as the institutions and individual involved,
whether of government or outside, should be persuade of their social
responsibility to take up issues relating to population and family welfare
voluntarily.
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12.10.5 The emphasis in IEC will be equally on men and women. Such
an emphasis will be nurtured and maintained through various steps
including the removal of gender bias in text books, and print and
electronic media.
12.10.6 Information, Education, Communication (IEC) efforts are not
a substitute for actual service in the field or for the quality and reliability
aspects of the programmes. IEC activities are supportive to the programme;
hence the linkages with the service delivery aspects and the ground
realities will be strengthened.
12.10.7 Informed choice is a pre-requisite to a radical paradigm shift
and change in the scene. Providing full information and supportive
counselling that enables informed choice is the only way for sustained
motivation and that will be a prime task of IEC.
12.10.8 Mass media should create a social environment for population
stabilisation and echo the initiatives and programmes at the panchayat
and negarpalika levels, as is the case with literacy campaigns. School,
college and university systems should have more vigorous population,
family health and reproductive health education modules as part of syllabi
at various levels in order to crystalise the concept of responsible parent
hood and safe sex.
12.10.9To strengthen abroadbased population stabilisation programme,
sustained efforts will be made to utilise the services of various media of
communication, corportae sector, private medical practitioners of allpathic
and indigenous systems of medicine, members of professional and para
professional organisations such as the Indian Medical Association, Medi
cal, Dental, Pharmacy and Nursing Councils, youth and womens’ as
sociations, and other reputed voluntary organisations. Special efforts will
be made to communicate the family planning messages in the cultural
context.
12.10.10 The need today is for a more decentralised, locally relevant
use of mediaof communication, in order to carry the messages effectively
at the grassrool level.
12.10.11 The motivation of field cadres in the social sector depart
ments and lheirinvolvemenl in the population stabilisation efforts will be
strengthened.
12.10.12 Curricula at various levels of the education system, formal
and non-formal, should encompass population issues and aspects related
to family life.
12.11 Political Support for the Population Programme
12.11.1 Total and sustained political support for the positive goals
involved in the population problem at all levels in the country will go a
long way toward fostering a mind set favourable for achieving goals and
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ihc desired results. The increase in the population is one of the most
serious problems facing the country today, and the political leadership
cannot remain aloof to this issue. The increase in the populations has
ramifications involving not only the welfare and development of the
country, but also social tranquility and harmony. Population issues,
therefore, need to be addressed by political leadership irrespective of
parly or political affiliation Suitable mechanisms have to be deve
loped at all levels to elicit support to the National Population Policy and
to the population programme. Similarly, other groups like social and
cultural leaders, trade unions, student bodies, professional associations of
health care providers and employers in the organised sector will be
sensitised for giving their support to the population programme of the
country.
12.11.2 The identification of family planning with contraception/
sterilisation has limited the perspective of the Family Welfare Programme
and has created a negative image in the minds of the people. This is turn
has not been conducive to enlisting the voice and advocacy of many
political entities. If the family planning/family welfare programme is to
succeed in enlisting a broad spectrum of political and public support, it is
essential to erase its present negative image, and substitute it with the
positive image of the programme. Such a programme will emphasise
measures like higher age al marriage, literacy, education, reduction of
infant mortality, increasing birth spacing, promotion of breast feeding,
management of infertility, adoption of orphan children, and the desir
ability of having a planned family.
12. 12 PANCHAYATS, NaGARPALIKAS AND COMMUNITY PARTICIPATION
12.12.1 Under the new local bodies legislation, one-third of the
members of these bodies will be women and one-third will belong to the
weaker sections of the community. In order to make decentralised,
democratic planning effective, every step will be taken to give the much
needed information to all members of the panchayats, zilla parishads and
ncgarpalikas about various ongoing programmes and also upgrade their
level of knowledge about the issues involved through continuous orien
tation programmes.
12.12.2 Initiatives should be left to the people to help themselves
through community participation and voluntary efforts, thereby redu
cing their dependence on the government. There should be increasing
community participation in areas like literacy, education, hygiene, sani
tation, public health, ’family welfare and environment protection.
Management of primary and community health centres and dispensaries
and hospitals in rural areas will be paseed on to the panchayati raj
institutions.
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12.13
Women and Children
12.13.1 During the last two decades, several programmes specifically
aimed at the girl child, adolescent girls and women have been in opera
tion. All such programmes will be reviewed, streamlined and strength
ened. Ever}' effort will be made to universalise female literacy and also
ensure high enrolment rate for girls right up to the secondary school level.
Circumstances which necessitate child labour will be addressed and the
process of abolition of child labour will be accelerated. Adoption of
orphan children will be promoted.
12.13.2 Health, including reproductive health, is another priority area.
The use of diagnostic techniques for prenatal sex determination to avoid
a female child has already been made illegal. Much more than this, n is
important to build up public opinion and social pressure against such
misdirected use of technology. Family life education and pre-marital and
marriage counselling will be introduced in the appropriate cultural
context Tor promoting responsible parenthood.
12.13.3 One of the factors which influence the use of contraception
by couples is the degree of expectation of survival of their progeny. Birth
rate tends to reduce with decrease in infant and child mortality rates.
Acceleration of the decline in infant and child mortality rates would be
ensured by addressing common causes of childhood morbidity and
mortality.
12.13.4Mortality in the newborn period contributes to over 60 percent
of the infant mortality. Special efforts would be directed towards reduc
ing neonatal mortality. Traditional birth attendants, para medical workers
and the community would be oriented towards home management of
newborn infants, with emphasis on prevention of common causes of
neonatal mortality.
12.13.5 In addition to universalising immunisation of all infants
against diphtheria, pertussis, tetanus, measles, tuberculosis and poliomy
elitis and against other diseases, vaccination against which may be
included in the programme at a later date, prevention of child death due
to diarrhoeal diseases and acute respiratory diseases would be imple
mented.
12.14
Youth
12.14.1 India continues to be a youthful country and for several
decades to come, the proportion of youth will continue to be high.
Therefore, every effort will be made to inculcate in youth, the dynamics
of population growth and the concept of responsible parenthood. Youth
organisations like NCC, NSS, Scouts and Guides, Nehru Yuvak Kendras,
etc, will be harnessed for activities related to population and social
development. Students of medical colleges will be involved in preparing
the district health and population profile.
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15.15
Non-Governmental Organisations (NGOs)
15.15.1 A new climate of partnership between government and volun
tary and non-governmental organisations will be created to encourage the
extensive participation of such organisations at all stages and at all levels
on the national programme for population stabilisation and social devel
opment. After mutual consultations, criteria will be developed to identify
such organisations as will be eligible for financial and technical assis
tance. Indices for accountability, monitoring and evaluation will also be
developed.
12.16
Monitoring and Evaluation
12.16.1 Currently, the monitoring and evaluation of the family welfare
programme is being done by the Evaluation and Intelligence Division in
the Department of Family Welfare. A new system of reporting of client
centred data, incorporating quality aspects, has already been introduced.
At present, female Multi-Purpose Workers (ANWs) in sub-centres are
burdened with several registers for maintaining and reporting-routine
data on MCH and family planning. The eligible couple registers are often
not being maintained properly. A Management Information System
(MIS) will be extended all over the country. It will also be necessary to
conduct field surveys periodically to supplement the routinely collected
data. It will be necessary to generate data on birth, death, maternal and
infant mortality rates and age at marriage, at the district and block levels.
At present, the vital statistics division in the Office of Registrar General
conducts regular sample surveys under the Sample Registration System
(SRS) to yield data on birth, death rates, etc, but because of the size and
scatter of samples, such data are not available at the district level, which
is a prime requirement. The data generated at district and block levels will
be fed back to the authorities at these levels to facilitate planning.
12.16.2 It is not necessary to centralise such data collection or
estimation. The whole work can be decentralised to the state level and
even district level, provided a uniform format is maintained for collection
of such data and a proper manual prepared in order to eliminate any bias
on the part of investigators. Modern techniques of sampling for generat
ing statistics of small areas can be effectively used. In particular, data,
must be collected on the age at marriage and marriage rate in order to
enforce the Child Marriage Restraint Act, which prohibits marriages
below the specified age limits. The central government will enact a
comprehensive Marriage Registration Act which will make it obligatory
to register marriages all over the country. Judging by the experience of the
Compulsory Registration of Births and Deaths Act which has so far not
succeeded in getting reliable and complete data on births and deaths in
most states of India, it would be unrealistic to rely on legislation alone.
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Hence, this is a fit area for a decentralised approach and accordingly, data
on births, deaths and marriages will be collected and the fullest coverage
ensured through village panchayats and nagarpalikas.
12.16.3 International migration as a proportion of total population is
small. Nevertheless, at the local and sub-regional level distress migration
as well as illegal migration create serious problems with far reaching
implications. The Census cannot give any estimate of illegal international
migration. Therefore, a suitable monitoring mechanism will be estab
lished for confidential assessment of illegal migration on a yearly basis in
order to take effective steps to deal with such migration.
12.17
Strengthening of Data Base
12.17.1 In future, greater demands will be made on the statistical
system by planners and policy makers in view of the key role assigned to
social development in this policy. The decennial census is the most
important single source of demographic data. The office of the registrar
general will be strengthened in order to enable it to conduct smoothly the
census of 2001 AD, covering over a billion people.
12.18
Social and Bio-medical Research and Technology
12.18.1 Networking among the existing institutions engaged in re
search and training in population dynamics, health and related subjects
will be promoted and new areas of research taken up to given the crucial
research back-up-to population programmes and policies. At the same
time, basic and theoretical research with long-term perspectives will be
encouraged. All institutions concerned and in particular, the International
Institute for Population Sciences (UPS), the National Institute of Health
and Family Welfare (NIHFW). Stale Institutes of Health and Family
Welfare and the Population Research Centres at various universities and
research institutions, will be given autonomy and the fullest academic
freedom in order to generate an environment of creativity, original
thinking and sensitivity to social concerns. Bio-medical research includ
ing traditional and frontier technologies will be promoted and funded in
suitable institutions. Effective co-ordination with the Indian Council of
Medical Research (ICMR), the Indian Council of Social Sciences Re
search (ICSSR) and other agencies will be ensured. The fullest coopera
tion of professional associations and selected NGOs will be sought in
research and training programmes. A data base will be developed on
indigenous knowledge systems and methods with reference to contracep
tion.
12.18.2 Research on biomedical and social sciences relevant to popu
lation stabilisation will be strengthened. The ethical aspects of field
testing of new contraceptive technologies will be thoroughly examined.
Every effort will be made to attract young scholars to work on population
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1996
issues, particularly on building indigenous knowledge systems and prac
tices relevant to health and family planning.
12.18.3 Production technology for contraceptives, vaccines and equip
ment will be reviwed and upgraded, and efforts will be made to improve
the level of self-sufficiency.
12.9 Differential Approaches
12.9.1 The Department of Family Welfare has an existing policy of
providing additional resources to identified areas, mainly for augmenting
infrastructure and training.
12.9.2 While the approach will continue, the areas to be selected shall
be identified on the basis of:
(i) Need for additional resources to compress the time required for
reaching the slated goal of Total Fertility Rate.
(ii) Adverse indicators of reproductive health status of the population.
12.20
Nutrition
12.20.1 Provision of adequate and balanced nutrition to women and
pre-school children are critical interventions for reducing maternal mor
tality arising out of nutritional deficiencies like anaemia, for ensuring
proper growth of the foetus, and for ensuring the health and well being of
children.
12.20.2 Pregnancy places a heavy demand on the nutritional needs of
women. Her caloric requirements increase by about 600 kcal a day in
additional to the increased requirements of iron other micronutrients and
vitamins. In the absence of proper care, a third of the children are born
malnourished with a birth weight of less than 2.5 kg and start life at a
disadvantage. One in five maternal deaths is due to cardiac failure
attributable to severe anaemia.
12.20.3 The nutritional status during infancy and childhood has a
pivotal role in determining child survival. Promotion of exclusive
breastfeeding in early infancy and appropriate weaning practices would
be undertaken.
12.20.4 A balanced diet is essential for healthy growth. Malnutrition
increases the risk of infections and death in children and reduces the
quality of life. Infections have an adverse impacton the nutritional status.
Prevention and appropriate treatment of diarrhoea, measles and other
infections in infancy and early childhood are important to reduce malnu
trition rate. The degree of malnutrition and its detrimental effect on health
is highest in the last trimester of pregnancy and in the first 12 months of
life. If the vicious cycle of malnutrition and infections can be prevented
in infancy and infants become healthier and better nourished, the positive
impact will also be reflected in the older age groups. Focused and
concerted attention will be directed to improving maternal and infant
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1996
259
nutrition through community awareness, and food and micronutrient
supplementation.
12.20.5 All states and Union Territories will be encouraged to institute
programme for providing supplementary nutrition to pregnant and lactat
ing women and pre-school children or sections thereof, identified either
on the basis of socio-economic indicators or on the basis of health status.
12.21 Funding of the National Family Welfare Programme
12.12.1 The National Family Welfare Programme has continued to be
underfunded consistently, with the result that large arrears payable to
states have accumulated. As reducing the rate of growth of population is
recognised as a priority action area, funding shall be need-based.
12.22 Introduction of User Charges
12.22.1 All states and union territories will be encouraged to introduce
user charges for services rendered and supplies provided under the
National Family Welfare Programme where demand for such supplies/
services exists. Care will be taken to ensure that pricing does not restrict
access.
12.22.2 Such user charges are intended not only as a method of funding
the programme, but also for ensuring greater accountability of service
providers to their clients and improving the quality of services rendered.
12.22.3 User charges may be introduced at a pace appropriate to the
situation and graded according to various parameters, including the
economic status of the user.
12.22.4 The institution or facility levying user charges shall be
allowed to retain the collections and to utilise these according to policies/
guidelines to be laid down by the State/UT Recurring grants to such
facilities/institutions being inadequate to meet the requirements for
renovation and supplies, the use change could become a useful supple
mentary source.
12.22.5 Funding support to NGOs shall be designed to make the NGO
self-sustaining, through user charges or through community support,
including support from local bodies, within a mutually agreed time frame.
13
Conclusion
13.1 This policy is based on the premise that positive, forward-looking
and proactive efforts leading to the achievement of its goals, within a
specific time-frame are not only necessary, but their accomplishment is
well within the capacity of the slate and central governments and of the
people.
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Vol JI: 4
1996
Foreign Investments: Who Really Benefits
Kavaljit Singh
Rs. SO
I
Powers and Prospects
Noam Chomsky
Rs. 140
Lent and Lost
Cheryl Payer
Rs. 80
Globalisation and Third World Trade Unions
Edited by Henk Thomas Rs. 140
I
-------------- --------------------------------------------------------------------------- ■
Swiss TNCs in India
Public Interest Research Group
Rs. 50
Testing Times
The Global Stake in a Nuclear Test Ban
Praful Bidwai & Achin Vanaik
Rs. 50
TNCs and India
Jed Greer & Kavaljit Singh
Rs. 50
Economic Reforms and the People
C. T. Kurien
Rs. 30
Crisis and Response
Vinod Vyasulu
Rs. 40
Unhealthy Trends
The World Bank. Structural Adjustment and Health Sector in India
Public Interest Research Group
Rs. 15
Madhyam Books
142, Maitri Apartments, Plot No. 28, Patparganj, Delhi-110 092.
Ph : 2432054 Fax : 222433 Post Free!
The inference is clear: we must seek to build
a reliable foundation of precise and
indisputable facts that can be confronted to
any of the “general” or “example-based”
arguments now so grossly misused in certain
countries. And if it is to be a real
foundation, we must take not individual facts,
but the sum total of facts, without a single
exception, relating to the question under
discussion. Otherwise there will be the
inevitable, and fully justified, suspicion that
the facts were selected or compiled
arbitrarily, that instead of historical
phenomena being presented in objective
interconnection and interdependence and
treated as a whole, we are presenting a
“subjective” concoction to justify what might
prove to be a dirty business. This does
happen... and more often than one might
think.
==l|
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