UNDER THE LENS HEALTH AND MEDICINE
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UNDER THE LENS
HEALTH AND MEDICINE
Edited by
Kamala S. Jayarao, M.D., Ph. D
and
Ashvin J. Patel, M.D., D.C.H.
Medico Friend Circle
Published for
MEDICO FRIEND CIRCLE
by VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14, Community Centre, S.D.A..
New Delhi-11L016. (India)
Views expressed in this book arc for dissemination and discus
sion. Anybody can use and reuse them through any medium with
proper acknowledgement given to the original author and this
book.
First published : January 19S6
Cover design : Ashok Bhargava
Price : In India Rs. 15
for other countries 6 U.S. S
08 9
CO H H ’SC&
COMMUNITY HSALTM Ct’.L
First Floor) St Maths Foan,
Printed at Printsman 18A/11 Doriwalan, New Delhi-110005.
Preface
Within ten years of its inception, the Medico Friend
Circle (MFC) has become a familiar name in various
circles of development workers. It is in response to this
growing interest in MFC’s analysis of health care, that
we venture out to offer yet another anthology of articles
selected from our monthly Bulletin.
This book does not carry the same degree of per
plexity, which its two predecessors did. For, amidst the
intricate scenario of problems, solutions and problems
arising out of solutions, one discerns certain well-defined
and definite areas of focus. The focus is at times a bit
unsteady and not so definite as to generate dogma- not
yet. We are still searching for solutions, and not the
solution.
After the mad rush of critiques, arguments and
counter-arguments, which characterised the earlier two
books, particularly the first one, we paused to take a
deep breath. A stage had arrived for some calm think
ing. This was, in a way, reflected in the narrowing down
of areas of focus, and the near total absence of debate
in issues Nos. 56, 96 of the MFC Bulletin, which formed
the source of this anthology. This was restructuring of
ideas.
Thus, definite areas started to come under focus.
What one sees Under The Lens is not the total picture,
but a few definite foci in it. Moreover, is not what one
sees under the lens, only an image? But the image helps
in understanding the situation, in arriving at a diagnosis
and thus in finding solutions.
We show you Under The Lens, some of the pathogens
and the pathology: the wrong paths in health care, traps
on seemingly right paths and a frightening pattern of
"no health". The book contains admissions of selfmade mistakes. (The other side of Health Education;
Role of VHW); the myths in community health (People’s
Participation; Community Participation in Health Care;
Health For all by 2000 A. D.); the wrong directions on
the national highway of health (Health Care Vs.the Strug
gle for life; Misuse of Antibiotics; Is BCG vaccination
useful? How successful arc Supplementary Feeding
Programmes?); the subtle and not so subtle, pressures
of international politics on health (Research: A Method
of Colonisation; Multinationals in Drug Industry).
In line with the earlier two books, the present one
is also a pot-purri of different aspects of health and
health care, a reflection of the wide and varied interests
(but always deep) of MFC. It covers community health
(questioning on the way, whether there is a homogenous
community, what is meant by People and by Health for
All), drug policies, clinical medicine, nutrition, contra
(vi)
ception and much more. There is a heavy emphasis on
various aspects of drug policy and therapeutics. The
analysis by Anant Phadke (Multinationals in Indian
Drug Industry) and Anil Agarwal (Towards a Relevant
Drug Policy), clearly bring into focus the growing con
cern of all genuine thinkers regarding the dangerous
and erroneous drug policies in the Third World.
An orthodox reader may wonder how a caste war
Among Medicos or Minimum Wages for Agricultural
Labourers could ever find a place in a debate on health.
This only helps to emphasize MFC’s main refrain that
Health is not a medical subject but a socio-economic
topic, and that no true health worker can isolate him
self (or herself) from the current of socio-cultural and
politico-economic forces. This understanding reveals
the other side of the coin too—finances are not the
main constraint in achieving Health Care for All (Family
Planning & Problem of Resources; Kerala, A Yardstick
for India).
This book is an attempt to bring under focus issues
which have hitherto been missed or ignored and to ade
quately magnify them, to put them under proper perspec
tive. We hope you will welcome it as enthusiastically as
you did its predecessors (there is a heavy demand for
the republication of the other two anthologies). If this
attempt proves to be an equal success, I do not know
whom to thank and whom not to. The MFC Bulletin
and the Anthologies have always been a group effort
(even the title of the book is chosen by a group of
members after serious debate). Personally, however,
1 wish to place on record my deep sense of apprecia
tion and gratitude to Anant Phadke, who as the de facto
editor, bore the whole brunt of the publication of the
(vii)
MFC Bulletin. We thank all those who contributed
articles to the Bulletin. Our sincere thanks to Augustine
Veliath of VHA I, New Delhi and his colleagues, who
have once again offered to oversee the publication of
our book. The title cover is always the special effort of
Ashok Bhargava, the founder-convenor of MFC, whose
sense of aesthetics and humour remains unsurpassed in
the group. Last, but not the least, we thank you, dear
reader. It is through your goodwill and encourage
ment that, despite continuous attacks of financial crisis,
we have mutated into a resistant strain.
Kamala S. Jay a Rao
September 1984
(viii)
Acknowledgement
We acknowledge with thanks the following con
tributions—
Science Today for cartoons appearing on pages
84, 148, 292.
New Internationalist for cartoons appearing on
pages 36, 302.
Health for the Millions for cartoon appearing on
page 134.
The book “Who Needs Drug Companies” for car
toon appearing on page 104.
Drug Action Forum, West Bengal for the cartoon
appearing on page 20.
“See How They Grow” for the Cartoon appearing
on page 276.
—Editor
About the Contributors
All articles included in this book were published in the
Medico Friend Circle bulletin (from issue No. 53 to 95)
and have been selected from there.
Abhay Bang M.D., M.P.H.
— Physician working in rural area for community
health and rural development.
— Past editor of MFC bulletins (1978-80).
P.O. Gopuri, Dist. Wardha, Maharashtra-442114.
Ulhas Jaju M.D.
— Reader, Department of Medicine and incharge of
Health Insurance Scheme, Mahatma Gandhi Institute
of Medical Sciences, Sevagram-442 102, Maharashtra.
Janet Aitken,
— Nurse, Health and Development activist.
(xi)
C/o. Bimalendu Das, P.O. Jagdishpur, Via Madhupur Santhal Parganas, Bihar-815 353.
David Nabarro
— Department of Human Nutrition, London School of
Hygiene and Tropical Medicine, London WC IE,
THT.
— Presently on secondment to Save the Children Fund,
P.O. Box 992, Kathmandu, Nepal.
Mira Sadgopal, M.B.B.S.
— Working in health and development in the Kishore
Bharati team.
— C/o. Kishore Bharati, P.O. Bankheri,
Dist. Hoshangabad, M.P.-461 990.
Rani Bang, M.D., M.P.H.
— Obstetrician working in rural areas for community
health and rural development.
— P.O. Gopuri, Dist. Wardha, Maharashtra-442 114.
Andrew Clerk
— Activist of Damoh Grameen Shramik Sewa
Damoh-470 661.
Anant Phadke, M.B.B.S.
— Convenor of MFC 1981-84, involved in teaching
village health workers in a health conscientization
project in villages around Pune. Also working for
Lok Vignyan Sangatana and coordinating MFC
rational drug policy cell.
Anil Aggarwal
— Science and environmental journalist and researcher.
Centre for Science and Environment, 807, Vishal
Bhawan, 95, Nehru Place, New Delhi-110 019.
Mark C. Stelnhoff
— Paediatrician, Department of Child Health, Chris
tian Medical College Hospital, Vellore-632 004,
Tamil Nadu
Sanjiv Chugh
— Student of Mahatma Gandhi Institute of Medical
Sciences and active member of MFC Sevagram.
M.G.I.M.S., Sevagram-442 102, Maharashtra.
Kamla S Jayarao, M.D., Ph. D.
— Retired scientist, National Institute of Nutrition and
Past Editor of MFC bulletin 1980-84.
— 3-6-515, Himayatnagar, Hyderabad-500 029.
Vineet Nayyar, M.B.B.S.
— Post Graduate student in Department of Medicine,
Christian Medical College Hospital, Vellore-632 004,
Tamil Nadu.
C. Gopalan
— Ex. Director, National Institute of Nutrition and
Director-General of Indian Council of Medical
Research.
— Presently President, Nutrition Foundation of India,
B-37, Gulmohar Park, New Delhi-110 049.
Dhruv Mankad
— Doctor activtist, working with Project on self reliant
alternatives to western medicine and union of
tobacco processing workers in Nipani.
(xiii)
— 1877 Joshi Galli, Nipani, Dist. Belgaum,
Karnataka-591 237.
Zafrullah Chowdhury
— Vascular surgeon and Director of Peoples Health
Centre, Savar, Bangladesh.
Gonoshasthya Kendra. P.O. Nayarhat, Via Dhamrai,
Dhaka, Bangladesh.
Ramana Dhara
— Doctor
— Jana Clinic, Kushaguda, Hyderabad-500 762.
Mahatab S. Banji,
— Scientist, National Institute of Nutrition, P.O. Jamai
Osmania, Hyderabad-500 007.
(xiv)
Contents
Page
1. Learning from the Savar Project
Abhay Bang
1
2. Role of the Village Health Workers
—A Glorified Image
Ulhas Jaju
13
3. Point of View : To Inject or not to inject
Janet Aitkin
19
4. Myths in Community Health (Peoples’
Participation and Economic Self-reliance)
25
Abhay Bang
5. Community Participation in Primary Health
Care (Observations based on a Case study)
Ulhas Jaju
(xv)
37
6. Health for All by the year 2000 :
A Great Polemic Dissolves into Platitudes?
David Nabarro
7. Health “Care” Vs. the Struggle for Life
Mira Sadgopal
8. The Other Side of Health Education
(Some Experiences of Health Education in
Rural Community)
Abhay Bang and Rani Bang
9. What Development Workers Expect From
Health Planners
Andrew Clerk
85
10. Multinationals In Indian Drug Industry
105
Anant Phadke
11. Towards a Relevant Drug Policy
Anil Agarwal
123
12. Misuse of Antibiotics and Antimicrobials
139
Ulhas Jaju
13. Treatment of Acute Diarrhoea in Children
M.C. Steinhoff
149
14. In search of Appropriate Medicine
—Cough Mixtures
47
63
95
159
Sanjiv Chugh
15. “Allo—Ayurvedopathy” A non-scientific
Hybridization
Kamala S. Jaya Rao
16. Appropriate Strategy for Childhood
Immunization in India
Vineet Nayyar and L. Sbarada
17. Kerala: A Health Yardstick for India
Kamala S. Jaya Rao
(xvi)
165
171
183
18. Food Requirements as a Basis for
Minimum Wages
Abhay Bang
195
19. Nutritional Basis of Minimum Wages
C. Gopalan
213
20. Food Requirements and Minimum Wages:
A Rejoinder
Abh»y Bang
219
21. How Successful are Supplementary
Feeding Programmes?
Kamala S. Jaja Rao
227
22. Health Problems of Tobacco Processing
Workers—Some Impressions
Dhruv Mankad
243
23. Is BCG Vaccination Useful?
Kamala S. Jaya Rao
253
24. Research: A Method of Colonization
Zafrullah Chowdhury
263
125. Caste War by Medicos
Anant Phndkc
277
26. The Attitude of Society and the
Psychiatrist Toward Madness
293
2'.7. Family Planning and the Problem of
Resources
Anant I’hadke
303
288. Male Contraception
Mehtab Bancrjl
309
29>. Medico Friend Circle
317
(xvii)
"The paramedic was struggling against these odds with
her small health kit and fighting spirit. Of course, the
picture of health might have been still worse without G.K.
and Salama."
—Abbay Bang
1
Learning from the Savar Project
Abhay Bang
The car was passing from Dhaka airport to the Gonoshosthaya Kendra of Savar. The landscape of Bangla
desh was unfolding before me. A decade ago while
working as a medical volunteer in the refugee camps
during the liberation war, 1 had a few glimpses of
Bangladesh. The news of political upheavals and
natural disasters were disturbing, but at the same time
some interesting, rather sensational news of the com
munity health work started in Bangladesh by a group of
young doctors led by Dr. Zafrullah Choudhary and their
paramedic programme had aroused my curiosity. And
here was I today heading towards the famous Gonoshos-
1
UNDER THE LENS
thaya Kendra (G K.) passing through the mainland of
Bangladesh seeing both her beauty and ugliness.
Beautiful, because of the natural greenery and
abundance of water. Ugly because of the poverty, the
worst I have ever seen. The per capita yearly income
for Bangladesh is Rs. 560: one of the lowest in the
world. There is gross disparity and the lower 50% of
the population has a per capita yearly income of Rs. 225
or less. Population density in this country of 85 million
is one of the highest in the world. 91% of the popula
tion live in the rural area. 50% of the total population
has either no land or less than half acre of land. Lite
racy rate is 20%, for women it is less than 10%.
Soon the car entered into the headquarters of GK.
The first to strike you are the buildings, a two-storey
hospital-cum-officc building and a four-storey hostel
for paramedics and other staff. The total cost is Rs. 9
lacs. “Was it so essential?” Same is the feeling of
Zafrullah Choudhary, who later said, “For the initial
U years we were living in tents and temporary sheds,
and had no money for buildings. An armed robbery,
heavy rains and inconvenience to the patients and the
staff created a need for buildings. Therefore, when we
received generous foreign aid for buildings, we com
mitted the mistake of accepting the offer and within
the next two years these incongruous edifices came up.”
What is more impressive is the simple and austere
living style of the staff and the equality in relationships.
Except for a few families with children, all other wor
kers live in the same building with similar accommo
dation. From the gate keeper to Zafrullah, all take the
same, ordinary food in a common mess. G.K. has a
2
LEARNING FROM THE SAVAR PROJECT
novel rule-reminding me of Gandhiji’s Ashram in his
time —everybody in the project works for 14 hours in
the morning on the farm. “This not only helps us to
become self-sufficient in our food requirements, but also
builds up a healthy equal relationship among us, an
identification with the manual labourers of rural areas
and also helps to screen and eliminate the elitist among
the new recruits”. Al) these things must have contri
buted to the creation of the warm, friendly and family
relationship which exists in the whole team of G K.
I shall not describe the history and the activities of
G.K. as these have already been published (MFC
Bulletin No:57). Instead, after a brief description of th:
activities, I shall try to discuss some questions and
inferences from their experiences and some of their
recent experiments.
The Paramedics
G.K. was started in 1972. With only 2500 doctors for the
75 million rural people (1 doctor for 30,000 popula
tion) and with only 700 trained nurses in the whole
country, the Western health model was irrelevent. “The
purpose of our project is to evolve some system by
which the medical care of the whole population of a
particular area can be undertaken efficiently and effec
tively with the minimum expenditure and maximum
benefit, with the employment of limited medical power"
(original project proposal, Feb. 1972.)
In the last eight years, G.K. has been able to
develop such a system with the paramedic as its main
health worker. There is a central 30-bedded hospital
with X’ray, pathology and operative facilities. Office
3
UNDER THE LENS
and training centre is attached to this hospital. The
headquarters and its 4 sub-centres together try to
deliver primary health care to the 91,000 population
of 100 villages of Savar thana.
Each paramedic (except village based) covers about
2500 population (2 to 5 villagcs-depcnding upon the size
of the villages). The subcentres have a weekly OPD
when a doctor from the headquarter visits, but offers
emergency services all the seven days. Some subcentres,
managed entirely by paramedics, have small indoor also.
The headquarter hospital runs a twice-a-week OPD.
Most of the cases are seen and treated by the para
medics. Doctors mainly work as referral persons, as
trainers and as administrators.
A paramedic has usually studied up to 7th standard
or 10th standard, an unmarried girl; almost all are
recruited from outside because of the lack of educated
women in the Savar area. They are given about one
year’s in-service training, contents being similar to ANM
training in India. They are full time workers of G.K..
Drop out rate is 50%.
How the Paramedic Works
Salama, the paramedic with whom I went to a village on
bicycle to sec her routine village visit covers 4 villages.
She visits each village about once a week, sometimes
twice; goes house to house about 25 houses in one visit.
The main assigned jobs arc (1) Treatment of minor ill
nesses (2) Immunisation-BCG & Triple antigen to all
children and tetanus toxoid to all the women of child
bearing age. (3) ANC check up (4) motivation for FP
and distribution of oral pills (5) Health education (6)
4
LEARNING FROM THE SAVAR PROJECT
Detection and referring complicated cases, specially
among pregnant women and children to the doctor at
subcentre or at the headquarters.
The sincerity and the efforts put in by Salama were
worth seeing; but the response of the people and the
health status didn’t seem good. The causes of low health
status were also obvious—terrible poverty, poor sani
tation (water, mud and flies everywhere), ignorance and
a resultant apathy. The paramedic was struggling
against these odds with her small health kit and fighting
spirit. Of course, the picture of health might have been
still worse without G.K. and Salama.
I accompanied Dr. Kamal to a subcentre. That was
the OP day for the subcentre. Three girl and two boy
paramedics, all unmarried, stayed at that subcentre —
must be a sensation in the rural Muslim community of
Bangladesh. The OPD was overflowing with patients.
One could observe that neither the paramedics nor the
doctor were over-using antibiotics or injections. Same
experience at the headquarters.
GK has innovated some unorthodox methods. Diarr
hoea and cholera are very common in Bangladesh.
When the Cholera Research Laboratory (CRL) at Dhaka
evolved the electrolyte mixture, GK modified it to
“Lobon-Gur”, that is salt and jaggery mixture. Jaggery
is easily available in every house, is cheap, and provides
sucrose and potassium. CRL later did field trials on
this ‘Lobon-Gur’ mixture and found it almost equally
effective.
About 85% of the tubectomies arc done by the
paramedics with very low complication rate. The patient
is discharged within two hours and spends the post
5
UNDER THE LENS
operative period at home. This has been found to be
safe and also prefered by the patients who avoided
tubectomies because of 7 days’ hospitalisation.
What do People Want?
The study of the coverage and health impact of G.K.
raises some questions and offers useful lessons.
In the year 1975-76 the OPDs (at headquarter and
subcentres) treated 48,000 patients while the paramedics
on their village rounds treated only 6000 cases.
We all speak hoarse on behalf of the dumb poor of
the villages and advocate a decentralised, simplified,
deprofessionalised, cheap medical care for them. But in
the GK. experience, when a fairly well trained (approx.
1 year) woman paramedic is going to the door step,
only few people are availing her curative service and
the majority are prefering to walk a longer distance to
the subcentre or to the headquarters.
There are two possible reasons which were discovered
during the discussion (1) People still felt that the cura
tive services offered at subcentre or headquarters are
superior to the services of the paramedic. The mystifica
tion about doctors, indoor buildings and injections influ
ences their choice. (2) Paramedics are ill-equipped in
their curative powers. They don’t have chemotherapy
beyond sulfas. This has acted as an impediment for
showing good curative results which in turn diminishes
the cooperation extended to her.
Thus Far and no Further
What is the impact of G.K. on the health status of the
people?
6
LEARNING FROM THE SAVAR PROJECT
Though comprehensive statistics are not available,
the one offered by G.K. shows that the infant mortality
rate in GK area is about 120 as against 140 in Bangla
desh and the birth rate is 29 as against 44 in Bangla
desh. The impact is definitely there but a point of
stagnation has come, beyond which further improve
ment in health indices has become difficult.
I felt that whatever improvement G.K. could achieve
is mainly because of cheap, effective, widely available
curative services. A cure at an early stage is a major
preventive force. Some improvement is attributable to
lower birth rate because of family planning, oral rchydration therapy in the cases of dehydration and tetanus
toxoid to mothers. But probably all these measures
have reached their saturation point. Some further im
provement might occur if the curative powers of the
paramedic arc increased and if her acceptability in
creases. But the poor paying capacity of the people will
limit their utilisation of curative service. Further, signi
ficant improvement will not occur unless poverty, illit
eracy and poor environmental factors are changed.
Improving environmental factors is difficult in Bangla
desh, where most of the land is under water for 6
months in a year. Huge inputs will be necessary to
change this situation, which people can’t afford.
So GK offers a good case, demonstrating to what
extent the health status can be improved by health
measures alone and then how an impasse comes because
of socio-economic factors acting as bottle neck. Such
conclusions are possible because though GK has a com
prehensive vision and has economic and educational
programmes also, they are too small to effectively in7
UNDER THE LENS
fluence the whole population and hence the main force
is still the health activity.
What about Peoples Participation?
In GK's experience it is very difficult to achieve active
community participation. Health committees formed in
the villages almost never functioned effectively. Health
is not the priority. The paramedics of GK mostly are
recruited from outside and being unmarried girls, stay
together in the dormitory rather than in the villages.
Thus the community health programme of GK is in the
Director, Dr. Qasem’s words, “village oriented but not
village based”.
Some of the conclusions thus drawn may seem ne
gative. But these are the hard facts of community health
work and anybody jumping into this field would better
learn these lessons rather than having illusions about
massive people’s mobilisation through health work,
economic self reliance and improving health by health
measures alone. I have found friends at GK very open
and honest in accepting and discussing their limitations
also. This is a rare quality in a successful project and
this increases the educative value of GK very much.
New Growth-Point
In the last few years Gonoshosthaya Kendra has grown
positively in many new directions and I shall summarise
them in brief.
1. Realising that health cannot be improved without
removing poverty and illiteracy, GK has started a
credit cooperative programme for the rural poor
(about Rs. 1.5 Lac in 34 villages) and literacy proS
LEARNING FROM THE SAVAR PROJECT
gramme for women.
2. Handicrafts training for women to make them eco
nomically strong.
3. A vocational school for children after realising how
useless is the present education system.
4. GK has developed a very good documentation centre
and library on various aspects of community health.
5. Realising that a change in the health status of a small
area by a new model of primary health care is not
sufficient, the doctors at GK. did systematic efforts
to influence the medical education system. With the
involvement of the Ministry of Health and PSM
departments of medical colleges, GK got recognition
as rural health centre for teaching post graduates in
PSM and the under-graduates. Students from 3
medical colleges came in batches of 15 and stayed
for 10 days. For the first time they were exposed to
hard rural realities, the real health problems and the
inadequacy of Govt, health system and their medi
cal education. A systematic course was developed
at GK for ‘the conscientisation’ of medical students.
Students found it very thrilling. They went back and
described their experiences to their friends and GK
became a craze among medical students. These stu
dents formed groups in Dacca and would discuss
the problems of health and the underlying socio
economic factors. A doctor from GK used to keep
in touch with this group and attended their weekly
meetings.
The novel experiment went into cold storage because
(1) The students started questioning their teachers in
PSM departments. “GK is making them communists?”
9
UNDER THE LENS
was the reaction of their teachers. They stopped send
ing the students. (2) The student group which had deve
loped could not find effective action programmes to
translate its theoretical understanding about the health
and social problems into concrete health action.
Gradually the group cooled down.
What do we in MFC who have tried similar methods
of student involvement learn from this experience?
6. The private medical practitioners, including the
‘quacks’ are still the most effective vehicles of the
curative health services, well accepted by the people.
How to make use of them for better health care to
the people? A few months ago GK has started a
Bengali monthly (64 pages) which aims at educating
these general practitioners specially in the rural
areas about scientific methods of curative as well as
preventive care.
7. Bangladesh has a drug consumption of Rs 55 crore,
80% of which is controlled by foreign multinationals.
They sell their products by brand names at very
high cost and also neglect the production and supply
of essential drugs, taking keen interest in tonics,
B’complcx preparations and drugs for the diseases
of the rich. This results in the scarcity of essential
drugs. To combat this situation. GK has jumped in
a big way into pharmaceutical production. Only the
110 essential drugs listed by WHO will be manufac
tured and will be supplied by the generic name at a
cost which will be 50 to 60% of the cost of brand
name preparations in the market. An effective pro
paganda will be made to convince doctors to accept
these preparations. A quality control unit, biggest
10
LEARNING FROM THE SAVAR PROJECT
in Bangladesh, has been set up to safeguard the
quality of these generic name products. The total
investment in this industry will be Rs. 4 crores, the
fourth largest pharmaceutical unit in Bangladesh.
These new ventures of GK cannot be evaluated at
present but arc definitely powerful effotls to influence
the health system in the country,
The team spirit and the “family” relationship in GK
is a thing to be experienced. But how to get new persons
is a problem faced by GK. The best of the GK team
arc still those doctors and girls who came together in
the initial war years.
The most crucial test was the time when an active
paramedic-Nizam was murdered in a village called
Shimulia where he had gone to start a GK subcentre.
This was a threat to a local medical piactitioncr and he
with some other influential vested interests arranged
for the cold blooded murder of Nizam. The whole area
was terrorized and GK was shaken. Zafrullah perso
nally stayed in that village and dug out the whole story
of the murder. Eye witnesses were available but still
the real culprit remains free even today.
But salutes to the determination and courage of the
paramedics, who, when questioned by the team leader
as to what to do, said that they would accept the
challenge and would start a subcentre in the same
village-and they did: Shimulia is one of the most popu
lar subcentres of GK:
GK offers immense potential for learning. Its succes
ses, its failures, its innovations and its mistakes—all
teach much to those interested in the problems of
community health.
11
hi a village meeting, when yon try to get a consensus,
the entire community does not turn up. The participation
is dominated by the vocal affluents, whose opinion cannot
be considered as that of “the community” we wish to
cater.
—Ulhas Jaju
2
Role of the Village Health Worker—
A Glorified Image
Ulhas Jaju
The MFC Bulletin Jan, 1980 (No. 49) has brought
out the comparison between the doctor and the village
health worker (David Werner in “VHW—Lackey or
Liberator”). The appropriate future role of a doctor,
according to the author is on tap (not on top), as an
auxiliary to the VHW, helping to teach him/her more
medical skills and attending referrals at the VHW’s
request (for the 2-3% of cases that are beyond the
VHW’s limits). The VHW has been recognised as the
key member of the health team, is the doctor’s equal,
and one who assumes leadership of health care activi
13
UNDER THE LENS
ties in his/her village, but relies on advice, support and
referral assistance from the doctor when he/she
needs it.
Our experience with village health workers in Nagapur village is as follows: A male matriculate 30 year
old village youth was selected by a Gram-Sabha (vill
age meeting) for medical work. He used to bring drugs
from the market, dispense them and keep the record
He was paid nominally through the village fund. He
was taught the treatment of common ailments but the
people did not like to take treatment from him and used
to wait for the doctor. Concepts of sanitation and good
nutrition suggested by him were not relevant in the exist
ing poverty. When we could not offer him a clerical job
as per his expectations, he started his “Pan Shop” in
the city nearby. Naturally he did not have much time
left to spare for village health work. We were forced
to think that the village health worker should be a less
educated or illiterate lady who will remain in the
village. Accordingly we now selected a ‘dai’ for our
work. She continues to be with us till today. But apart
from conducting delivery and post partum care, nothing
much is contributed by her.
We were thus forced to re-think about the role of
the village health worker and his/her effectiveness. Let
us take up some important aspects.
Selection of Village Health Worker
As is quoted, ideally VHW should be selected by the
community. In a village meeting, when you try to
get a consensus, the entire community docs not turn
up. The participation is dominated by the vocal
14
ROLE OF THE VILLAGE HEALTH WORKER
affluents, whose opinion cannot be considered as that
of “the community” we wish to cater to. These vocal
people try to select some one of their interest and the
real community remains silent. As the maternal care
during delivery is supposed to be a filthy job, the edu
cated and high caste candidate does not volunteer.
The low caste, illiterate worker unless backed by a
medical team (this includes the referral hospital), is
not respected by the village folk. Thus the insistence
that VHW should be selected by the entire community is
impractical in the field. What matters is the selection
of a less educated or illiterate VHW from the poor
section of community by the doctor who secs poten
tialities in the candidate to carry on the work as
expected.
Acceptability of VHW by the Community
Merc living in the same village docs not make a person
acceptable as VHW specifically if VHW comes from the
poorer section and a low caste. Acceptability is directly
related to the benefits that are offered through VHW.
VHW by himself can not offer much. Thus in prac
tice, acceptability of VHW depends on how strongly
the medical team (which provides these benefits)
supports her as a link between the community and the
health delivery structure. If all the benefits are
channelised through VHW and if they are such that they
appeal to the people, then only VHW is accepted. The
curative role that the VHW can perform is minimal
(mild gastroenteritis, short term fever, skin infections,
upper respiratory infection, etc) which alone cannot
confer much acceptability. If the drugs doled out by
15
UNDER THE LENS
VHW are not free, then the acceptability of curative
role further sinks down. It is but natural that one
likes to consult a medical man for his illness if he has to
pay the cost. The glorificat'on that VHW can be a
doctor of the community, that ‘VHW can take care of
almost all the cases’, is too much of a simplification.
Moreover to say that 95% of illlncsscs in the village
OPD are within VHW’s limits, is to forget that it is
not important what percentage of illness (which are
mostly self-limiting) can be treated by VHW but how
many cases can be picked up in time and promptly
referred to the doctor. Death due to delayed recognition
of its seriousness may kill only 5% of the patients but
it is 100% for the person who dies, and credibility is
achieved only through proper treatment of such cases.
Incentives to VHW for a Qualitative Role
The incentives for putting all efforts in any endea
vour can be, money/matcrial, prestige, power or an
enjoyment of creativity. The last is out of question
for a poor and low caste VHW who is trying to find
out his/her own identity today, struggling to make two
ends meet. Prestige and power incentives attract
those who have their bare necessities satisfied. Thus in
practice it is the material incentive which dominates
the picture. If the VHW is paid by the medical team
(as is seen in most of the projects) VHW is then res
ponsible to the team and not much to the community
unless the team is receptive to the feed-back from the
“real community’’. If VHW is expected to be paid
through the contribution from the community he/she
serves (as we did) then the contribution depends on the
16
ROLE OF THE VILLAGE HEALTH WORKER
acceptability of VHW by the community. In trying to
insist that VHW should get remuneration from the
community they serve, we observed that in due course
of time the rich section starts keeping away (we collec
ted money proportional to their economic status: thus
rich persons had to contribute much more in compari
son to a landless labourer.)
Naturally the community we were serving was split
in two, the rich minority being deprived of all facilities
as they refused to contribute towards the village fund.
If we do not insist on contribution according to the
capacity of the contributor, the total amount collected
is too little to meet the requirement. The other alter
native is to pay the community health worker through
a nationwide government scheme. The VHW then be
comes equally irresponsible to the people as is the
government today.
What can be the Role of VHW?
With the above hard facts in mind, in the existing
structure, I see VHW only as a link between the
community and the medical team. This link can func
tion for, (i) imparting health education, (ii) offering
drug treatment for some specified mild, illnesses, (iii)
quick referral of other illnesses to the doctor, (iv) con
ducting home deliveries when approved by the doctor
after regular ANC check up and (v) running commu
nity kitchen for underfives. It is imperative that the
medical team should fully back VHW and should refuse
patients when they come directly to the medical team.
She cannot be the doctor’s equal at least for curative
services. VHW’s limitations must be realised and definite
17
UNDER THE LENS
responsibilities should only be given. All these func
tions have to be under close supervision of the medical
team.
I strongly feel that some material incentive must
come from the community (contribution collected from
every bod}’ who enjoys the facility but according to
their capacity) and the prestige and power incentive
be supplemented with the backing of the medical team.
In the process, some VHW’s may enjoy the satisfaction
of creativity. When a common man contributes towards
the remuneration of VHW, he also sees to it that the
facilities which should percolate through VHW must
reach him and if he fails to get them, he comes out
aloud to fight for his right (he has paid for it!).
The purpose of writing this article is to invite dis
cussion on this issue, specially from those who are in
the field and have experienced the difficulties in imple
menting the three tier system. Let actual field experi
ence of all of us clearly define the role of VHW in
today’s structure.
18
3
Point of View: To inject or not to inject
Janet Aitkin
A mystique has grown around the giving of injections.
When allopathic treatment is sought, an injection is ex
pected or demanded by the patient and he will not be
satisfied without it. “Ek sui dijiye theek ho jayega” is a
common refrain. Anyone who gives an injection is con
sidered to be a doctor and a villager will quite willingly
pay many rupees for the often dubious benefit of one.
The villagers do not regard injections are simply a means
of putting medicine into the body. For them the needle
itself is seen as a part of the cure (cf acupuncture) as,
in a similar way pulse-taking and even X-raying is some
times mistakenly regarded as part of treatment rather
19
TO INJECT OR NOT TO INJECT
than as a preliminary to it. The occasional quick result,
the accompanying discomfort and the extra expense
incurred are factors which have served to boost faith in
injections.
Obviously there are dangers inherent in this great
demand for injections. The danger of sepsis, paralysis,
reaction and besides this, the exploitation of the villagers,
the unscrupulous money-making which takes place in
their time of misfortune.
We should educate the villagers and teach them what
an injection is and that treatment with tablets may be
just as efficacious, cheaper and less hazardous. But it is
a hard task when the attitude is already ingrained to
such an extent that when given only tablets a villager
will go and seek his injection elsewhere and be convinc
ed that this is what brought about the cure even when,
obviously to us, it did not. And then there are bound
to be those cases when an injection was really necessary
.and worked and we unwillingly reinforce the villagers
faith in them. Unless we studiously avoid the use of
tthem, this is inevitable.
It is the view of some that village health workers
should not be taught to give injections because they are
s:o susceptible to abuse. I would like to answer that it
iss those in the medical profession itself who are largely
nesponsiblc for this abuse. During my time in India I
h;ave not noticed any difference at all in the method of
giiving injections used by qualified doctors and by
quuacks. It is apparently common practice to keep a
sy/ringe in a dirty card-board box, to wipe a needle and
rimse a syringe in spirit rather than boil them and to
puish the needle along one’s unwashed index finger while
21
UNDER THE LENS
injecting. I have seen a qualified doctor rinse a syringe
and needle in water, I wouldn’t even drink, before
giving the injection. Misuse applies to unnecessarily
giving injections as well as to bad technique; for exam
ple, a single injection of tetracycline or penicilin for
common cold or cough; use of streptomycin (with peni
cillin) for non-specific infections in T.B. endemic areas;
frequent recourse to Vitamin B injections (with no
advice about diet, one might add). How can one expect
them to use higher standards when doctors themselves
do not?
On the whole, a doctor is immune to repercussions
in the event of something untoward happening to a
patient as a result of his treatment. He may be shielded
by the ignorance of his patient, by his institution, by
his government posting, his pocket or, as a private
practitioner he will probably have the means, if the
worst come to the worst, to move elsewhere. He has
much less to fear from his injections harming someone
than a village health worker. A village health worker
is living among his patients, they are his people, his
friends, his relatives and he has to continue to live with
them. If he is originally taught in a correct manner and
is fully aware of the dangers and precautions to be
taken I see no reason why he should not give injections.
Besides, it is a part of his task to enlighten his neigh
bours about the nature of disease and of medicine. If
he is denied the right to give injections we are reinforc
ing the mystique surrounding them. Whilst giving injec
tions when they are really necessary, the village health
worker is in a better position to gain the confidence of
people and teach them, than if he never gives them. If
22
TO INJECT OR NOT TO INJECT
he is an unsuitable person for this role in the first place,
then it is not only injections that he is likely to misuse;
an overdose of tablets for example, could have just as
serious results.
It is important to be flexible in one’s attitudes; the
need for a village health worker to learn to give injec
tions will vary from place to place. But I have an uneasy
feeling that those who categorically refuse to teach
village health workers to give injections are demons
trating a distrust towards them and imagine them to
represent a threat to the medical profession. To answer
that village health workers should be more concerned
with prevention and education is to deny the reality
which is that, for optimum effect, curative and preven
tive work must go hand in hand.
23
Ultimately this results in the community health project
becoming dependent on rich clientele for it's economic
self-reliance. To satisfy this clientele conies sophistication
{X-rays, E.C.G.), more specialization, and more and
more workers and time to cope up with all this. The pro
ject also follows unscientific, unethical practices like
giving unnecessary injections, tonics, mystifying sym
ptomatic relief etc. to draw and retain the paying
patients."
—Abbay Bang
4
Myths in Community Health
Peoples' Participation and Economic Self-reliance
Abhay Bang
Some decades ago, development meant doling out food,
clothes, medicines and money to the poor who were
just passive recipients. Gradually it came to be realised
that this was a bottomless pit. Thus, came the concept
that ‘people’ should work for their own improvement.
However it was won realised- that people cannot be
made to work unless they were involved in the process
of development. Thus came the idea of people’s parti
cipation.
There are three questions I want to ask.
25
UNDER THE LENS
1. What do we mean by people’s participation?
2. Who are the "people’?
3. Is people’s participation possible in community
health?
Different people have different meanings for people’s
participation. Some project workers claim overwhelm
ing people’s participation in their projects; thereby
meaning that people are taking benefits from their pro
gramme. Some call it people’s participation when the
people are receiving benefits not as charity but are pay
ing or rather arc forced to pay for the benefits.
A very successful community health project claimed
that “the villagers collectively constructed a road from
our hospital to the village so that our health team
could reach the village’’, and foreigners are much im
pressed by this ‘people’s participation’. One however
finds that the road was constructed by the labourers of
the village in ‘food for work’ programme.
That same community health project says, “Our
village health workers have been selected by the people
of the village and our project has a people’s committee
as advisory board’’. Though this is meant to be parti
cipation by the people in decision making, on closer
enquiry, one finds that almost every V.H.W. was
selected by the head of the village and two or three
influential persons and the project staff. The people’s
committee consists of established leaders and the rich
people of that area.
Obviously all these are not examples of people’s
participation.
The next question ‘who are the people?,’ is a tricky
and political question. A big power invades a small
26
MYTHS IN COMMUNITY HEALTH
nation and puts its ‘yes man’ in power and says ‘people
of this nation have invited us to liberate them’. A rich
man heading the Gram Panchayat takes a decision as
to who should be the VHW from that village. The male
head of the family says “the tradition of our family
requires women to remain in purdah and all people
approve of this tradition”.
In all these instances decision making docs not re
present the desire of all the people, definitely not of
those who have no voice and freedom to speak but
who very badly need an opportunity to take part in the
decision making to ensure that it is in their interest and
not to oppress them. Thus I have tried to show what
is not people’s participation and who are not ‘the
people’.
For operational purposes, we will have to say that
the oppressed, the exploited and the needy should have
priority in the comprehensive definition of‘people’.
When these people understand the situation and
issues by critical consciousness and take part in deci
sion making, implementation and evaluation of pro
grammes and take the responsibility of the work as well
as share in the benefits...it becomes people’s partici
pation.
There cannot be genuine people’s participation
without a proper political atmosphere and educational
process. Even then true people’s participation may be a
distant goal.
Prerequisites of people’s participation
Today’s political and socio-economic system is directly
opposed to real people’s participation. How can there
27
UNDER THE LENS
be a true people’s participation when women have no
equality, the poor have no strength to assert and the
oppressed have no opportunity to participate in the
decision making of the political system? When we, the
enlightened elite have no scope to participate in the
affairs of the nation except to vote for the best of the
available bad choices once in five years or to write a
letter to the editor once in a while, how can those who
arc weak, poor, oppressed and ignorant, really parti
cipate?
It is obvious that real people's participation is a dis
tant dream to be achieved by a process of economic,
political and cultural liberation.
The expectation that people will participate in a real
sense in a mere community health programme is un
realistic. This conclusion is also supported by the ex
perience of numerous workers in community health who
have learnt it the hard way that people cannot be mobi
lised and organised through and for health work. It
does not mean that there should be no efforts towards
people’s participation in health programmes. All efforts
to involve the people, especially the needy and the
oppressed in making decisions and their implementation
should be made. This will marginally help a parti
cipatory culture to be created. But it must be realised
that people’s participation is essentially a political and
educational process, and health work has only weak
political implications. Without a proper political con
text, not much of genuine people’s participation can be
achieved in community health work alone. Hence
people’s participation per se cannot be a primary ob
jective of community health programmes.
28
MYTHS IN COMMUNITY HEALTH
Some workers use another misguiding term, ‘commu
nity participation’ in community health programmes.
There are two obvious fallacies. One, there is no
organised entity as a ‘community’ in the villages of
India. There are individuals, families, castes, classes,
political groups and one cannot create communities out
of such individuals and groups for the purpose of and
through mere community health work (though commu
nity health work might marginally help this process).
Secondly, claims of community participation, in reality
mean only the existing social organisations (Panchayats,
etc.) and established leadership are involved in decision
making.
Economic self-reliance: Why?
Another popular fashion-word is ‘economic self re
liance’. commonly used as a criterion of evaluation by
many agencies and projects in community health. How
did this get such importance that it has almost become
an important objective of community health pro
grammes? The workers arc desperately after this ob
jective, forgetting that economic self-reliance is not the
purpose of their work and they cannot afford to sacri
fice their original purpose i.c. to improve the health of
the vulnerable people.
With growing realisation in the developed (exploiter)
world that doling out food and clothes cannot perma
nently improve the life of the poor in the undeveloped
(exploited) countries, a concept was born that people
should be given such economic programmes which can
generate income for themselves and hence they don’t
have to depend on outside help eternally.
29
UNDER THE LENS
Self-reliance Logic
Fine! Good policy! But this has to be an objective of
economic programmes to be achieved through economic
activities. This has been implicitly accepted in the field
of community health also. This has caused tremendous
diversion and confusion and the time has come to chal
lenge this assumption. When a community health pro
ject tries to become economically self reliant, it adopts
two methods.
(a) It starts charging the rich to gain more income,
(the so called ‘Robinhood’ method). Ultimately this
results in the commmunity health project becoming
dependent on rich clientele for it’s economic selfreliance. To satisfy this clientele comes sophistication
(X-rays, E.C.G.), more specialization, and more and
more workers and time to cope up with all this. The pro
ject also follows unscientific, unethical practices like
giving unnecessary injections, tonics, mystifying sympto
matic relief etc. to draw and retain the paying patients.
The shrewd rich class is almost never dependent on
this community health project alone for its own health
care. They almost always get their health needs fulfilled
through the commercial private health system. Only in
very remote places, such persons might depend on
community health projects. Thus the community health
project becomes dependent on the rich for its income
and survival rather than otherwise. This brings in
gradual changes in priorities, strategies, methods, be
haviour, and the community health project ends up in
serving primarily the needs and priorities of the rich.
An analysis of the clientele of most of the mission
hospitals, who in an attempt to become economically
30
MYTHS IN COMMUNITY HEALTH
self reliant started charging the cost of the treatment to
patients, shows that ultimately they ended up with two
maladies. They were underutilized, and were utilized
predominantly by the rich class.
Sathyamala from VHAI has described (Health For
The Millions, February 1980) how she saw at many
places voluntary hospitals half empty and beds occupied
by the rich who alone could pay the charges; and the
next door Government hospitals and dispensariesinefficient, low quality, corrupt but still overburdened,
full of poor patients. What an irony! Then why should
dedicated missionaries run such hospitals? Even the
private commercial health care system (eg. Jaslok Hos
pital) can do and does the same.
(b) The second strategy adopted is to charge the
poor at least the cost of the treatment. We have already
seen how it results in elimination of the poor from the
curative health care, 60% of admissions in a hospital
of a famous community health project which claims to
be economically self-reliant are the rich, coming from
the area outside the project. The remaining include
rich and poor from the project area but again in what
proportion? The hospital is mainly utilized by the rich.
An argument forwarded is that the poor are given
primary health care through VHWs financed by the
income generated from the rich in the hospital. It means
the VHWs give elementary care in the village to the
poor and rich also but doctors and hospitals are mainly
for the rich. Such discriminatory strategy becomes
inevitable when community health projects accept the
objective of economic self reliance and try to raise in
come through health programmes.
31
UNDER THE LENS
It is Irue that the poor should be charged a little for
health care so that they do not become objects of
charity and pity. Also, if they arc charged they feel
that they have paid for health care and so the care must
be of some quality, earned by them. It is common ex
perience that the poor also value such treatment and
advice. However this logic when taken to its extreme
that the poor should pay the whole cost of treatment,
the poor, already exploited by the present economic
system, arc exploited further.
When this objective of economic self reliance is al
most thrust on the community health projects in the
voluntary sector by funding agencies, let us ask a few
questions.
Who is self-reliant today?
Is the government self-reliant in the sense it generates
all its necessary income by productive activity? No! It
depends on squeezing the people by taxes, direct and
indirect. None of the welfare programmes of the govern
ment arc self-sufficient.
Are the funding agencies self-reliant? In spite of
decades of working, all of them continually depend on
donations from people in the developed countries. They
do not generate their own income by an economic pro
gramme run by themselves, even though their main
field of work is fund raising.
Funding agencies can raise money through Western
capitalism. However this capitalistic system depends,
at least partly on the developing countries for its mar
ket, and remember, the market is the source of income
for capitalism.
32
MYTHS IN COMMUNITY HEALTH
It is unrealistic to expect in such a situation that
community health projects should be able to generate
enough income to become economically self sufficient.
Many community health projects tacitly accept this
objective of economic self reliance under increased pres
sure by funding agencies and they are forced to either
deviate from their primary objectives or to do various
manipulations and show that they are economically
self-reliant. This includes artificially swelling the health
income, (some times by selling the donated drugs or by
including the farm income) or by hiding certain expendi
tures on health programme. Some projects reduce the
expenditure by underpaying their staff. All these com
pulsions come because of the acceptance of the criterion
of economic self-reliance.
Having observed closely many community health
projects in India and abroad, and following our own
experience, I wish to say that no community health pro
ject which is predominantly preventive and educative
in nature and which serves mainly the poor can become
economically self-reliant. All such claims need to be
re-examined.
Projects should try to generate income either through
economic programmes or from committed supporters
who have money to donate for the cause. Such income
generation will make it less dependent on outside aid.
This cannot however be the primary objective of com
munity health work.
False Limitations
Another aspect which community health projects should
not uncritically accept is to maintain per capita health
33
UNDER THE LENS
expenses in their programme equal to that of the govern
ment. Government spends money on wrong priorities
and allocates meagre resources for health. Voluntary
health projects need not take it as their responsibility to
show ways to fulfil health objectives within the false
low limits set by the government. What voluntary
agencies could do is to decide the minimum health care
every person should get and work out the low cost level,
whatever that be. This is the way by which one can
press a system to mend its ways. Voluntary health
projects should not try to fit into the System’s false
limitations. While deciding the minimum health care,
the nation’s economic standard (GNP or per capita
average income) should be taken into consideration but
not the per capita health expenses by the government.
Otherwise we land up with a community health care
which gives less than minimum to the real needy.
34
"The chances that community participation will emerge
around a health issue is bleak. It may be possible in an
area where some conscientisation is already going on and
mass-organization has been successful."
—Uihas Jaju
5
Community Participation in Primary
Health Care
(Observations based on a case study)
Ulhas Jaju
This is a case study started by a voluntary medicogroup in a village—Nagapur —6 k.m. away from Sevagram about three years ago. Having realised that health
is not available or accessible to the rural people, a
teacher in the department of medicine, initiated a study
circle of like-minded students. This group took the
initiative in starting voluntary health work in the
villages around.
The work was initiated by the group with little or
no direct exposure to community health. The whole
37
UNDER THE LENS
process served as a learning experience and the pro
gramme evolved over a period of time. To do this it
was decided not to put monetary or material inputs and
to utilise the available resources- The group believed
that services if doled out free may earn benovelence but
will increase dependency in the minds of the people.
The selection of the village Nagapur was based on
lack of health services in the village, cooperation from
the village folk, approachability of the village on foot
and the small size of the village which could enable
closer contact.
The entry to the village was welcomed by a leader
of the community, who collected people for a village
meeting (Gram Sabha). People requested a regular
weekly clinic. They offered the School building to run
the clinic, an initial contribution towards the drug
bank and also agreed to pay the cost of the drugs.
A village health worker (Dai) was selected by the
group in a Gram-Sabha to help them in the treatment
of minor ailments, drug purchase, dispensing, follow
up of the treated patients and basic antenatal and post
natal care. The Gram-Sabha agreed to pay the village
health worker through a village fund which was to be
collected in the harvesting season. Thereafter frequent
meetings of the villagers were arranged to discuss
health problems and organisation of health care.
The village fund was collected by house to house
visit with the local leaders. The Gram-Sabha unani
mously accepted the idea of contribution according to
capacity i.e. according to land-holding. Most of the
people preferred to pay in kind. The noncontributors
were denied health facilities.
38
COMMUNITY PARTICIPATION IN PRIMARY HEALTH CARE
A socio-economic survey was done. Health talks on
tuberculosis, leprosy, malnutrition, vitamin deficien
cies, diarrhoea, family planning, vaccinations were held
with the help of transparencies and case demonstra
tions. Importance of sanitation, the utility of soakage
pits, sanitary latrine were also discussed.
The families were divided into four socio-economic
grades and utilisation of services by them were studied.
(I) Utilisation of O.P.D. services by the people of
different socio-economic grades.
Total
Socio
No. of
economic population people
availing
Grade
services
I
II
III
IV
V
No. of
Ratio of
times
clinic
clinic
attendance
attended to people
in 1979
availing
(41 clinics) services.
155
126
117
34
42
83
101
66
15
37
151
144
139
21
18
474
302
473
1.8 : 1
1.4 : 1
2.1 : 1
1.4 : 1
0.48 : I
Grade 1—Families who employ labourers on yearly
contracts (SALDAR) for agricultural
work.
Grade 2—Families who own irrigated land, a pairof bullocks, but do not employ SALDAR.
Grade 3—Families who own unirrigated land, a
39
UNDER THE LENS
pair of bullocks but do not employ
SALDAR.
Grade 4—Families who own land but neither em
ploy SALDAR nor have bullocks.
Grade 5—Landless labourer.
Note—-Any other additional occupation (e.g. Dairy)
raises the economic grade by 1.
Obviously the village clinic was not much utilised
by the poor community. It was realised that the poor
man could not afford even the cheapest drug treatment
for acute illness.
IT. Utilisation of V.H.W. services
(a) Treatment of minor ailments was availed by few
patients. They preferred to wait for the doctor
to come.
(b) People did call her to conduct home deliveries
but her advice to come during antenatal period
for regular check-up was rarely acccepted.
Pregnant women turned up at the clinic for
examination only when the lady doctor was
available.
III.
Vaccination Coverage
Not more than 40% of the target group could be
given B.C.G. vaccine. One child developed fulminating
B.C.G. reaction and few others abscesses, which gave a
set-back to the campaign. Polio vaccine was accepted
by few people only as they were required to pay the
cost and the vaccine according to them was not worth
it.
40
COMMUNITY PARTICIPATION IN PRIMARY HEALTH CARE
IV.
Sanitation measures
Only two soakage pits could be prepared. None accept
ed the sanitary latrines. Attempts to repair the commu
nity well proved futile as Gram Panchayat members
were not keen and people could not force them to make
Gram Panchayat funds available. A survey was done to
understand people’s reaction towards road-side defaecation practice. Interesting facts were revealed:
(a) Inability to spend money for latrine cons
truction,
(b) Road-side is the safest place during night beca
use the approaching road has street lights.
(c) Road-side is the cleanest place during rainyseason.
(d) They doubt whether they will move bowels
satisfactorily when covered from all sides in a
shelter.
V. Health talks
People did not collect in large numbers for meeting on
health and health related issues. They did collect to see
the “CINEMA” but the health message did not get
through.
(vi) Nutritional supplement programme to undernouris
hed did not take root because the mother was required
to pay the cost of the food supplement and the feeding
programme could not be sustained through the village
fund.
These experiences made the group to evaluate their
approach as to why sincere efforts did not breed success.
The deep socio-economic and political roots were
41
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identified through series of discussions, based on field
results. It was realised that the concept of prevention of
disease and promotion of health did not appeal to the
people because, (i) there is not much that can be done
effectively in a low socio-economic setting without
depending on additional input, (ii) health is not the
priority need of the people. They are totally involved in
trying to make both ends meet. Therefore a health
activity which can not show immediate results does not
make sense to the poor man.
By the end of three years the group could analyse,
who regards this health work useful, from the data
collected. By then (1980) curative inpatient treatment
for acute illnesses was provided free by linking them to
a health insurance scheme of M.G. Institute of Medical
Sciences, Sevagram.
The data revealed that contribution towards village
fund dropped slowly over three years. The drop-cuts
were from the richer families who tried to calculate the
cost benefits for their contribution. They were not
treated as ‘‘more equal” and therefore they kept them
selves away from the idea of graded contribution i.e.
more contribution by the rich community, which they
accepted initially.
With more and more realisation of people’s needs,
the voluntary group got involved in other problems such
as help in getting bank loans, electric connections to the
water pumps in the field, approach road to the village,
cross breed cows at a subsidised rate through available
Government scheme, to start Balwadi etc. To provide
wage earnings a scheme of Khadi Commission-AmbarCharkha was initiated.
42
COMMUNITY PARTICIPATION IN PRIMARY HEALTH CARE
The results so far are elating. People readily collect
ed for all the meetings. They came out with more and
more problems for seeking guidance. The group com
manded the faith of the poor community.
Summary
Health is not the priority need of the people. The initial
active enthusiasm of the “Leaders” of the community
was due to other reasons; the prestige incentive alone
did not attract them for long. The participation of such
vocal people in a community programme did not give a
chance of equal participation to the poor.
The poof man, being lost in making both ends meet
does not feel an imminent need' for health care unless
he is absolutely helpless without it.
In a poor socio-economic setting; self reliance in
health care activities is a myth. The poor community
has to depend on someone from outside, may be a volun
tary agency or the state service. For channelisation of
state services to the poor, the beneficiaries must be
conscious enough of their rights and should be prepared
to stand-up and demand for them. Health problems
being the last in the priority list, it is very much doubt
ful whether health issues can be the tool around which
people will organise.
3. Community participation in primary health care
is a slogan that is glibly used without understanding
what it really means. We must differentiate between
community oriented projects and community based
projects. In most of the community oriented projects,
services are doled out free for which people gather
around and it is then misinterpreted as community
43
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participation. One must understand that community
participation is basically a political act which emerges
only if the issues involved are of priority. The chances
that community participation will emerge around a
health issue is bleak. It may be possible in an area
where some conscientisation is already going on and
mass-organisation has been successful.
[ I always wonder how this myth, that the poor
should also pay for health services to feel it is their right
to demand, ever started. Nowhere in the world, not
even in capitalist West do the poor pay. It is the duty
of the State to provide certain services free, at least to
the poorest sections and health is one of them. Health
care delivery has really been successful in those socia
list countries where free health care is really ‘freely’
available. To think that health care in the U.S. is the
best is a big illusion—Editor ]
44
The implementation of the activities embodied in Primary
Health Care Programmes inevitably involves conflict. Yet
so much that is written about Primary Health Care
ignores the financial, political and professional barriers
to improving people's health and to developing new
patterns of health services.
—David Nabarro
6
Health for all by the Year 2000:
A Greal Polemic Dissolves into Platitudes?
David Nabarro
I
Introduction: Health for all and Primary Health Care
The appealing slogan “Health for all by the year
2000’’ was coined by international agencies in the mid1970’s to usher in an era of intensive activity by Health
Ministries in many Third World countries. The minis
tries haive adopted policies which concentrate on pro
viding Primary Health Care for their people—on bring
ing a new style of comprehensive health services within
reach oif those who traditionally have been deprived of
them. ,
Tha Primary Health Care (PHC) approach is rad.i47
UNDER THE LENS
cally different from the conventional pattern. It has,
since 1977, been promoted widely by the Wirld Health
Organisation (WHO).
The PHC approach has three major components:
(I) increasing the availability of medical care facilities
that tackle life-threatening problems commonly
encountered by all sections of the population—
men, women and children.
(2) emphasizing the extent to which people can help
to prevent illness for themselves by adopting
healthier lifestyles and changing harmful practices.
(3) promoting the involvement of the people in the
delivery of their health services.
In order to develop PHC Services with wide cover
age, Health Ministries throughout the world have esta
blished new croups and medical manpower—different
grades of medical and nursing auxilarics, trained over
a short period to undertake a small number of basic
tasks.
However, many countries have found it difficult
to fully implement PHC. They have also begun to
question whether PHC services really can be expected
to improve health—particularly whether they a ill lead
to the achievement of “Health for all by the year 2000 ’.
Health—a problem of definition
It is difficult to find a widely acceptable definition of
"health for all. Good health is not an absolute condition.
What does each of us mean by a healthy indiv Huai or
a healthy community? Does the healthy person not
suffer from any diseases? Does he or she experience
48
A GREAT POLEMIC DISSOLVES INTO PLATITUDES
illness, just like anyone else, but have a low risk of
dying or becoming disabled when young? Most of us
would identify the healthy person as some-one who is
unlikely to experience physical and mental disability
and who faces low risks of premature death.
In a community of healthy people infant mortality
rates would be low; average life expectancy would be
long; and average growth rates of children would be
fast. Few children would suffer disabilities like blindnsss or lameness. Using numbers which describe levels
of illness, death or nutrition in the population (like
infant morality rates, child growth velocity, child blind
ness prevalence or average life expectancy), we can
identify populations that are more or less healthy
than others. But there is no absolute value for any one
of these variables which indicates good health.
We can identify countries in Western Europe which
have infant Mortality Rates of 15 per thousand
and others in South Asia where the rates arc 100 per
thousand or more. Countries with high Infant Mortality
Rates will usually be described as less healthy than
those with lower rates. Inside each country it will
always be possible to identify groups of people whose
infant mortality rates vary. Usually, it is the wealthiest
families whose members have the highest life expectancy
and lowest infant mortality rates. The poorest families
experience the reverse. They are the least healthy.
Variations in health of different population groups in
side countries are found both in the “developed”
nations of Western Europe and in the “undeveloped”
nations of the Third World. Although national averages
for health indices emphasise the extent or deprivation
49
UNDER THE LENS
faced by most people in Third World countries they
disguise the existence of intra-country variations.
In practice, the goal of the “Health for All by the
year 2000“ movement is to reduce the disability and
mortality rates experienced by groups of people
throughout the world to the level currently experienced
by the most healthy (who are usually the privileged).
This means reducing, for example, infant mortality,
child and adult disability rates for countries in the
Third World towards levels experienced by countries in
the West. Similarly, the rates for different population
groups within the countries need to be reduced to the
level of the healthiest.
Effective ways for improving the health of unhealthy
populations
How best can "health for all” be achieved? First we
have to consider the causes of ill health among the
world’s least healthy populations. Many of the deaths
and disabilities in population groups with high infant
and child mortality rates are due to infectious diseases.
The PHC approach recognises that many of the
infections which cause deaths and disability are prev
entable. Through intensive healh education and promo
tion, combined with mass immunisation, water chlorina
tion and so on, PHC workers attempt to modify people's
lifestyles. People are encouraged to take steps to re
duce the contamination of their environment, lessen
the number of occasions on which they come into
contact with these pathogens and to increase their body
defences against those pathogens which do succeed in
invading. PHC also involves the regular surveillance of
50
A GREAT POLEMIC DISSOLVES INTO PLATITUDES
groups of people who are likely to become ill (particu
larly children), the detection of early illness and its
prompt treatment using the minimum of safe medicines.
Uncertain benefits of health education
For the last five years I have worked alongside Primary
Health Care Workers in South Asia and the Middle
East. Frequently I have been struck by the way in
which even the unhcalthiest groups of people in a
population (usually the poorest) try to respond to
educational messages about how they can modify their
lifestyles and make themselves healthier. Families often
recognise the value of, and understand, the changes
being required of them. They may change their prac
tices, but only in special circumstances, such as when in
hospital or a nutrition centre. Yet, back in their own
homes, they are less able and likely to alter the way
they live and the practices they follow.
The people who do change behaviour consistently
in response to education are usually those who have
spare cash, food, time and consider the investment
worthwhile. Other families do not have the spare re
sources to make the changes required—or even if they
have the resources, do not see the point of changing.
Health care workers, after delivering educational mes
sages, may well receive challenging replies: Why should
I make these changes in the hope of living a year or
two more when I do not know where I will find the
next month’s food?” Poor people are not likely to be
confident that the future has good things in store for
them: this hopelessness is an inevitable barrier to adopt
ing new “healthier” behaviour.
UNDER THE LENS
One example of this is found in the rural areas of
South Asia, where severe disease is most common dur
ing the early monsoon months when family members
are particularly busy in the fields: irrigating, ploughing,
sowing, planting, weeding and so on. Time is precious
—families may well consider that an hour or two away
from fields during these months will have an adverse
effect on the subsequent harvest. Yet it is spare time,
more than anything, which is needed for nursing a sick
child through a bad attack of diarrhoea—time to en
courage the child to eat or drink, and time to attend a
clinic to receive treatment and medical advice. During
these months, too, food is in short supply. The family
may not have the special nourishing foods needed by a
sick child.
During the months when they and their children
are more likely to be ill, poor farmers and agricultural
labourers are so short of time, food and cash that they
arc unlikely to adopt measures which will prevent or
contain illness.
It is no surprise that the people who arc most at
risk of being ill—or having children who are ill—are
also least likely to come regularly to child health clinics
for health check-ups. They may not even be able to
afford to give up time at work and stay at home to wait
for a health worker’s visit. Regular personal health
surveillance only becomes possible when people con
sider it worth their while to attend health clinics or to
wait at home when a health worker is due to visit. Per
haps they face fewer competing demands on their time
or have decided that the services provided by the clinic
or health worker are really useful and beneficial.
52
A GREAT POLEMIC DISSOLVES INTO PLATITUDES
A number of well-reported non-governmental pro
grammes provide very popular services which are regu
larly attended by a wide range of people from the popu
lations they serve. In some situations, government run
programmes achieve the same results. In these excep
tional cases, much of the success results from the perso
nal commitment and organisational skill of district
medical and nursing officers.
To what extent can medical professionals improve
people’s health?
The observations I describe have primarily been made
in South Asia. They suggest that attempts to change
people’s lifestyles are likely to be ineffective or, ineffi
cient ways of improving the health of the least healthy
people in that region. Personal health surveillance pro
grammes will only work if they arc wanted by the people
they serve—this inevitably restricts their effectiveness
to the more privileged groups in society. Among poorer
communities, surveillance activities arc only likely to
reach people if they are run by committed health
workers who communicate well and inspire the people
they set out to serve. They may still only have a very
small impact on the health of the people they set out
to serve.
These observations suggest to me that even most
carefully managed new-style Primary Health Care pro
grammes will be unlikely to lead to substantial improve
ments in the health of the least healthy people in a
population. They will only become more healthy if their
income, access to services like water or sanitation, and
intakes of food improve first.
53
UNDER THE LENS
My observations have been based on a few health
programmes in a small number of countries from one
part of the world. But they are not unique—the kinds
of constraints described are felt by health workers in
other parts of the world.
Behind the “Health for all” slogan is WHO’s major
concern, the health of people throughout the world.
But WHO is also specifically concerned with the medi
cal, nursing, public health and allied professions, and
their work. The WHO's main point of contact with
member nations is with their health ministries and with
medical and allied professionals worldwide. It is im
portant that all of us make clear our personal commit
ment to the goal of health for all, and that we recognise
that members of the medical profession can do little to
help achieve this goal. Medical and paramedical pro
fessionals are well positioned to investigate the causes
and consequences of ill health. However, they arc
rarely in a position effectively to promote improve
ments in the health of unhealthy populations.
By launching a campaign for “Health for all by the
year 2000” WHO has issued a polemic. The concept is
revolutionary—it implies that there should be redistri
bution of resources to the poorest by the year 2000.
One professional group, on its own, cannot possibly
hope to manage the revolutionary transformation re
quired to achieve health for all. By implying that poor
people’s health can be improved without enabling them
to increase the productive resources at their disposal
or to improve their access to water, fuel, housing and
so on, WHO and other international organisations who
adopt the slogan might even be working against the
54
A GREAT POLEMIC DISSOLVES INTO PLATITUDES
achievement of “Health for AU’’.
Indeed, “Health for all” is not a realistic goal for
people who are trying to plan and run basic health care
services. They end up designing policies or drawing up
proposals for programmes that sound good and read
well, but are almost impossible to implement success
fully. The plans are just wishful thinking or platitudes.
The whole Primary Health Care movement is awash
with platitudes at every level, and they distract us from
making a critical assessment of the issues that underlie
the World Health Organisation’s challenge. In the
villages where they work, Primary Health Care field
workers are often confused and disheartened—the
people they serve disenchanted. Increasing numbers of
health processionals and administrators criticise the
Primary Health Care approach because they arc unable
to make it work. But wc should not be surprised that
improving the health of the least healthy people in the
world is difficult. We should not expect that it will be
easy—or inexpensive—to provide widespread health
care services, change people’s lifestyles through health
education or elicit people’s participation in their health
care. These are all political activities: they require
action by groups and communities; they are concerned
with the distribution of power between different groups
in society, between professionals and the people they
serve. The implementation of the activities embodied
in Primary Health Care programmes inevitably involves
conflict. Yet so much that is written about Primary
Health Care ignores the financial, political and profes
sional barriers to improving people’s health and to
developing new patterns of health services. In this res
55
UNDER THE LENS
pect, the guidance health professionals receive is often
misleading, unrealistic and unhelpful. One example is
the way in which health professionals are encouraged
to seek people’s participation in the services they
provide.
Community participation: a practical possibility or
more wishful thinking?
A central feature of the PHC approach is the involve
ment of people in the delivery of the health services they
receive. Inevitably conflicts—between factions in the
community, between professionals and community
representatives, between funders and professionals, for
example—are bound to arise whenever participation is
initiated. These conflicts are faced by PHC workers, not
only in South Asia, but throughout the world.
We can all conjure up the ideal scenario which is
presented by some proponents of the PHC philosophy.
A group of people who live in a village or street meet
together, discuss their health problems, decide that they
need more knowledge and skills with which to tackle
these problems, and then nominate (and if necessary,
elect) someone who will be sent for training as a health
worker. The government health services set up a special
health worker training programme. The people then
evolve a system for paying the worker for his/her ser
vices and for covering costs of medicines. As a result of
the information they receive from the newly trained
worker, the people change their life styles, the health
risks they face are reduced, then child mortality rates
and other health indices change for the better. It sounds
good and we would all like it to happen.
56
A GREAT POLEMIC DISSOLVES INTO PLATITUDES
What PHC workers actually find is that the people
of a particular village, street or district—the community
—belong to different groups. Members of any one group
may be characterised by, for example, family ties, caste
status, ethnic origin or religion. Groups may be further
distinguished by their allegiances to different leaders,
political ideologies or established political parties. Few
communities have evolved ways of making decisions by
mutual agreement. In practice, the decisions that carry
the day ate made by the most powerful, and they are
not always the group that is in the majority. If power
is shared between different groups they may attempt to
reach a decision by compromise. But in the end the
compromise could still be elusive because opposing
groups take different positions on principle.
If there is active dissent over a particular issue in
side a community, professionals who automatically side
with the majority viewpoint may well be met with
active resistance from members of an outspoken and
powerful minority. The latter may cause trouble for the
elected health worker, interfere with the career of the
local government doctor, and even damage property
used by the health services. These political realities may
influence even the most carefully conceived, fair sound
ing and humanitarian Primary Health Care project.
Conflicts can be anticipated, even if they cannot be
avoided, if those involved in designing projects analyse
the political and economic processes that affect the
people to be served as well undertaking a more usual
study of the diseases they experience.
But it is not only the “community” that has to
“participate” if people are to be actively involved in
57
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health care systems. Medical professionals will also be
expected to provide support and training to nominated
health workers, to heed the criticisms or to respond to
the demands of community representatives, and to
provide an effective back-up curative service for people
who are seriously ill.
Inevitably medical professionals will have their own
priorities—and their own interests (be they the discovery
of rare diseases, providing a service to people who re
quest it or simply earning enough money to survive).
They will also have knowledge and skills with which to
identify health problems in the community, methods for
tackling them. However, the professionals’ specialised
view of health problems may well be different. They
will suggest what they see to be the most suitable.
Certainly the professional will want to adopt the
approach that he—on the basis of training and experi
ence—considers appropriate.
Consider a situation where community groups, after
discussing their health care problems, reach some kind
of a compromise about the kinds of services they want.
The most powerful group (in a minority) has won the
day with a request for a curative service which tackles
problems faced by middle aged men. A less powerful
group (representing a majority) has failed in its
attempts to get improved curative facilities for women.
The professionals responsible for providing services for
the community take several different viewpoints. Some
favour a preventative and educational programme.
Others propose a specialist, curative programme that
will meet the needs of the most powerful. Inevitably
there will be conflict—both in the profession and bet
58
A GREAT POLEMIC DISSOLVES INTO PLATITUDES
ween some members of the profession and some groups
in the community.
“Health for all” or “Medical Care for all”?
I wonder whether “Health for all” really is an appro
priate slogan for activities that are undertaken primarily
by the medical and allied professions. “Health for all”
is a vital goal for all development workers as ill-health
is inevitably a matter of poverty and deprivation.
Health for all will only be achieved through collective
action from technicians and administrators involved in
all sectors of development, and they can only do this
if they have the necessary political backing. Important
sectors of government which can contribute to this pro
cess include those concerned with agricultural develop
ment and industrialisation, with the provision of ameni
ties (like water supplies and sanitation), with the redis
tribution of resources (particularly land reform) and
with the development of the machinery of government,
financial institutions and communication. Doctors,
nurses, nutritionists and the like are well placed to
identify “unhealthy” population groups needing pri
ority help.
At the same time, everyone gets ill. Those of us
working in the medical profession need to ensure that
these medical and nursing skills are as widely accessible
as possible. We can debate and try to define levels of
medical care to be provided for a population, the
quality of care and the accessibility of services. To do
this well will need access to good epidemiological
information. Our goal, for example, may be to reduce
the distance between people’s homes and different kinds
59
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of services, relating availability of service to the needs
of the population and minimising the time people have
to wait for attention when they seek help. We may also
want to ensure that the services provided are of high
quality and the costs that people are charged are within
their means. When we are considering these kinds of
levels and patterns of medical care, we are considering
activities that can be put into practice by the medical
profession. These are very different from the activities
which might one day lead to health for all, and in which
the majority of medical professionals can only play a
very limited role.
If we are serious about improving the provision of
medical care, we have to consider manpower issues,
too. Given the limited number of medical and nursing
professionals available to provide medical care in dis
advantaged communities, we need to set out clearly the
tasks for which medical auxiliaries should be trained.
Their requirements for in-service training and super
vision need to be spelt out, too. All of us have a role
to play in providing good quality, relevant task-orienta
ted training to people working at a number of different
levels in medical care services.
During the planning process the medical services
proposed for each community need to be debated with
its representatives. Professionals involved in programme
planning and implementation need to be prepared for
the inevitable conflicts between different interests invo
lved, wherever they are working. These conflicts will
increase as more people are involved in and participate
in their own “development”.
Medical and nursing professionals working in Third
60
A GREAT POLEMIC DISSOLVES INTO PLATITUDES
World countries need to work to spread the availability
and accessibility of appropriate medical care services
among all population groups—particularly the groups
who are traditionally disadvantaged and denied services.
This will not be easy. There arc vested professional
interests attempting to keep control over the avail
ability of medical care; to profit from the illness of
others; to encourage the overprescription of unneces
sary drugs and to concentrate on the rare, dramatic and
interesting illnesses in society. Rather than concerning
themselves almost uniquely with complex issues that
have implications outside the medical professional
sphere, international medical organisations would do
better to concentrate their efforts on promoting im
proved provision of curative medical care and public
health services throughout the world. They need to
provide maximum support to those who arc trying to
counter the vested interests inside the medical profes
sions that work so effectively against the objective.
Perhaps a new operational objective for activities
undertaken by the World Health Organisation, Govern
ment Health Ministries and the Medical Professionals is
“Medical care for all by the year 2000’’. The aim
should be to provide good, appropriate, accessible,
effective curative care and public health services, and
to train and supervise doctors, nurses and auxiliaries
to provide them. This is within the context of a broad
world development goal of “Health for all”—a great
and important polemic that must never be allowed to
dissolve in a sea of platitudes.
61
‘"The doctor well recognises the story and the appearance.
He suspects it is tuberculosis. He knows the capacity
of the poor—they will pay for the belief that they will get
well, and as long as that belief can be sustained, they
will keep on paying the same doctor. ... It will be suffi
cient to see that the man gets temporary relief and is
kept fluctuating within a safe margin between cure and
death, with an occasional dramatic rescue from death’s
clutches, for as long as possible.”
—Mira Sadgopal
7
Health “Care” Vs. the Struggle
for Life
Mira Sadgopal
India’s people, and the world’s people, are faced with
a gigantic health “care” establishment. It is far from
being a vacuum, a situation of “neglect” as most politi
cians and planners would have us believe, or sometime
themselves believe. Like a huge and ungainly bureau
cracy, it is both organised and unorganised. Its various
parts arc linked with each other in both gross and
subtle ways: equally, the parts function in contradic
tion with each other. Some of the parts of the estab
lishment succeed in holding sway in certain spheres by
virtue of historical advantage and the forces that back
63
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them at the moment. Any group claiming to explore
“alternatives” must understand human health, and like
wise any other sphere of human welfare (like education,
economic development, legal justice, etc.) in this pers
pective. The individual man, woman or child is power
less and thus always prone to being sucked, duped or
dragged into the establishment system.
India provides a magnificent panorama of such a
health care establishment. Most obviously, wc have in
this country a giant multi-tiered government-operated
public health infrastructure, the bottom levels of which
are organised into something called the “primary health
care” system. It is topped by a spread of state hospitals
and national medical institutes as well as various large
central public health agencies. Ultimately, this govern
ment system is empowered through finance by inter
national organisations and agencies like the WHO,
UNICEF, DANIDA, etc.
Second in consequence is the vast body of “quali
fied” private practitioners which, although less orga
nised and partially thrives on its own disorganisation,
also exhibits a hierarchy of influence and power largely
corresponding to the proximity of its parts to the cities
and the drug industries. It includes graduates of ‘allo
pathic” medicine as well as graduates of the ayurvedic
colleges, although most of the latter depend on the
use of modern allopathic medicines. The minimum
requirement for the organisation to promote and pro
tect the interests of their members as a class is fulfilled
by the Indian Medical Association.
Taking third place in visibility, although it exerts
the most pervasive and devasting influence, is the huge
64
THE STRUGGLE FOR LIFE
drug industry complex. There is a polarisation within
this group between competing indigenous and multi
national companies which is unequal, so that indigenous
industry either succumbs to or adopts policies in tune
with the multinationals. The multinational drug in
dustry profoundly controls policy and practice within
the government health system as well as the behaviour
of private practitioners by plying central government
committees and deploying a large army of medical
representatives.
Fourth is a large group on the fringe of the health
establishment power structure, loudly named “Quacks”
by the Private Practitioners. It is a very interesting
group without any real political power or legal sanc
tion, which thrives on the contradiction of the estab
lishment, the extreme powerlessness of the masses and
the total culture of mystification which maintains this.
This group finds its niche in the rural areas and the
lacunae of the towns.
A fifth group exists in the twilight beyond the fringe,
often indistinguishable from the masses but merging
into the category known as “quacks”. They cannot
really be called part of the establishment, but they are
quite often the first, last, and sometimes the only re
course of the poor. These arc the village dais, the bonesetters, the guinas, ojhas and bhagats (faith healers and
magicians). They are traditional, invisible from the
belief system of the masses. The larger health care esta
blishment has an ambivalent attitude towards this
section—it is largely ignored or ridiculed. Recognising
their hold over the people, some members, such as the
dais, are sought to be co-opted by government training
65
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into the primary health system.
Also according to establishment values, organised
health services are operated to a greater or lesser extent
by large public and private industries and by the central
government for its employees. These are all subject to
the same pressures of the health care culture which bear
on society in general and are only partially modified by
local or specific political conditions. For practical pur
poses, we may add to this category the attempts of a
number of voluntary agencies to provide proper and
uniform health services in project areas.
Seeing the large interconnecting structure of the
health establishment in this way gives us an intellectual
idea of its magnitudes, but what does it mean for the
common man and woman in India?
For a start, we can listen to the stories of hundreds
upon thousands of men and women suffering from
tuberculosis in our cities, towns and villages. Over and
over again we can see a plot thus exposed in stark
nakedness, as each tells the struggle to get treated and
cured by any possible means.
For instance, a villager who gins cotton has noticed
a gradual loss of weight and energy and may be, a cough
for several months. But so many of the poor are already
exhausted and emaciated by life—they find the line bet
ween relative health and disease imperceptibly crossed
—and they think it is only “weakness”. When work
becomes impossible they seek quick help from private
practitioners, knowing its cost, but anxious to get well
and back to work. They hope to get by with a strength
giving injection, a few pills may be, and a bottle of
life-giving tonic which the doctor will prescribe. So a
66
THE STRUGGLE FOR LIFE
couple of chickens and some grain is sold to raise
money.
The doctor well recognises the story and the appea
rance. He suspects it is tuberculosis. He knows the
capacity of the poor—they will pay for the belief that
they will get well, and as long as that belief can be
sustained, they will keep on paying the same doctor.
He also knows that this disease, if properly managed,
has a good chance of continuing without cure for seve
ral years before the patient dies. Furthermore, the
widespread attitude that TB is incurable, supported by
the vast majority of cases which eventually end in death,
and the doctor’s own observation that patients cannot
sustain regular treatment does not lead him to nurture
any professional interest in obtaining a cure. Therefore,
neither is he interested in proving the diagnosis. A
private practitioner will avoid telling that he is treating
a man for TB as long as possible. Otherwise he is sure
to lose his patient to another doctor. Likewise, sending
him for sputum test or X-ray, which may be available
through the nearest government hospital, would be
giving him away, or privately done would use up avail
able funds. He is not interested in prognosis either—it
will be sufficient to see that the man gets temporary
relief and is kept fluctuating within a safe margin bet
ween cure and death, with an occasional dramatic rescue
from death’s clutches, for as long as possible.
What does the doctor’s treatment consist of, aside
from its psychological content? First on the list is
Streptomycin injections, one daily if possible, which is
more likely impossible if the patient lives far away.
(He may be given tablets of Isoniazid in various pro-
67
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prictary preparations in place of streptomycin, in which
case he is certain to be sent off with a couple of impres
sive on-the-spot injections, such as liver extract and
red-coloured vitamin B12.) Next, he will be prescribed
ethambutol tablets (under one of the marketed brand
names), a second-line drug for TB which is compara
tively expensive but which is being promoted by multi
national companies through their medical representa
tives as a first-line drug. Third, a corticosteroid like
betamethazone (again, under numerous brand names)
will be routinely given or prescribed by most private
practitioners at the start of anti-TB treatment, as it is
expected to bring about rapid relief from symptoms and
a specific false sense of physical well-being which may
be the major factor in hooking the patient. Fourth will
be a large bottle of mineral, and vitamin tonic which
also ironically contains something to stimulate the
appetite of the person who is basically dying of hunger
anyway. Fifth, a syrup will be added to suppress the
cough.
The expense of the first week of such treatment
works out as follows (approximately):
1. Inj. SM @ Rs. 3.00/dayx7
21.00
2. Tab. Ethambutol I twice/day
@ Rs. 2.50/dayx7
17.50
3. Tab. Betamethazone I thrice/
day X 7=21 tablets
8.00
4. Vita-mineral tonic—single large bottle
20.00
5. Cough syrup—single bottle
8.00
74.50
The doctor’s initial fee will vary, but he will also
68
THE STRUGGLE FOR LIFE
take a daily fee for injecting streptomycin. Ifheisa
good dramatist and psychologist, and the family is
obviously prepared to pay, he may set up an intravenous
drip and charge heavily.
Quite often, the person does not have enough cash
to buy some of the medicines. Typically, the tonics and
non-TB medicines will be bought and the anti-TB medi
cines will be partially or totally dropped from the list.
(A survey done by Veena Shatrughna has shown that
many doctors write the tonics and less necessary medi
cines first, perhaps to oblige the drug companies, and
the specific curative medicine last. See, Health Carewhich way to Go? MFC).
How long is this to go on? We have found that a
doctor tells the patient initially that his treatment may
take a varying period between two weeks to three
months. He may decide to further prepare a mental
frame work by stating that the man is lucky that the
doctor has caught the “disease” at this stage because,
although he doesn’t have TB yet, “There is a chance of
it turning into TB!”
Even if a man has collected enough funds for the
initial treatment, he may not be able to follow it up.
After a varying number of visits to the doctor, and
especially after a marked improvement, he stops going
—he may go back to work. He also meanwhile consults
a gunia of his community about warding off the risks of
getting TB, and after certain divination the gunia advises
him to carry out certain rituals and sacrifice, which are
usually done.
After some time, he again loses weight, and his
cough worsens. He thinks about returning to the doctor.
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The doctor’s mention of TB has scared him, and he is
ambivalent. He may do one of three things: he may go
to another private doctor or a quack, he may go to the
government doctor, or he may return to the same
doctor. If he goes to another doctor, he goes with a
blank slate—he doesn’t mention that he has seen another
doctor, or flatly denies previous treatment. Hence, a
second version of his first experience is likely to unfold.
A streak of realism may hit him. He may realise that
the chance he has TB is high now, and decide to see the
government doctor. At least he may get a clear answer
even if he doesn’t have faith in the government treat
ment.
The government doctor is a strange kind of super
man. He is invested with the power to treat when he
pleases at the government's expense. (He also carries
out a respectable private practice in his home at the
government’s expense.) A patient approaches him in
fear and trembling. Diagnosis for purposes of initiating
government treatment is obtained through sputum exam.
or X-ray, whichever is feasible. Anti-TB treatment is
started on the doctor’s orders. He tells the patient he
has TB, or he says, “There is a chance of it turning
into TB!” depending on the role he wishes to play in
the drama with the patient—government doctor or pri
vate practitioner. Sometimes he adopts a dual role,
issuing government drugs from the Primary Health
Centre for seeing him privately at home, too.
Government rules for the treatment of new cases of
TB are clear and rational, the full treatment of eighteen
months provided for under the National Tuberculosis
Control Programme. After positive sputum examination,
70
THE STRUGGLE FOR LIFE
treatment is started. Streptomycin injections are to be
given daily for one month, then on alternate days for
two months more. (An abbreviated schedule which is
medically acceptable is ‘daily X 15 days, then alternate
days X 2 weeks, then twice weekly X 2 months, again
totalling 3 months.) Daily Isoniazid (INH) tablets arc
also given.
After three months, sputum examination is to be
repeated (if the patient is still coughing up sputum).
There should be no more tuberculosis bacilli detectable
in the sputum. Then, if not before, an X-ray screening
is called for if feasible from the nearest TB, X-ray faci
lity. The reduction in the extent of lung damage is
thus monitored every six months. Six months after
disappearance of the signs of damage, treatment may
be officially discontinued.
If progress is satisfactory, Streptomycin is to be
replaced after three months by another drug, usually
Thiacetazone (THZ) but it might be Para-Amino
Salicylic Acid (PAS). The PHCs dispense Isoniazid
and Thiacetazone in combined tablets for the re
maining period of treatment. To ensure that a patient
keeps up regular treatment, he is supposed to be called
every month on a particular date three days before the
drugs with him are due to finish. In case he does not
turn up within a few days, a printed postcard reminder
is to be sent to him. If he does not respond to three
such reminders (and he has not died), he is known as
“defaulter,”.
But what really happens to the ordinary patient,
or to our village friend who gins cotton?
There are innumerable obstacles in the way that
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ensure failure of treatment or “default”. We can list
these, as follows:
1.
Problems of Diagnosis
(a) sputum exam: technician not available, or
refuses
(b) x-ray/screening facility distant, expensive, out
of order, or x-ray plates not available.
2.
Failure of Communication to Patient by Doctor
(a) intention, or lack of intention of doctor to in
form
(b) patient’s fear
(c) contradiction in the belief system in society
about disease.
(d) doctor’s impatience
(e) mystification of doctor’s role
(f) poor relations/faulty communication between
PHC staff
3.
Problems of Drug supply and Regular Issue
(a)
(b)
(c)
(d)
(e)
4.
genuine short supply to PHC from District HQ
siphoning off of TB drugs into the market
siphoning off of TB drug into private practice
incomplete issue of drugs
doctor’s failure to indent (maladministration)
Problems of Medicine Cost from Market when
unavailable through government supply
(a) high and rising prices of essential firstline drugs,
especially Streptomycin
(b) shortage of all first-line drugs in the n^arket due
72
THE STRUGGLE FOR LIFE
(c)
5.
to gross under-production.
increase in market supply of expensive secondline anti-TB drugs like ethambutol, rifampicin
Unnecessary Cost on Vitamin and Mineral Injections
and Tonics and costly Cough Mixtures
(a) brainwashing of doctors by medical represen
tatives
(b) overproduction beyond licenced capacity of
tonics, etc., by large and multinational drug
companies
(c) mystification among the masses about tonics
and the desperation for quick life-giving cures
6.
Problems of Local Arrangement to Inject
Streptomycin
(a) unavailability of doctor/health worker to inject
(b) fee for injection daily
(c) PHC may refuse to issue injections to patient
to take home
7.
Problems of Transport
(a) distance
(b) cost in time, energy, fare
(c) irregular public transport services
8.
The Social Milieu at Home
(a) poverty—poor shelter, starvation
(b) demoralisation
(c) sex-bias in case of women, especially when
childless or without living male offspring
(d) belief in magic and lack of scientific concept of
disease
73
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9.
Conditions of workplace and Occupation
(a) economic exploitation
(b) noxious physical conditions, like inhalation of
cotton fibre and poor ventilation, etc.
(c) lack of safety standards
(d) lack of alternatives
10.
Specific Malpractices by PHC Staff and Doctor
(a)
(b)
(c)
(d)
(e)
(f)
Private practice
misinformation or non-information of patient
failure to record (incomplete) issue of drugs
neglect of monitoring schedule
failure to maintain treatment card
failure to contact defaulters by postcard.
It is sufficient to say that the average poor man of
India who gets TB today is likely to face every single
one of these obstacles, except 8(c) as he is not a woman.
Inevitably, he becomes a defaulter, or he dies, or more
likely both. Are there really any alternatives?
Numerous groups and individuals are making
attempts to challenge the might of the establishment.
The outlook of all at this point is at best, partial. Again,
the problems of tuberculosis can serve as a useful refe
rence point for illustration. We will mention a few
of these efforts known to us which we consider signi
ficant.
The Voluntary Health Association of India (VHAI)
is at present carrying out a countrywide investigation,
with the help of a number of local and regional groups,
of the widely reported shortage of first-line anti-TB
drugs in the market and in the Government TB treat74
the struggle for life
ment centres. This effort has arisen from a couple of
workshops on issues related to rational drug therapy
organized in 1982 in joint collaboration with the Medico
Friend Circle. During the workshop held in Jaipur in
August 1982, evidence from within the pharmaceutical
industry was presented by spokesmen of the Federation
of Medical Representatives’ Associations of India (affi
liated to the All-India Chemical and Pharmaceutical
Employees Federation, a non-party trade union organisa
tion) to show that the large multinational drug companies
are manipulating the supply of anti-TB drugs by pro
ducing essential first-line drugs far below their licenced
capacities and promoting the newer second-line drugs
which are at present imported from abroad. A number
of field groups, including members of the Medico Friend
Circle, members of the State Voluntary Health Associa
tions, and local units of the Federation of Medical Re
presentatives are collecting data to assess the magnitude
of the problem and whether, as many suspect, the inci
dence of TB among the people is on the increase.
The first weapon against the establishment is in
formation. A second can be formed from a “network
of socially conscious health workers” (quoting from
VHAI’s appeal for cooperation in collecting field data
on TB drugs and incidence). The ultimate weapon is a
conscious movement within the masses.
As in many parts of the world, we see in India today,
various attempts being made in the direction of building
a conscious peoples’ movement. Only thus will it be
possible to really challenge the establishment on issues
of health care and more important, to gather the neces
sary power and democratic perspective for evolving a
75
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real scientific alternative which rests on social justice.
At present these initiatives are small and fragmented,
particularly in the sphere of health action. Therefore
they arc weak in comparison to the total strength of
the establishment. However, the experience steadily
being built up and the link with other democratic deve
lopment is significant.
On the regional and national level is the surprising
example of the Federation of Medical Representatives’
Associations of India, a healthy, growing, non-partyaffiliated trade union organisation with a vision which
is somehow startlingly free from the blindfold of narrow
economism. This group’s role in collecting vital infor
mation about the TB drug situation has already been
mentioned.
Another regional example is that of two other nonparty organizations in the Chhatisgarh region of eastern
Madhya Pradesh—the Chhatisgarh Mine workers Union
(CMU) and the Chhattisgarh Mukti Morcha (CMM).
The CMM, an organisation drawing strength from
agricultural labour is constructing a peoples’ hospital
and both organisations launched a joint movement in
1981 which they call “Struggle for Health’’. At present,
understanding of health issues is crude: primarily a
realisation of what is grossly wrong and a struggle
against blatant injustice. Slowly and painfully these
two organisations are struggling to overcome their own
inadequacies, faulty habits and traditional beliefs to
build up a viable and just health care alternative.
At the local level in areas where there is no esta
blished mass organization, small activities and micro
initiatives are being carried out which begin to challenge
76
THE STRUGGLE FOR LIFE
parts of the health establishment. This has been the
case with our own group. In a series of three block
level “Youth Leadership Training Camps” sponsored
by the Nehru Yuvak Kendra (Government of India)
of Hoshangabad, we organized groups of literate youth
to study the social aspects of the problem of tuberculosis
by moving among the people and listening to patients
tell their stories. The campers compared the people’s
experience with the provisions of the National TB Con
trol Programme and analysed reasons for the discre
pancies. They organized a diagnosis camp, poster ex
hibition and cultural programme and a public questionand-answer meeting in the presence of the government
doctor and the district TB Control authorities. Many
contradictions arose which could not be resolved.
At the village level, we initiated an interesting ex
periment with the women of the labouring class. The
male villagers of one large village had formed a labou
rers’ union about eight months previously. One day,
knowing that I am a doctor, a woman named Bhagwati
suffering from untreated advanced TB dragged her
emaciated frame to my door. She related a story of
neglect and desperation. Her husband was an inactive
member of the union, although she was not even aware
of the existence of the union. Her husband Kaliram had
failed to take her to the government hospital for diag
nosis and she insisted that the elders in her family
wanted her to die. We brought up the case in the union
meeting, but were shocked to find total apathy towards
her plight. The only concern was that her husband,
who failed to attend meetings, was a scoundrel and a
coward and not worth any attention at all. It appeared
77
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as if his wife was only an appendage of him. Untilthat
time, no woman had been involved in the union meet
ings. We decided to see how the women would react to
this woman’s problems.
Approached individually and in small groups, the
women’s response, on hearing that TB is curable and
the treatment provided for through the Government
PHC, was spontaneous. They decided to hold a meeting
of their own to build up pressure for the treatment.
This they did. In the meeting I agreed to act in a super
visory capacity to see that the treatment given through
the PHC was correct and was properly understood.
Kaliram took his wife to the PHC and the treatment
was started. At the time I was working there voluntarily
on a once-a-week basis, so I was able to intervene to
some extent. We trained a local person to inject Strepto
mycin and, on my responsibility, a month’s supply was
issued from the PHC.
The initial phase of treatment was stormy. Bhagwati
had high fever and severe lung damage. We held an
emergency meeting one night to help the family, now
alarmed, to decide whether to take her to the Govern
ment TB Hospital at Chhindwara. Four women related
stories of their relatives who had gone to the TB Hos
pital. In three cases, the victims had died anyway. The
fourth person, alive and well, had gone there twenty
years before when the hospital was run by a mission.
Nowadays the hospital is ridden with corruption at all
levels and over-crowded so that the expense is great- It
was pointed out that the treatment would be no diffe
rent from that she was getting at home from the PHC.
So it was decided that the wisest course was to continue
78
THE STRUGGLE FOR LIFE
to take care of her at home.
In the first ten days, one or two women began to
visit her daily along with me, turn by turn. This was a
hurdle for them, as Bhagwati is a Harijan and, although
all the women were poor, they were nearly all nonHarijans tribals, Muslims and low-caste Hindus who
were used to strictly abiding by the code of untoucha
bility. They had never set foot on the aangan of Bhagwati’s hut, and they had not seen her about the village
for several months. It was an unforgettable sight when
one woman, seeing her shrunken form on the cot, irresistably lifted aside her veil, with which she had covered
her face in shame, and exclaimed, “Oh, my sister, what
has happened to you!’’
The women were so excited at the first two meetings
that they decided to meet frequently. At their next
meeting, the women who had already visited the house
described Bhagwati’s condition and observed that there
were obstacles to her treatment at home. Her motherin-law was being nasty and un-cooperative, refusing to
give her food and continuously commenting that she
would be better dead. The rest of the family was demo
ralised and the house was messy. I told them that it was
a problem for me as a doctor to keep on giving neces
sary advice to improve diet and hygiene which had gone
unheeded for a week. They decided to control the
mother-in-law and had a lively discussion about a
proper diet for a TB patient and about fixing up
Bhagwati’s surroundings to make the place liveable and
hygienic. The next day one woman tackled the feisty
old mother-in-law and convinced her to draw a truce in
the battle with her daughter-in-law until Bhagwati
79
UNDER THE LENS
would be fit to fight back again. Another woman sat on
the edge of the cot explaining to her husband and eldest
daughter what she could be fed, how to arrange that
part of the hut, and how to dispose off infected sputum.
The heat was sweltering. The next day we were
surprised to find that Kaliiam, a bamboo worker, had
woven a large overhead fan and attached a long grass
rope to it. The small children were kept at a safe
distance pulling the rope to and fro in turns, singing
songs to the rhythm of the fan. The house was tidy and
clean. The sick woman’s fever was much less. She was
smiling. Her mother-in-law was grumbling, but about
other things, and in masked good humour. The family
had got the taste of self-respect through social concern.
Recovery was steady for some time thereafter. At
the end of one month, Bhagwati was anxious to get her
sputum re-examined because she wanted to be able to
hold her four-year-old son on her lap, and she wanted
to sit-in at the women’s weekly meeting. She had lost
her one-year-old daughter a year previously, probably
because of having infected her with TB. To collect her
sputum, she scrubbed a Streptomycin vial thrice with
soap and boiled it in water (so as not to kill any bacilli!)
and waited for the bus on the road from eight in the
morning. The eight o’clock bus did not come. The
eleven o’clock bus did not come. At 11.15 she began
walking in the scorching sun barefoot. The PHC was
seven kms. away, and she was afraid it would close, so
she nearly ran the whole distance. One hour later, she
reached the PHC to find that it had closed at 12 o’clock.
She waited until it reopened at 4.30 p.m. and proudly
offered the vial of sputum to the compounder-technician.
80
THE STRUGGLE FOR LIFE
He grabbed the vial and threw it on the ground shout
ing, “We won’t do your sputum test seventeen times.
Bring it after three months!”. Then she asked for her
month’s supply of drugs, only to be told that the doctor
had gone and she would have to come the next morn
ing.
Bhagwati returned home exhausted, down-cast, but
amazed at herself that she had been able to make the
journey. Next day, she had fever, but she was determin
ed to go back to get her medicines. Kaliram accom
panied her. He decided in addition, to take her to the
next town and get her first X-ray done and the sputum
test repeated privately. When they faced the PHC
doctor, they had to tolerate his sarcastic comment that
they had “become big people now”. All the drugs were
given, but no amount was recorded on the card. In the
next town, they paid Rs. 5/- for the sputum exam and
Rs. 24/- for an X-ray. The sputum test was negative.
The X-ray showed cavitation, but signs of active
healing.
Probably because of the heavy exertion, Bhagwati
was not well for about two weeks, but again began to
pick up. The following month she went to a wedding
and took her vials of Streptomycin and pills along with
her, getting them injected by an available doctor. In the
fourth month she started work again. She is a tradition
al dai as arc all the women of her caste. An orphan, she
had started her midwifery career at the age of seven,
as she described to me later. In the same month, some
other villagers reported to me that she was catching
fish in the river with her nephew.
In the fifth month, Kaliram discovered that Bhag81
UNDER THE LENS
waii had brought back only white tablets from the PHC.
Streptomycin has been discontinued, but he knew that
anti-TB drugs were necessary, and she had been receiv
ing both Isoniazid (white-coloured) and Thiacetazone
(yellow-coloured) in the form of combined light-yellow
coloured tablets. He took the pills back to the doctor
the next day complaining, squarely that she had been
given “only one” anti-TB drug by mistake. He didn’t
flinch when the doctor’s cold gaze hit him, and after a
moment’s hesitation, the compounder was called and
told to exchange the white tablets for the familiar light
yellow ones.
And so her treatment will go on, maybe without
serious lapse until she is totally cured. Kaliram now
attends union meetings when he can manage it. Bhagwati attends the women’s meetings. He farms his small
piece of land, and plays music at weddings. They make
bamboo baskets. She delivers babies. They are people
of courage, like the others. In the meetings they don’t
talk about TB, but of the struggle to survive and thrive
against the forces of the establishment.
82
Let us mention from our experience that the key to
growth is not in believing but in questioning. An honest
doubt is worthy more than thousand dogmas. Therefore,
We asked—why?
—Abbay Bang and Rani Bang
MUKUND TALWALKAR
.V .
.'I'.'
The Other Side of Health Education
■ ,
Some Experiences of Health Education in
•
■
Rural Community
Abhay Bang and Rani. Bang
Let us clarify in the beginning that we are not academi
cians in this field. Nor was our work an experiment in
health education as such. We were fresh M.D.s from
clinical side and we started rural health work with a
view to organise people for their own health as well as
other needs. During, this effort we came . face to face
with many realities.. Here we. shall recollect a. few of
these experiences- and try .to understand and analyse
them.
:■ <
. •• . .
- ■ .
.
85
UNDER THE LENS
Education: A two Way process
Not knowing how sensitive is the tool of health educa
tion, in our initial enthusiasm to teach ignorant people
many new and scientific things, we tumbled into the
field of health education also. It is common rhetoric
now-a-days in the field of health education to say that
‘education is a two-way process’. There is no teacher
or giver of knowledge and nobody is mere recipient of
knowledge. Both learn together. But in reality usually,
we the prophets of scientific knowledge, sit on a high
pedestal and deliver sermons to the illiterate, ignorant
masses as to how stupid they are, how they don’t know
anything and hence how it is now up to us to deliver
these from this hell of ignorance. This is called health
education. With such an attitude and relationship,
obviously there cannot be a two way process of educa
tion. We are the net losers because we have lost the
opportunity to learn.
When we look at our efforts in health education, we
must admit that we began with this attitude. But today
when we recollect the whole experience, we feel that
though we cannot say whether people learnt anything
from us or not, we definitely learnt a lot. Health educa
tion has definitely proved to be our education. What
did we learn?
Why Do People Not Behave ‘Rationally’?
In our clinical and community health work in the
villages, this question always used to crop in our minds
—why do people not behave rationally? Why do they
not practise certain scientific advice given to them? You
ask them to use latrines—they won’t. You ask them to
86
THE OTHER SIDE OF HEALTH EDUCATION
keep roads clean—they would defaecate on it. You ask
them to dig soak—pits—they would nod their heads
but won’t do anything. You ask women to come for
antenatal check up or bring their children to under five
care clinic, they won’t. This always led to a sense of
frustration and anger in us. We used to get annoyed
with their non-compliance. But still a question used to
creep in our mind—why do they behave like this?
Let us mention from our experience that the key to
growth is not in believing but in questioning. An honest
doubt is worth more than thousand dogmas. Therefore,
We asked—why?
Raibai
Raibai Dabolc, a woman of 30 years age brought her
1 A year old baby to our clinic in Kanhapur. The child
had severe mal-nourishment with bronchopneumonia,
obviously in very serious condition. We advised im
mediate hospitalisation of the baby. She stared at us.
We again explained to her that the child will not
survive unless she takes him to hospital and keeps him
there for at least a week or more. She left the clinic
with the sick child—obviously unconvinced about our
advice. We cursed her—“these rural people don’t
understand the value of a child’s life. They are callous
about it, that is why children die like flies. Without
bothering about children’s life, they produce new
babies. Thus our birth-rate and infant mortality rate
both go high”.
Next day this baby was lying near a public well,
with convulsions. By the time we reached, the baby was
dead. We didn’t find the mother around. We were told
87
UNDER THE 1 I NS
that this 14 year old was left in the care of a 4 year old
elder child and mother had gone out. Our view about
the stupidity of our people was further strengthened.
Next time when Raibai came to our clinic we scold
ed her for such utterly negligent and callous behaviour.
Then she told her side of the story:
She was a widow with 3 children. Exploited and
harrassed by everybody, she was leading an unsupport
ed life. She was the only wage earner in the family and
was waiting for her elder son, (7 years then) to grow up
and share her burden. When we advised her to hospi
talise her youngest child, she had a difficult choice. If
she had to stay in hospital with the baby for a week,
the two older children would starve. Older children
were valuable to her because they would reach the
earning-age earlier. She decided to save the older
children at the risk of the youngest one’s life. At the
time of the death of the baby she had gone to the fields
to earn her daily wages leaving the baby in the custody
of the older sibling, four years old. Was it irrational
behaviour?
Munnakhan
Munnakhan came to our clinic. He. was found to have
cardio-myopathy with cirrhosis of liver. Cause: chronic
alcoholism. We admitted him to the hospital and gave
him a sermon on the ill-effects of alcohol. We tried to
convince him that he had already wrecked his body by
alcohol consumption and he could’t afford to continue
to consume more. He seemed unconvinced. After im
provement we discharged him and he continued his
alcohol.
88
THE OTHER SIDE OF HEALTH EDUCATION
The question perturbed us—why doesn’t he sec a
simple rational thing? Munnakhan told us that he was
working as ‘hamal’ in railway godown on daily wages.
There, the hamal had to load and unload wagons very
fast as there was wagon shortage. In one day he lifted
500 bags of one quintal each. After such strenuous
exertion, he said, the coolies had to drink alcohol to
relieve tremendous body pain.
“You can’t work as a coolie in godowns without
drinking alcohol. We come out of godowns in the even
ing craving for alcohol. The extreme tiredness and pain
is unbearable. Body asks for alcohol’’. Within few days
he died.
A few days later one of us, Abhay, had to spend 3
hours in a godown for purchasing and loading grain
for a grain bank programme of Chetana-Vikas. It was
not summer. The godown was tin roofed and was hot
like an oven. Coolies were lifting bag after bag. Within
3 hours, when he was just standing he had to remove
his shirt thrice and dry it of the dripping sweat. He
could not stand after 3 hours and went home for some
cold drink. Now, he realised what Munnakhan had
said. Munnakhan was lifting bags of 100 kg each
which Abhay couldn’t even move-and such 500 bags in
a day. Such inhuman labour was not possible without
alcohol. These human cranes were working on alcohol.
Who was irrational? Munnakhan or we, who didn’t
see the inhumanness of such labour?
Mabakal: Latrines
Your entry into the village Mahakal—where we ran a
clinic—is greeted by a paradoxical sight. There is a
89
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row of 10 pucca public latrines built by the Govern
ment years ago, on one side of the road, and women
and children defaccating on the road-side just in front
of these latrines. Now this sight immediataly creates
an urge to deliver a health education sermon. We did
it. No change. Then we realised that the people had
to fetch water from about one km for their domestic
use and drinking water was a precious commodity.
Who would be willing to spend such a precious thing
in abundance for keeping these public latrines clean? So
they found it much more sanitary and clean to respond
to nature's call in open where they could select a clean
place, than to sit in those public latrines full of faecal
material.
We also must mention two other reasons for this
behaviour. We found that women always defaecate on
road side. This annoys us because we have to pass
through that dirt while entering the village. But women
have their reasons. In the dark hours or in the rainy
season, road and road sides are the only safe and dry
places available.
One study has found out that women in the village
have two occasions for socialisation—for talking with
other women. One on the wells, when they go to fetch
water and another while defaccating. Public latrines
being walled from all sides deprive women of this
opportunity of chit-chatting with other women. Hence
they prefer open space.
Soak Pits
Kanhapur has a high prevaiance of Filaria. Mosquitoes
breed all around houses and wells because there is no
90
THE OTHER SIDE OF HEALTH EDUCATION
arrangement for drainage. So people were advised to
dig soak-pits. Now the soil of Kanhapur is black
cotton soil of best type. It holds water like anything.
All soakpits were choked, filled and overflowing. It
worsened the problem. People said that they were
better off without these.
Who needs Education?
Now the question is who needs education? We talk from
a scientific ideal. But the appropriate measures that
we advise are often inappropriate in their situations.
It is our blindness that we don’t sec these reasons and
blame for their non-compliance.
It is our experience that we need to see the situation
in which people live and understand the reasons for
their behaviour before giving them any advice or health
education. That is why we said in the beginning that
health education is a very delicate and sensitive tool.
In the absence of such precaution quite often our advice
is as irrelevant as Sanjay Gandhi’s. He had mugged
up a 5 minute speech which he used to deliver every
where. When he went into thick forests of Baster he
delivered the same sermon to the naked hungry tribalsplant more trees!
Most of us come from a common type of back
ground: educated urbanised, middle class life. We
have our certain needs fulfilled and hence we see certain
things as priorities. Cleanliness, education, health,
morality and so on arc what we sec as priorities—we
offer these to people. People don’t bother and continue
their own pattern of behaviour because they have their
own reasons and priorities. We blame women for not
91
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attending ante-natal clinic or under five clinic saying
that the ignorant people don’t realise the importance of
prevention. But we hardly see that poor people are in
such a neck to neck struggle for survival that immediate
existence is a greater priority than preventing future
calamity. When the labourers eat in the evening what
they earn in the day, how can a woman afford to re
main absent from her work to attend an ANC clinic?
Now, while saying all this we don’t mean that
whatever people do is all correct. They have been
applying cow dung on umbilical cord and killing the
neonates (tetanus) for centuries. This is obviously
wrong. But the point is, we need to see their reasons,
compulsions before blaming them.
Who Needs to Change?
So the question, who needs to change?
Brecht was a German dramatist and poet. When
the Russian tanks rolled on the streets of Berlin to
suppress the voice of the people, he sarcastically
wrote—the Party and the Government is always correct.
People are stupid. This Government really deserves
better people. So—instead of people changing the
Govt., the Govt, should get the people changed. We
are not such a Government. So, we need to change our
methods and advice to quite a large extent to suit the
people’s life and needs.
Our action has to be comprehensive. Isolated
health education and action becomes ineffective. We
learnt it from Raibai. We started Balwadis and Cretches
so that mothers could go to fields leaving their child
ren in safe care. We took up issues of minimum
92
THE OTHER SIDE OF HEALTH EDUCATION
wages of the labourers. The increase in wages in cash
didn’t mean much in the face of rising prices of food
grains. So we started Grain Banks. We undertook pro
grammes like adult education, labour organisation,
agricultural programmes to increase production—these
are the premises of health action. Without these our
health messages cannot be brought into practice by the
people.
For doing this, we need self questioning instead of
standard dogmas. People could be right. We could be
wrong. Let us understand and examine. Another thing
we need is—faith in the people. As the old Chinese
proverb says: Go to the People. Live among them.
Love them. Learn from them, Start with what they
know. Build up on what they have.
93
"Arranged marriages" between health and dese.'.-rment
workers are not uncommon in the
c/' ••
w’grnc/ej’ programmes. Development iwverj
/rercr/r
rather alarmed by the vagueness and
their
oirn goals of "economic justice" and
awareness". S’o health is dragged it
“sgrammc to gain rhe peoples' e.'-fdc-.ce a-.d —a'.e ::
as if something funv;i!’!e 5r:.’tR
Ardrc” Clerk
9
What Development Workers Expect
From Health Planners
Andrew Clerk
The Word doctor comes from the Latin ‘docco’, mean
ing “I teach”. The sad lesson is that when doctors do
attempt to teach ordinary village women, they are not
particularly good at it. Experienced ANMs or other
paramedics tend to have a much better rapport and
ability to communicate. Doctors have their own langu
age, professional pride, class identity and vested
interests to maintain (consciously or unconsciously).
More defensible is the situation where conscientious
doctors are overwhelmed by the demand for curative
medical care, and thus they have neither the time nor
95
UNDER THE LENS
the space to do anything else.
Since most diseases have a social aetiology, their
physiological causes are themselves symptomatic of
social disorganisation or malfunctioning. Lack of food,
unprotected or inadequate water, crowded living con
ditions, inadequate clothing or bedding deprivation of
access to scientific knowledge, physical exhaustion,
sexual exploitation and so on, all appear as medical
statistics, malnutrition, dysentry, tuberculosis, pneu
monia, neo-natal tetanus, anaemia, or venereal disease.
The medical profession is just plain lucky since it
is suspected that the majority of patients eventually
recover regardless of the treatment which they receive—
good, bad, ineffective or none. The probable truth
underlying this assertion has sustained every shade of
medical practitioner from witch doctor to Harley Street
consultant alike through the centuries.
The Medico-Friends Circle is one of the honour
able exceptions in India to the over-prescription, vested
interest, mis-diagnosis and wrongly-placed priorities of
a whole profession. MFC is questioning at a more
fundamental level, and in this context I want to share
my own differently-biased outlook as a so-called “rural
development worker”. I must therefore face the inevi
table question “what do you mean by development
work?”
Wrong expectations?
Development work treats the poor as a class, and is
concerned with changes in: (i) Production relationships
(ii) The balance of power in rural areas and (Hi) the
dignity and equal status of the poor vis-a-vis the better
96
WORKERS FROM HEALTH PLANNERS
off. The goal is that of permanent social improvement.
Health planners exist at many different levels; the
concept is used very broadly here to mean any health
practitioner at the point where he or she is able to
exercise choice over the way in which he will allocate
his resources of time, skill, budget and facilities. The
overall goal is to ensure that the state of health of a
target population reaches and remains at an acceptable
level.
The best example so far of the use of the medical
profession to support a fundamental socio-economic
analysis of society has been the family planning pro
gramme. Based on the fallacy that the poor are prim
arily irresponsible consumers and not gravely abused
producers, doctors have put their skills at the disposal
of the demographers, allowing the latter to give priority
to operations and devices over economic justice and
socio-political awareness. In this it is difficult to blame
the medical profession which after all is licensed to
practice medicine, and not to analyse society.
What therefore can we as development workers
reasonably expect from medical practitioners? Must
it remain true that health is much too serious a matter
to leave to doctors? And what of those who put “com
munity” in the description of what they have to offer?
Presumably we can judge them according to the attain
ment of some sustainable standards of health in the
communities concerned.
“Arranged marriages” between health and develop
ment workers are not uncommon in the field of volun
tary agencies’ programmes. Development workers arc
secretly rather alarmed by the vagueness and vastness
97
UNDER THE LENS
of their own goals of “economic justice” and “socio
political awareness”. So health is dragged in as an
'’entry-point” programme to gain the peoples’ confi
dence and make it look as if something tangible is being
done. The expectation here thus raises ethical questions.
Unless the doctor in question shares the same basic
analysis and/or ideology as the non-medical workers,
then he or she should think twice about being used as a
decoy. Particularly as the whole medical services section
can become bogged down in misunderstandings with
the villagers.
However assuming the development workers and
medical practitioners share a common analysis, then
the expectations, as I see them in the context of voluntary
agency programmes, are:
1. To make opportunities to teach the nature, causes,
treatment and prevention of illness. This should be at
a ratio of 50% of total staff working time (exclud
ing travel and administration). Since teaching and
treatment can be done simultaneously at times, since
several outpatients in the queue will have the same
ailment, and since the doctor himself (as suggested
above) may not be the best teacher, then grouping,
logical organisation, and supervision would make this
goal attainable.
2. Medical staff should appreciate the implications of
working in an entity as complex as a village or gram
panchayat. Transistor radios and calculators have a
wiring diagram and one can study the circuit, resistance
and power input points etc. A village is so much more
complex and yet if our understanding is broadly that
“poverty is powerlessness”, then medicine (to serve a
98
WORKERS FROM HEALTH PLANNERS
development objective) must be directed to the poor
and put under their control. Medicine is a small, but
important, sub-system within the whole circuit.
3. Medical staff should participate actively in making
the link between a malfunctioning body and a malfunc
tioning society. Other things being equal, a copy of the
Government’s “schedule of Rates” for earth work is
of infinitely more worth then a homily on “balanced
diet’’, to an undernourished labourer.
Prescribing and selling packets of vegetable seed to
small and marginal farmers at the right seasons makes
more sense than vitamin pills, (although both could be
given where justified). Could the doctor have them on
his desk?
4. If, as implied in point 2 above, knowledge is a form
of power, and as argued initially, the doctor’s duty is
to see that learning takes place, then medical staff better
start to prepare themselves—and by this I do not mean
the usual box of gimmicks such as flannel graphs, flash
cards and posters.
First, you need to know the labourers’ lives, and
from this flow a mutual respect for the way they manage
in circumstances which would kill the average doctor.
Next you need to ask what is their experience and ideas
about a disease (assuming it is not an emergency). Good
ideas can be reinforced, bad ideas can be questioned
and an alternative implied by asking them about other
poor people who do things differently. In particular,
looking at other sections in their village, poor people
can be encouraged to see the extent to which their illhealth is linked to their poverty. The medium communi
cation is respect and not audio-visual aids.
99
UNDER. THE LENS
5. The usual basis of power for poor people
is organisation. The richer people have their family
members in the bureaucracy and legal system, and
reputedly have the police in their pockets, so organisa
tion poses little problem. The “medical sub-system”
to which we refered in 2 above, may be a practising
ground for newly organised people to try such social
actions as:
(i) Demanding the proper implementation of those
government services, including public health and drink
ing water, to which they are entitled. (Could a cons
cientious doctor determine the prevalence of certain
diseases as evidence to back them up?)
(ii) Organising themselves and electing one woman
from every twenty or so families to learn basic medical
skills (particularly child care): she should stock the
appropriate remedies. This entails diffusing the power
of “medical knowledge” throughout the community,
and avoiding the current trend of “domesticating” one
woman and paying her a stipend to be on your side, a
part of your system.
(iii) Setting up a “medical emergencies fund” so that
the poor do not have to turn to moneylenders in crises.
This entails practising various administrative skills, dis
cussions and mutual trust. (If those who borrowed had
to repay at the same rate as they would had to pay to
the moneylender, they would lose nothing more, learn
a lot possibly including an interest in prevention, and
the exhorbitant interest paid could be credited to their
name as savings).
(iv) Initiating action programmes: such as child care
(balwadis) at earthwork or agricultural sites (first de100
WORKERS FROM HEALTH PLANNERS
manding that contractors fulfil their legal obligations);
ensuring that child feeding programmes are honestly
managed and utilised to the best effect; looking for
alternatives to occupational hazards; examining practi
cally the whole complex of social factors which deny
children their childhood, or encourage culturally appro
priate modifications to house design and waste disposal.
The point is that, at least in the voluntary agency
sector, doctors have a respected position in the agencies
in which they serve and they could:
(a) Insist that a proportion of their time and autho
rity should be devoted to integrating the medical sub
system into the wider quest for power.
(b) Utilise their peripatetic work pattern and credi
bility to carry the good news of what others are doing
in other villages, and their struggles.
(c) Assemble the necessary evidence when it appears
as medical symptoms, of the systematic deprivation, ex
ploitation and harrassment from which poor suffer.
(d) Challenge rural development co-workers to spell
out clearly a strategy and method of responding to
groups of poor people in villages or areas, based on an
analysis of how the power of medicine can reinforce an
existing or potential movement towards change in the
situation of the oppressed in those areas.
Such ambitious ideas and concepts as these arc
original only in the mixture which has been prescribed.
The emphasis attached to certain words and phrases
derives from the author’s social and medical experience
with voluntary agencies in India, contrasted with
Nigeria, Ethiopia, Bangladesh, Vietnam, a poor rural
Cent- Ft- 3o0
101
.
"
8
C'- ■ ■ •••'’■
J7/’ [First f-xv. st V
Bangalore
1 ')V
UNDER THE LENS
area of America and a rich rural area of U.K. The sad
or exciting conclusion is that the endeavours of doctors
and development workers alike to assist individual poor
people are no longer relevant to a quest for “ensuring
the state of health of a target population”, i.c. the poor
as a class.
This then is the starting point: should the underlying
purpose of medical work in communities be to assist in
the removal of povetty? Poverty is not the lack of
medical services as such, but the absence of power
flowing through the veins of the poor.
102
“Because of their profit motive and monopolistic form of
competition of product differentiation through brand
names, advertising etc., these companies are primarily
interested in manufacture of fancy formulations for the
well-to-do at the expense of essential drugs for the vast
majority."
—Anant Phatlke
“Making drugs is more of a sideline now we've put
so much research into making money ...”
10
Multinationals in Indian Drug Industry
—No postive role to play
—Findings of a seminar
Anant Phadke
I was one of the participants of the Seminar— The Drug
Industry and The Indian People—held at Delhi on 7th and
Sth November 1981. It was organized by five different
organizations of scientists, medicos. Substantial amount
of concrete material was presented in this Seminar on how
the drug industry, especially the Multinationals is deceiv
ing, exploiting the people. In this article, I have tried
to present in a somewhat coherent manner, some of the
most important facts presented in different papers in this
Seminar. I have also used a couple oj other sources.
105
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I bear the responsibility of interpreting the facts and
figures. The authors of these papers or the organizers
of this seminar may not agree with my interpretation.
Monopolistic Structure
The pharmaceutical industry all over the commercial
world is controlled by a few giant corporations. “In
1974, the top 30 multinational firms accounted for 52
per cent of the total sale of pharmaceutical products in
the world. In 1973, the top 20 firms accounted for over
75 per cent of the total ethical drug sales in the U.S.A.
and the U.K. ... Individual enterprises tend to specialise
in sub-markets leading to a concentration within pro
duct classes. For instance in 1973 according to Roche’s
own estimates, their two main tranquilizer formulations
—Librium and Valium help more than a third of the
entire world tranquilizer market.”1 These giant corpo
rations can apply the latest fruits of scientific, technical
research because they have the resources to do so. They
can also set aside large sums of money to do research
for newer, better drugs. But since their primary motive
is to maximise their profits, this potential is not realized
properly. Instead, their strength is used mainly to
manipulate things to serve their narrow profit-inte
rests. This is clearly seen if we see their role in a deve
loping country like India.
The pharmaceutical industry in India has been
dominated by the giant foreign companies mentioned
above. Even after 30 years of Independence, their
domination continues. In India, “while the value of
drug production increased from Rs. 10 crores (almost
solely formulation) in 1948 to Rs. 445 crores in 1973
106
MULTINATIONALS IN INDIAN DRUG INDUSTRY
and Rs. 1376 crores (Rs. 226 crores bulk drugs and
Rs. 1150 crores formulations) in 1979-80, the share
of MNC subsidiaries and minority ventures still remains
substantial. In 1973-74, 60 firms with foreign shares
accounted for 70 per cent of the country’s total drug
sales. The remaining 30 per cent was shared by 116 large
and 2500 small manufacturing companies”2
Since
most of the research in pharmaceuticals in the com
mercial sector of the capitalist world is done by giant
multinationals and since pharmaceutical industry is
protected by patent laws, 90 per cent of patents in the
pharmaceutical industry in India are also held by these
forcign-controlled companies. What are the ill-effects of
this commercial profit-oriented, giant monopolistic
sector ? Let us know about these one by one.
Emphasis on drug formulations
Production of bulk drugs requires setting up complex
manufacturing units here in India. But foreign com
panies, which started here as marketing subsidiaries
of their giant parents, are not interested in this. They
have been forced by circumstances into manufacturing
activity. But this mainly consists of importing bulk
drugs from parent companies and merely mixing them
together in various proportions to make various formu
lations with particular brand names. In 1978-79 out of
a total production of Rs. 220 crores of bulk drugs in
India, the foreign sector accounted for 16.7 per cent,
whereas out of Rs. 1050 crores of drug formulations, it
accounted for 43.8 per cent worth of formulations.3
This affinity for formulations exists because formula
tions mean more profit. The average profitability
107
UNDER THE LENS
[pre-tax] of four foreign companies during 1974-77 was
7 per cent for bulk drugs and 21.8 per cent for formu
lations?
One of the main reasons given for allowing the
foreign companies to operate in India is that these
companies will bring their complex technology with
them and thereby help set up a modern, manufactring drug industry in India. Though this has happened
to a certain extent, the main effect has been to thwart
the development of modern drug industry in India.
Since the foreign companies are the prime movers in
the drug industry in India, Indian private companies
also indulge mainly in production of formulations. Thus
in 1978-79 these Indian companies accounted for 22.3
per cent of bulk drug production and 32.4 per cent of
formulations. The public sector however, produces
14.6 per cent of bulk drugs and only 5.7 per cent of
drug-formulations?
Social Waste
As we know, many of the formulations in the market
are useless on account of unnecessary, wrong ingre
dients, subtherapeutic dosages, wrong combinations
etc. It is estimated that “out of Rs 1260 crores worth
of drugs manufactured in our country in 1979-80,
essential and life saving drugs accounted for Rs. 350
crores only; the rest were pick-ups, tonics and formu
lations of marginal value’’0 The WHO, the Indian
Medical Association and the Hathi Committee have
recommended respectively 200, 156 and 116 essential
active substance as essential drugs. The WHO has in
addition, recommended 30 complementary drugs for
108
MULTIN/XTIONALS IN INDIAN DRUG INDUSTRY
treating rare disorders. To this list could be added a
few rational drug combinations. As opposed to these
250 (at the most) drugs, in India, about 15000 formula
tions are being marketed under different brand names.
Most of these are repetative. An analysis of 289
manufacturing units (accounting for over 85 percent of
drug-production) showed that in 1972, these units were
marketing 244 multivitamin-C preparation, 262 Vitamin
B complex tonics and 126 cough syrups.7 Since none
of them are better than any other, the main way of
selling these brands is high-pressure advertising and
marketing. This advertising pushes up the price to be
paid by the consumer. “According to one estimate, as
much as 18 per cent of turnover on an average is spent
by pharmaceutical firms on sales promotion in India”8
In case of foreign drug companies, this expense is even
more... . “In the case of 24 foreign drug companies
studied, overhead costs (including sales promotion
expenditure) amounted to 33.32 per cent during 197477 as opposed to an average of 20 per cent in other
industries.”9 These expenses are a huge social waste.
They arc however necessary for the drug companies
for competition amongst themselves.
Irrational combinations
To justify a different brand-name, drug companies many
times add some ingredients to the essential drug. Most
of the times these additions are irrational. A sub-com
mittee under the Drugs Consultative Committee stated
that of the 34 categories of fixed combinations examined,
23 categories were to be weeded out. We know many
examples of irrational combinations. But it would not
109
UNDER THE LENS
be out of place to quote a couple of scandalous com
binations. “It is well known that Analgin causes
serious blood dyscrasias as well as gastric ulcers. Phenyl
butazone and oxyphenbutazone are equally hazardous
drugs. But a combination of Analgin and phenylbuta
zone achieves a record sale of over Rs. 2 crores within
a year of its introduction... Amidopyrine is a very toxic
drug that is banned the world over; but most of our
antispasmodic combinations contain amidopyrine.10” In
1979-80 we imported 95 tonnes of Amidopyrine.11
Because of their monopoly-control, leading manufac
turers can dump these products into the consumer’s
body, doctors virtually acting as agents of these
companies.
Not for the poor
Because of the brand-names, advertising, unnecessary
ingredients and high profit-margins, most of these com
binations are too costly for the vast majority of our
population. The drugs that the poor need-drugs against
tuberculosis, leprosy etc. and also vaccines are under
produced [see Table 1 and 2] because those who
need these do not have the money to buy them. Even
amongst the Vitamins, a similar pattern is seen. Vit.
B complex preparations of various sorts consisting
mostly of irrational combinations consumed by the rich
account for 5.5 per cent of total drug production. How
ever Vit. A, the deficiency of which is extremly wide
spread (and turns 12000 children blind every year)
amongst the poor, accounts for a mere 0.3 percent of
total drug production. This is even less than the pro
duction of Vit. K and other such elements I14
110
MULTINATIONALS IN INDIAN DRUG INDUSTRY
TABLE I12
Name of the
drug
1978
installed capacity
tonnes
Production
tonnes
1.
2.
Isonex
PAS and its salts
539
94
1290
558
3.
Thiacetazonc
153
13
4.
Streptomycin
257
225
5.
Chloroquin
176
45
6.
DDS and its
derivatives
38
17
WHO recommended oral electrolyte powders are
hardly ever available in the market. The one that is
sold maximum is Electral; but it does not conform to
the WHO formula.
TABLE 2.13
Vaccine agninst
1980-81
Target
lakh doses
(estimates)
Production
lakh doses
Diphth; Pertu; Tetanus
Diphth; Tetanus
400
250
145
Tetanus
Poliomyelitis
210
60
70
Ill
120
20
UNDLR HIE LENS
As against this, the drugs consumed mainly by the
well-to-do or pushed by the doctors for their own
interests (for example-Inj. Terramycin) have been pro
duced beyond their licensed capacity. Table 3 gives
figures for Pfizer Ltd.
TABLE 3.11
Product
INH
Licensed capacity
metric tonnes.
Production
during 1979
metric tonnes
PAS and its salts
Terramycin
80
110
14
54
Protinex
1 10
2)0
52
94
“The drug firms, when they find that the profit is
less, do not use the licenses and letters of intent granted
to them. It was reported that of 32 bulk items covered
by 13 licenses, 21 items were not produced by Glaxo
Laboratories during the last five years.”’6
Very little research for the poor
Out of a total world production of drugs of 50 billion,
the developing countries in 1974 imported about 2.1
1
worth i.c. about 4.2 per cent. But out of an
cMirmtcd annual research bill of 2 billion, only 30
million i.e. 1.5 per cent was spent by the companies on
Tropical Diseases which constitute one of the most
pressing health-problems in developing countries. This
11
MULTINATIONALS IN INDIAN DRUG INDUSTRY
amount is equivalent to the “cost of building a few
miles of motorway” says WHO, and is less than one
fiftieth of the annual expenditure on cancer research.17
Whatever research that is being done by Western agen
cies on tropical diseases, takes place in developed coun
tries and is focused mainly on the problems which they
are concerned with. For example, The US Walter Reed
Army Research Institute is the only Western agency
doing systematic research on malaria. It got interested
in malaria because of U.S. involvement in Vietnam
where malaria caused more American casualties than
did the Vietcong army.13
In India, out of 45 foreign companies identified by
the Hathi committee as under the Foreign Exchange
Regulation Act (FERA), only 7 companies performed R
and D in the manufacture of basic drugs. An analysis
of 20 multinationals in India showed that during 19741975, the R & D expenditue of these firms ranged bet
ween 1.5 to 2.5 per cent of their sales turnover, whereas
their parent-companies in the West spend typically bet
ween 5 to 15 per cent of their annual turnover on R &
D 19. The Sandoz group as a whole spends nearly 9
per cent of its worldwide turnover on R & D, while its
Indian subsidiary spent only 1.4 per cent of its turnover
on R & D in 1975.20
The reason for this behaviour is simple. The multi
nationals “cannot afford” to spend on research on
drugs to be used by the poor: the poor being unable
to pay for the research through higher prices for new
drugs. This state of affairs is not going to change unless
the profit motive of the drug industry is abolished, un
less human needs take priority. Drug research is now
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no more a virgin ground. Now it costs around 50
million to develop a new drug, more so in case of tropi
cal diseases since in this field lot of ground-work needs
to be done first. The multinationals are not going to
change their research strategy unless strong public
pressure forces them to do so.
MNCs not needed in India
Even the fruits of the research done in the Western
countries do not percolate quickly through their subsi
diaries here. This has been shown by a study by B.V.
Rangarao. [see Table 4.]
TABLE 4.21
Name of drug
Year of produc
tion abroad
Year of produc
tion in India
Sulfadiazine
Sulfathiazole
Tolbutamide
Penicillin-G
Streptomycin
1940
1955
1955
1960
1955
1963
Chloramphenicol
Prednisolone
1939
1956
1941
1947
1948
1956
1957
1963
Out of 138 drugs listed as major pharmaceutical
innovations from 1950 to 1967, only 20 were being
manufactured in India in 1973. Now in the West in
spite of growing expenditure on drug research, less
114
MULTINATIONALS IN INDIAN DRUG INDUSTRY
and less new drugs are being innovated since the scope
for newer drugs is becoming less and less for the
developed societies. Thus in 1974, out of the 1500
drug patents filed in 1972, only 45 (3 per cent) were
■‘genuine new drugs,” 154 (150 per cent) were “major
modifications’ and the remaining 1305 (87 per cent)
were purely imitative.22 This means that the post
war period of explosion of new, better drugs is
over. Therefore one of the important arguments in
favour of allowing the multinationals to continue here
—‘they bring new, better drugs’—is now less valid than
it ever was.
As of today, the Indian drug industry is technically
competent to produce most of the drugs that are beingproduced here. In 1977, there were 64 foreign contro
lled firms of which only 38 produced bulk drugs num
bering 207. Out of these 207 bulk drugs, 93 were pro
duced exclusively by the foreign companies. The Indian
sector [private and public] was also producing the
rest of these 237 drugs. Out of these 93 drugs
only 29 were ‘high technology drugs,’ the produc
tion of which probably cannot be taken up by the
Indian sector because of lack of know-how.23 The
Indian sector has the technology for producing the
remaining 64 drugs currently being produced exclusively
by the foreign sector. Amongst the 29 high technology
drugs’ some may be closely related chemical analogues.
In that case, this number will go down. Further, ‘high
technology’ has become a tricky word. The committee
on High Technology constituted by the Government
has in its report [October 1979] included even the follow
ing in ‘high technology’—use of potentially explosive
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UNDER THE LENS
materials; use of toxic materials: careful on—line con
trols!24 Even in case of the drugs which cannot be
produced by the Indian sector, Indian companies can
enter into technological collaborations (as they have
been doing currently) with foreign companies. It is not
necessary to allow foreign companies to operate in
India. Thus on technological grounds it is not at all
necessary to allow foreign coinponies to operate here.
Pumping off money out of India
MNCs are not only unnecessary, but they also have dele
terious effects on our industry and the people. Some
of these have already been outlined above. In the
economic field, we find that MNCs have been pumping
off money out of India, firstly through repatriation of
profitsand secondly through a “transfer pricing.”
A case study of 42 foreign drug companies showed
that during the period 1968-69 to 1977-78, these com
panies repatriated Rs. 45.11 crores out of India in the
form of profits, dividends, royalties, office expenses
etc.25 This means that though these companies earn
huge profits by exploiting cheap labour in India, they
do not reinvest all of it here.
Repatriation of profits is only one of the mecha
nisms. The other mechanism is “transfer pricing.”
The subsidiaries of multinationals import raw materials
from parent companies at rates higher than the prices
in the international market. This raises the prices of
final products and thereby pumps off money from the
pockets of our people into the coffers of the parent
companies. A systematic study was made by Chandra
sekhar and Purkayastha to calculate the amount of
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MULTINATIONALS IN INDIAN DRUG INDUSTRY
money being transferred through this mechanism. In
the case of the 29 foreign companies for which they
could get sufficient data, they found that the outflow
through transfer pricing was an estimated 20 to 40 per
cent more than the outflow through repatriations during
1977.
A couple of individual examples will give a concrete
idea about transfer pricing. A foreign subsidiary charged
Rs. 60,000 / Kg. for dexamethasone which was later
reduced to Rs. 16000 I Kg. at the intervention of the
Controller of Imports. Gentamycin was being imported
into India by a multinational subsidiary at the rate of
Rs. 45000 / Kg. When import of some drugs was
canalised through a Gov ernment agency, the price
was lowered to Rs. 10,000 / Kg. Similarly the price
of doxycycline was brought down from Rs. 3000 to
Rs. 1500 / Kg.27
To summarise—Multinationals in Indian drug in
dustry have hardly any positive role to play. Because
of their profit motive and monopolistic form of com
petition of product differentiation through brand names,
advertising etc., these companies are primarily interested
in manufacture of fancy formulations for the well-to-do
at the expense of essential drugs for the vast majority.
For the same reasons, they are not interested in research
in areas vital for our people’s health. Their presence
in our country cannot be justified even on technological
grounds. These companies have moreover pumped out
large sums of money [out of the profits gained by ex
ploiting cheap Indian labour] into the coffers of their
parent company. In the Delhi Seminar therefore, the
following resolution was unanimously approved—“The
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UNDER THE LENS
multinational drug companies operating in India should
be nationalized. At the same time, the functioning of
the Public Sector should be improved in order to make
it truly national and truly pro-people.”
One cannot go here into the functioning of the
Indian private sector and the public sector. But even
a glance at the functioning of Indian private sector
will show that it is also dominated by monopoly profit
motives. The public sector has not reversed the basic
trends in the drug industry in India. An analysis of
the drug industry will not of course be complete with
out analysing the dynamics of the Indian sector.
All socially conscious medicos must know the dyna
mics of the Indian sector also in order to know the
important obstacles before a rational drug policy.
References
Unless otherwise stated, all papers quoted below were
presented at Delhi Seminar. Page numbers are from
the yet unpublished cyclostyled papers. Those inte
rested, should write to—Delhi Science Forum, J-55,
Saket, New Delhi-110017.
1. Kumar Nagesh and Chenoy Kamal Mitra.
MNCs in the Indian Drugs and Pharmaceutical Indus
try. pp. 6, 7.
2. Chandrasekhar C. P. and Purkayastha Prabir.
Multinational Investment, Profit Repatriation and the
Production of Drugs in India, pp. 129, 130.
3. Banerjee Naresh. Common diseases of the
Indian people and their requirements of basic and bulk
drugs: p. 12.
118
MULTINATIONALS IN INDIAN DRUG INDUSTRY
4. Average taken from Chandrasekhar, Purkayasthaop. cit. table No. 5.
5. Banerjee Naresh op. cit. p. 12.
6. Banerjee op. cit. p. 12.
7. Chandrasekhar—Purkayastha; op. cit. p. 14.
8. Kumar Nagesh and Chenoy Kamal Mitra.
MNCs In The Drugs and Pharmaceutical Industry; p. 8.
9. Chandrsekhar and Purkayastha op. cit. p. 4.
10. Majumdar J. S. Drug Industry-Instruments of
Policy; p. 10.
11. Rane W. V. and Patwardhan A. R. Priorities
In Drug Manufacture; pp. 6, 7.
12. Majumdar J. S. op. cit. p. 6.
13. Ghosh. Pattern of Diseases and The Drug Pro
duction in India, (lecture).
14. Rane and Patwardhan, op. cit. Table No. 2.
15. Majumdar J. S. op. cit; p. 7.
16. Majumdar J. S. op. cit. p. 8.
17. Anil Agarwal. Drugs and The Third World An
Earthscan document, London, August, 1978; pp. 6, 12,
13.
18. Agarwal Anil op. cit. p. 16.
19. Rao J. Manohar. A Note On Research And
Development In Private Pharmaceutical Firms In India
pp. 11.
20. Kumar Nagesh and Chenoy Kamal Mitra op. cit.
p. 3.8.
21. Rangarao B. V. Foreign Technology In Indian
Drug Industry—paper presented at the International
Seminar on Technology Transfer, New Delhi, 1973.
22. Agarwal Anil op. cit. p. 25.
23. Rao Manohar J. op. cit. 1,2.
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UNDER THE LENS
24.
25.
26.
27.
Majumdar op. cit. pp. 2,3.
Chandrasekhar and Purkayastha op. cit, p. 5.
Chandrasekhar and Purkayastha op. cit. pp. 7,8.
Kumar Nagesh and Chenoy Kamal Mitra op. cit.
pp. 16, 17.
120
“Most of the states in USA now allow substitution of
brand names by pharmacists according to an interchan
geability list prepared by the Federal Drug Authority
(FDA). Only the cheapest drug is reimbursed by the
government's social service scheme. Bioavailability pro
blems are overplayed by the companies. FDA does not
consider this to be a problem in more than 30 drugs.”
—Anil Agarwal
11
Towards a Relevant Drug Policy
Anil Agarwal
There can be no rational drug policy as long as govern
ments sec the drug issue primarily as a trade or indu
strialization issue. It is first and foremost a health issue.
In fact, when governments sec it as a health issue will
it be possible to tackle the trade and industrial aspects
of drugs in a sensible manner.
1.
Choice of Drugs
From a health point of view, some 220 generic drugs
can meet 95 per cent of the therapeutic needs of the
entire world, regardless of the level of development of
any country. For countries which want to give priority
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to primary health needs, about 100 drugs would be
adequate. Cough syrups, throat lozenges, ear drops and
nasal sprays are all inessential. Combination drugs are
generally not needed.
The size of each national list would depend to some
extent on how much foreign exchange and national
funds a nation is able to allocate to drugs.
The presence of one drug on the market or within
the medical system, when accompanied with the absence
of another, means that a deliberate choice is being made
in favour of life despite one disease and death by ano
ther. Given the socio-economic character of many
disease this means that the society is choosing to save
the member of one economic class while sacrificing
another.
No country has dared to restrict prescribing to the
small number of therapeutically essential drugs. Sri
Lanka’s attempt to restrict the number of drugs on the
market to about 600 met with stiff resistance from:
(a) the drug companies who were afraid of losing
profits, and,
(b) the medical profession which argued that its
freedom to prescribe was being restricted.
The relative success of Mozambique in restricting
the number of drugs on the market appears to have
been facilitated by the absence of a medical profession
within the country. Most doctors were Portuguese and
they left the country after liberation. The importance
of cost in prescribing is not taught to doctors cither in
the developed or in the developing world.
Even developed countries like Sweden and Norway
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TOWARDS A RELEVANT DRUG POLICY
deal with a restricted list of about 2000 drugs in their
state-run drug distribution system.
Drug MNCs are strongly opposed to the concept of
essential drugs, especially the suggestion that the con
cept is equally applicable to developed country markets
at a time when West European and North American
governments are keen to rationalise health care costs.
But drug companies quietly realise that the concept of
essential drugs, if applied only the public health sector
of the developing countries, could actually increase their
markets.
2. Choice of Names
Brand names help to keep control over the market even
when a product has lost patent protection.
Considerable research money is spent uselessly on
producing new brand products which do not. possess
any new therapeutic value. In 1972, patents were filed
in USA for 1500 drugs: 3 per cent were genuine new
drugs; 10 per cent contained major modifications, and
87 per cent were purely imitative. Generic drugs are
invariably cheaper than branded products. Therefore,
drug companies strongly oppose efforts to promote
prescribing by generic names. Attempts to introduce
generic names have failed in Pakistan and Sri Lanka
and are facing strong opposition in India. But what
these companies are really afraid of is that the idea of
prescribing by generic names will catch on in the West.
Most of the states in USA now allow substitution of
brand names by pharmacists according to an inter
changeability list prepared by the Federal Drug Autho
rity (FDA). Only the cheapest drug is reimbursed by the
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UNDER THE LENS
government’s social service scheme. Bioavailability
problems are overplayed by the companies. FDA does
not consider this to be a problem in more than 30 drugs.
Recognising the trend towards generics, the companies
have started introducing ‘branded generics’ in the US
market priced half-way between branded and generic
products.
3. Bulk Purchasing
The larger the order a customer places, the lower will
be the price offered: this is a common rule in the chemi
cal industry. Most developing countries possess small
markets compared to the total sales of the major drug
MNCs. In fact, the annual sales of companies like
Roche and Hoechst will exceed the GNPs of many deve
loping countries. This market gets further fragmented
when there are many importers of the same products,
each importing a different branded product correspond
ing to the same therapeutically equivalent generic
product.
Centralising the country's drug purchases through
international tenders after doing away with (1) brand
names and (2) private importers, can pay rich dividends.
Sri Lanka found that its drug purchase prices went
down by over 40 per cent through bulk purchasing But
there was strong opposition locally: by local subsidiries
of multinational corporations with the local medical
profession behind them. A general rule can be pro
nounced—more advanced a country in local drug pro
duction, stronger will be the opposition to bulk pur
chasing because of entrenched vested interests.
Bulk purchasing also means relying on public sector
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TOWARDS A RELEVANT DRUG POLICY
companies, which can often be inefficient, unimaginative
and lethargic, and its lackadaisical operations can get
a bad name for the concept of bulk purchasing.
4.
Indigenous Production
Focussing on essential drugs is essential. For a country
which focusses its manufacturing policy to these drugs,
the problem becomes immensely simplified.
Most of the essential drugs are old, established drugs
with patent protection having expired.
A country can begin backward integration with
formulation and packaging using imported bulk drugs.
Know-how for this stage is easily available. This alone
can cut foreign exchange, requirements by as much as
40-50 per cent of the final packaged, imported product.
But opposition can be expected from drug companies
which will control supplies of bulk drugs. However
alternatives sources of supply are available.
Production of bulk drugs is more sophisticated
technologically but sources of technical know-how are
becoming available. Many European companies know
they cannot compete with larger European MNCs in
selling drugs. So they are prepared to sell us know-how
for manufacture. To what extent drug MNCs control
supplies of raw materials required to produce bulk
drugs is not fully documented. The raw materials and
intermediates required by the drug industries are gene
rally products of the petrochemical industry. Drug
MNCs prefer to produce bulk drugs centrally in their
parent country and undertake only formulation and
packaging operations in a Third World country.
To what extent a country can force a MNC to under127
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take bulk drug production locally will depend on its
bargaining power—a combination of the level of its
political will, size of local market and knowledge of
alternate sources of know-how.
Indian government policy is focussed on foreign
drug MNCs to reduce formulation activities and in
creased bulk drug production. For this reason, drug
policy is formulated in the Ministry of Petroleum and
Chemicals rather than the Ministry of Health. It must
be remembered that local production per se will not
ensure that the poor majority will have access to drugs.
Local production is basically an industrialization issue
and nationalization of the drug industry is an emotive
issue. From a health point of view, it is important but
not of primary importance. Local drug companies do
not behave much better, especially local private com
panies. Local production of drugs must fit into an
overall policy of drugs from a health point of view to
make it meaningful—and, I will further argue, even
possible.
5.
What to do when funds arc inadequate
Rationalisation of pharmaceutical production, purchase
and consumption may be able to lower drug prices but
to meet the full needs of the people, both health and
drug expenditures must increase. For many decades,
therefore, modern pharmaceuticals will be in short
supply and their cost beyond the purchasing power of
the majority of the people. A large portion of medicinal
needs at the primary health care level can be met
through herbs—especially herbs which can be grown
simply and easily by every family.
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TOWARDS A. RELEVANT DRUG POLICY
This strategy can reduce the need for modern
pharmaceuticals for trivial reasons, even without the
effectiveness of these herbs having been proved in
modern scientific terms.
Every culture has its Pandora’s box of medicinal
herbs and practices. These ought to be studied and
spread amongst the people in an organised manner.
Often demystification is required even with medicinal
herbs. Vietnam and China testify to the success of this
strategy, especially the former.
In brief, the concepts of essential drugs, generic pres
cribing, bulk purchasing, local production of pharma
ceuticals and use of herbs, are all measures aimed at
reducing costs of medicines on the market; ensuring
that important medicines arc available on the market;
and, making the best medical use of the available
financial resources to meet the curative needs of the
maximum number of people. Each measure comple
ments the other and taken in isolation will probably not
turn out to be fully effective.
The Action Areas.
What are the Obstacles?
Drug MNCs and doctors are more interested in making
quick profits than meeting the health needs of the
people. This is at the root of the current irrational and
unsafe therapeutics.
Controlling drug companies poses few problems if
we can get.
(i) a less indifferent government; and,
(ii) a medical profession that wants to be more
scientific and socially conscious about its prac
tice of medicine.
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UNDER THE LENS
One rationale for the existence of the physician is to
safeguard the ill man against wrong use of medicine.
But unfortunately the physician himself has become the
long arm of the drug companies, pushing (both safe and
unsafe) pills unnecessarily to make quick profits himself.
To get rational therapeutics practised, the medical pro
fession must be re-educated. This will not be an easy
task given the power of the medical profession.
Therefore, simultaneous efforts must be made to
make the consumers of medicine better informed and
demystify medicine; and, to inform them, about the
irrationality in current therapeutics.
Role of Voluntary Groups
We can expect both the drug industry and the medical
profession to fight this.
The role of voluntary groups like MFC which arc
trying to create a greater understanding within the
medical profession of its social responsibility is vital.
Every doctor must be made conscious of the cost of
medicines; in fact, of the cost of health services itself.
This will lead far more to rational therapeutics than
simple criticisms of drug companies and demands for
their control. I am not even sure that this is even a
necessary condition. I remain convinced with all the
evidence available uptil now, that a responsible medical
profession is both a ‘necessary and sufficient’ condition
for getting rational and relevant therapeutics. This is a
matter of national action. Many Western and inter
national groups, unfortunately, find themselves irrele
vant for this role. Their programmes are generally
restricted to campaigns against the marketing operations
130
TOWARDS A RELEVANT DRUG POLICY
of multinational companies. The information they
generate will be a big help for national action, but it
cannot become a substitute for national action. What can
we do to make the public more aware of the depred
ations of doctors and drug companies? The following
action points have been prepared by Dr. R.K. Anand
of the Consumer Guidance Society of India and deserve
our strong consideration.
1. Action at the government level:
The Drug Controller’s office for instance is a small
one and remains starved of information. Though this
may be a reflection of the importance that the
government attaches to such problems, providing
information about harmful drugs to such government
agencies can hopefully get the official machinery
moving.
2. Action at the international level:
This can be done through UN agencies and inter
national voluntary associations like Health Action
International.
The success of the campaign against bottlefeeding
shows the results that can be obtained through
coordinated international efforts.
3. Coordination and information exchange with natio
nal health action groups.
4. Campaigns to change the medical education curri
culum.
5. Information Dissemination to Pharmacology Depart
ments of Medical Colleges.
6. Setting up an information dissemination system for
doctors—Bad prescribing practices amongst some
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doctors may be simply because of ignorance, because
of lack of access to adequate and relevant infor
mation. With some doctors they may be because of
both ignorance and laziness, that is, they do have
access to good information sources but do not care
to read them; with some others, they may be because
of utter callousness, because this is the best way to
make quick money. A good information system for
doctors would at least help those who want to help
themselves.
Unfortunately all the information that doctors today
get about drugs comes through industry and is commer
cially based. This, in fact, makes the practice of medi
cine very unscientific today.
But this problem can be solved. We can regularly
collect information about drugs from standard text
books and regulatory agencies like the FDA in USA,
from UK France etc. (where this information is readily
available) and provide it regularly to our doctors.
Doctors’ associations can collect this information and
circulate it to their members. Doctors owe it to their
patients. Yet why don’t they do it? The cost would be
peanuts. This is a question to ponder. (A beginning has
been made by the Drugs Bulletin and Pune Journal of
Continuing Health Education. Ed). It is however impor
tant to note that simply providing better information
v/ill not bring enough medicine to all the people.
7. Involve medical students in discussions on rational
therapeutics.
8. Educate consumers of medicine (i.e. lay people)
Educating them about the practice and practitioners
of medicine, that is, attempt to demystify medicine.
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TOWARDS A RELEVANT DRUG POLICY
The media can be used for this purpose and from al\
indications it is prepared to take a keen interest in
such efforts. But these efforts will certainly be oppos
ed by the medical profession and the drug compa
nies.
9. Spread the idea of social responsibility by question
ing existing values:
The practice of medicine and sales of drugs are there
to meet the health needs of the people, not to make
quick profits. Can health really grow in a society
where the basic motivating force even behind the
health industry is profits?
(Extracted from the Talk Delivered by Anil Agarwal
at the VUIth Annual meet of Medico Friend Circle, at
Tara, January 24, 1982).
Banning harmful, non-essential drugs in Bangladesh
MFC Resolution
On 7th June 1982, on the recommendation of an expert
advisory committee, (of which Zafrullah Chowdhury of
the Gonoshasthaya Kendra was a member,) the Govern
ment of Bangladesh decided to ban 1707 non-essential
or harmful drugs being marketed in Bangladesh. The
expert committee had recommended 16 criteria for
weeding out such drugs. In brief these criteria were
—(1) Combination of an antibiotic with another anti
biotic or steroids: liquid preparations of antibiotics
harmful to children (e. g. Tetracycline). (2) Combina
tion of one analgesic with another, or with any other
drugs. (3) Use of codeine in any combination form.
(4) Combination drugs in general, 'except eye, skin,
133
for tb» tAMoni. Vol, V, No. 6. VMM Intfa. Dec. 1973
12
towards a relevant drug policy
respiratory preparations, co-trimexazole, Oral Rehy
dration salt, antimalarial, iron-folic acid, Vit. B’
complex (eight in all) (5) Combination of vitamins with
minerals, glycerophosphates liquid preparations except
paediatric ones (6) Cough mixtures, throat lozenges,
gripe-water, alkalis etc. (7) Over-the-counter tonics,
enzymes, “restorative” products etc. (8) drugs only
with a slight difference in composition from others (9)
products of doubtful little, or no therapeutic value and
rather, sometimes harmful, and are subject to misuse.
(10) All prescription chemicals and galenical prepara
tions not included in the later editions of B. P. or BPC.
Other six criteria relate to the selection of drugs
to be manufactured by a foreign company. These
criteria allow a foreign company to manufacture only
those drugs which require high technology and which
cannot be produced in sufficient quantity by the national
companies.
Multinational drug companies and the American
Govt, is putting pressure on the Bangladesh govt, to
“reconsider the new national drug policy.” The MNCs
who control 80% of the drug sales in Bangladesh fear
that other developing countries may follow Bangla
desh’s example and jeopardise their 30 million dollar
market. The Bangladesh drug industry and the whole
of its economy is dependent to a great extent (unlike
India) on American loans and investments. It will be
very difficult for Bangladesh Govt, to resist the
pressure of the American lobby. A number of voluntary
groups like Health Action International, International
Organization of Consumer’s Union, Penang, War On
Want, OXFAM, U.K., Public Citizens Health Group
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USA etc. have supported the ban and condemned the
MNCs for their tactics. We passed a resolution con
demning the tactics of the MNCs and the American
Govt. It was decided to launch an educational cam
paign about the ban-order and its aftermath. [On 7th
September the Bangladesh Govt, announced some con
cessions to the drug companies. These include re
moval of 41 drugs from the list of 237 harmful drugs.]
136
But there are indirect means to judge that doctors do
overshoot. Indian literature in this regard is scarce. How
ever there are studies available where the prescriber is
informed in advance that hisI her prescription will be
screened for appropriateness of the drug prescribed or
helshe is asked to fill up a form justifying the use of
antibiotics.
—Ulhas Jaju
12
Misuse of Antibiotics and Antimicrobials
Ulhas Jaju
A medical practitioner slowly realises with time that
there arc really few diseases where allopathy can offer
a cure. Infective illnesses is one such area. ‘Antibiotic’
is the greatest tool that modern medicine offers today
against bacterial infections. However, it is a doubleedged sword, if not utilised properly it not only harms
the patient but also has wide ranging social implica
tions, evidence of which is ample in the medical lite
rature.
Will you call this misuse?
Antibiotics account for 20% of drug sale in India (1976
figures). Many times it is difficult to prove that drugs
139
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are being misused or irrationally used, because in majo
rity of prescriptions, the doctor hardly ever writes the
diagnosis. Even from the hospital records it is difficult
to conclude correctly because written documents do not
mention all that is in the mind of a treating doctor (It
speaks of our recording quality.), say for example:
(i) A critically ill patient of meningo-enccphalitis
where diagnosis is uncertain, use of Inj Chloromycetin,
Inj. Chloroquin, Inj. S/M, INH can be justified to cover
up enteric encephalopathy, cerebral malaria, tubercular
encephalitis and pyogenic meningitis. It is a shot-gun
therapy, but is justified if one takes into consideration
the seriousness of the illness and non-availability of
investigational support.
(ii) A child with upper respiratory infection may
have conducted throat sounds in chest which arc
wrongly interpreted as crepitations and thus patient is
thought to have bronchopneumonia. Use of antibiotics
now is perfectly justified. It may be a serious mistake
on the part of the treating doctor that he did not exa
mine after the child is made to cough, but it is a part
of the game which has to be conceded.
(iii) A child with severe diarrhoea is treated with a
combination of anti-protozoal (Metronidazole) and
antibiotics to cover up a wide range of diarrhoeal
diseases in a setting where examination facility is not
available. This may also be justified if one keeps in
mind that the doctor will not like to delay the treat
ment and risk the child’s life.
(iv) If patient with fever of more than 7 days dura
tion who cannot afford to get his blood investigations
140
MISUSE OF ANTIBIOTICS AND ANTIMICROBIALS
(Widal, blood culture, peripheral smear for parasites)
is put on Trimethoprim+sulpha combination to cover
up resistant malaria, resistant typhoid fever, and gram
negative septicaemia, this may be justified.
It all means, that the prescriptions may vary consi
derably in the same patient in different settings. The
budget of the patient, availability of investigative pro
cedures, error on the part of the doctor all have their
say. Therefore it is difficult to rationally analyse some
one clse’s prescription without knowing the situation
in detail.
But there are indirect means to judge that doctors
do overshoot. Indian literature in this regard is scarce.
However there are studies available where the prescriber
is informed in advance that his/her prescription will be
screened for appropriateness of the drug prescribed or
he/she is asked to fill up a form justifying the use of
antibiotics. These trials have shown decreasing trends
in antibiotic use up to 25% (1-5). In other studies
where physicians have been made to write the diagnosis
over the prescription, it was found that antibiotics were
prescribed without any evidence of infection in as many
as 62%—90% prescriptions.0 Thus there is no doubt
that antibiotics arc improperly used.
How are antibiotics improperly used?
(A) Used when not indicated,
(i) For common cold and all upper respiratory illnesses
which are in majority self limiting viral infections. It
is estimated that as many as 12% prescriptions of
antibiotics are given for common cold?
141
UNDER THE LENS
(ii) For acute diarrhoea in children without any
evidence of dysentry, severe malnutrition, septicaemia.
(iii) For viral infections without any evidence of
bacterial superinfection.
(B) Used when contraindicated
(i) A patient of chronic renal failure gets sulpha
drugs, tetracycline, aminoglycosides (Nephrotoxic).
(ii) A new born infant gets Chloromycetin (grey-baby
syndrome).
(iii) A diabetic patient gets sulpha drug like trime
thoprim-}-sulpha combination (Papillitis Necroticans).
(iv) Inj. streptomycin in a patient of ear-disease
(ototoxicity).
(C) Irrational combination
(i) Penicillin with tetracycline or Chloromycetin (See
appendix).
(ii) Gentamycin-PKanamycin (two drugs of the same
group).
(D) Improper selection of drug
(i) Use of Ampicillin because organisms are thought
to be resistant to penicillin (Ampicillin docs not act
against penicillase producing organisms).
(ii) Demeclocyclin is used when other tetracyclines
which have less toxicity and equal effectivity arc
available.
(iii) Erythromycin Esteolate (hepatotoxic) is used
when one other salt of erythromycin (erythromycin
ethylsuccinate) which is less toxic and equally effective
is available.
(iv) Use of penicillin G when more acid stable pre
142
MISUSE OF ANTIBIOTICS AND ANTIMICROBIALS
pation (Penicillin V) is available.
(v) Routine use of Inj. streptopenicillin for bacterial
infection. Tuberculosis being so rampant and strepto
mycin being one of the cheap primary line of drugs,
routine use of this combination is not justified if one
keeps in mind the drug resistant tuberculous infection.
(vi) Use of Rifampicin+Pyrazinamidc+INH in a
case of defaulter of tuberculous treatment who has
turned up for the first time to the hospital. Majority of
these patients still respond to primary drugs,9 and in
our setting shift to costly drugs of secondary line is not
justified.
(vii) Use of Chloromycetin ear drops which contain
propylene glycol as preservative which irritates the ear.
(viii) Using chloromycetin+streptomycetin combi
nation orally for cases of acute diarrhoea (streptomycin
need not be given in short-lasting bacterial diarrhoea.
The common organisms arc not sensitive to this drug.)
(E) Defective route of administration
(i) Use of Injection Chloromycetin when patient can
be given oral drug. (Injectable drug has erratic absorp
tion).
(F) Inadequate doses
(i) Doctor prescribes dose for inadequate duration (ii)
The patient does not have enough money to buy the
total course of antibiotics, thus either reduces the dose
or the duration. The notorious drug misused by doctors
is injection terramycin which is available in a concen
tration of 50mg/ml. For adequate dose, 5 cc of this oily
preparation has to be given to an adult which is so
painful that probably patient will not come back. The
143
UNDER THE LENS
most convenient way is to reduce the dose. (125 mg/ml.
concentration is not generally available). It serves two
purposes; one it reduces cost to the doctor and second
it continues to give satisfaction to the patient of getting
a coloured injection.
What are the harmful effects?
(i) Adverse reactions
(ii) High cost of the prescription (See appendix)
(iii) Resistant bacterial infection.
Gene mutation destroys affinity to larger site for
the antibiotics or modifies permeability of the cell so
that antibiotics cannot enter the cell and find its target
site. This is the mechanism for development of resis
tance. However the problem of drug resistance does
not remain limited to the patient. Drug resistance in
an infectious organism can be transmitted to other
sensitive organism of the same or different species
through so-called ‘‘Resistant Factor”. This drug resis
tance is due to ability of the bacteria to modify the
antibiotics with the help of certain enzymes that they
can produce. The modified antibiotics cannot recognise
their cellular target and therefore have no inhibitory
effect on the cell.
To make things worse, this transmissible resistance
is against a series of drugs (multiple drug resistance).
The fact that R factors can be transferred to every
genus of enterobacteriasae through non-pathogenic
bacteria like E coli (normal inhabitants of intestine)
has become a major public health problem. If a person
harbours E coli with R—factor in the intestinal tract,
they can turn sensitive pathogenic organisms like
144
MISUSE OF ANTIBIOTICS AND ANTIMICROBIALS
shigella, salmonella, V. Cholera to resistant ones. If
this continues further, we may reach a situation when
the future of chemotherapy can become bleak.
Evidences for this type of resistance in the Indian
situation arc many.7 Studies done on healthy subjects
who had not consumed any antibiotics for atleast one
month showed 28% of them harboured multiple drug
resistant strains of E. coli and much lower (6%) inci
dence of multiple drug resistant strains among indivi
duals of nearby village. The resistance was predomin
antly for drugs like Sulfonamide, Streptomycin, chlo
ramphenicol, ampicillin, kanamycin, and tetracycline
which are most commonly used antibiotics. Resis
tance to newer drugs like gcntamycin and trimethoprim
has also emerged.
Why arc antibiotics misused?
The possible reasons could be:—
(i) Poverty of knowledge of the prcscribcr
(ii) Shot-gun therapy
(iii) Antibiotics are prescribed also by doctors from
other disciplines of medicine such as Ayurveda,
Homeopathy, Unani etc. i.c. those who are not
qualified allopathic practitioners.
(iv) Persuasive sales promotion by pharmaceuticals
which are often the only source of knowledge for
a busy practitioner.
(v) Easy availability of these drugs over the counter
to the public who quite often practice self-medi
cation.
(vi) Absence of cross-checks on the prescribing habits
of the doctors.
145
UNDER THE LENS
(vii) Consumer is unaware of the harm that mis-use of
antibiotics can inflict.
Is there a solution to the problem ?
— Refresher course for doctors on indication of anti
biotics in infective disorders?
— Availability of antibiotics only on prescription from
qualified allopathic doctors?
— A mandatory justification by a doctor for the pre
scription of antibiotics?
— Abolition of different brand names and insistence on
generic name?
— Mass education of the “Consumers” about the indi
cations of antibiotic use in common infective
illnesses?
I personally feel that the last option will be most
effective, if one keeps in mind that antibiotic misuse
involves vested interests of both doctors and drug
industry.
References
I. JAMA 2585: 242, 1979.
2. JAMA 242: 1981, 1979 237: 2819, 1977; 227: 1023,
1974, 227: 1048, 1974,
3. Annals of Int. Med. 76: 537, 1972; 79: 55, 1973.
4. Med Assoc. J. 116: 253, 1977.
5. Lancet: 2: 407, 1981; 2,461: 1981; 2: 349, 1981.
6. JAMA. 213: 264, 1970.
7. Science Today: Sept. 1981 page 26.
8. Insult or Injury 1979, published by Social Audit,
Charles Medawar p. 123.
146
MISUSE OF ANTIBIOTICS AND ANTIMICROBIALS
9. WHO Expert Committee on Tuberculosis—No. 552,
p. 21.
10. Ann. of Int. Med. 128: 623, 1971.
11. The pharmacological basis of therapeutics, 5th
edition, by Goodman and Gilman.
Appendix
Cost of Commonly used antibiotics
Sr.
Drug
1. Sulphadiazinc
(M & B)
2. Penicillin-V
(M & B)
3. Tetracycline
(Paran)
4. Chloramphenicol
5. Septran
(Bruxwcll)
6. Inj. Gcntamycin
(Lyka)—80 mg.
7. Kanamycin—Igm
8. Amoxycillin
9. Doxycyclin
(US ViO-lOOmg
Dose
per tabj Total
cciplinj. cost
cost
Rs.
2 tabs 3 times
0.30
9.00
x 5 days
130mg 6 hrly. x 0.48
9.60
5 days
0.34
500 mg 6 hrly.
13.60
X 5 days
500 mg 6 hrly.
0.31
12.40
x 5 days
2 tabs, twice
1.00 20.00
a day X 5 days
40 mg 8 hrly.
10.20 76.50
x 5 days
1.5 gm total
15.75 133.00
X 5 days
1 tab. 3 times
1.70 25. .‘0
a day X 5 days
2 stat; 1 O.D.
1.80
10.80
x 4 days.
147
13
Treatment of Acute Diarrhoea
in Children
M.C. Stcinhoff
Diarrhoea is the excessive loss of fluid and electro
lytes in stool and its treatment can be conceived as two
fold:
(I) replacement of lost fluids and electrolytes—
rehydration and
(2) reduction of further losses of stool—anti-diarr
hoeal therapy.
The first goal or rehydration with oral rehydration
solutions (ORS) and parenteral fluids has been discus
sed previously (MFC Bull. 47-48.)
149
UNDER THE LENS
Antimicrobials—very limited role
This discussion is concerned with the many antidiarrhoeal preparations available in this country, usually
advertised as infallible, suitable for all diarrhoeas and
of low toxicity. Since most acute diarhoeal diseases arc
both self-limited and short-lived, well designed double
blind and placebo controlled studies in which stool
output or duration of diarrhoea are measured and com
pared arc required to prove the efficacy of therapyTables 1 and 2 summarize selected therapeutic trials. A
plus sign in the efficacy column indicates that stool
outputs were clinically and statistically significantly
reduced.
Tabic 1 presents one classification of antidiarrhoeal
preparations, lists examples, describes efficacy as de
monstrated in therapeutic trials and lists side effects2,'1.
The secretion-reducing drugs arc potentially useful
in the secretary diarrhoeas caused by V. cholera: or
toxogenic E. coli., and are all currently experimental.
Note that only ORS has unquestioned efficacy with
low toxicity. ORS is the mainstay as it actually meets
both goals of diarrheoa treatment.
Antimicrobial therapy may also be considered anti
diarrhoeal, but since each organism must be treated
specifically, efficacy data is presented by organism in
Table 2. Viruses probably arc the most important
cause of diarrhoea in children; the organisms listed
account for a minority of cases in most locales. Anti
microbial therapy may also reduce the excretion and
spread of organisms and this is detailed as “effect on
duration of positive culture. The antimicrobials selec
150
TREATMENT OF ACUTE DIARRHOEA IN CHILDREN
ted here are those to which the listed organisms are
usually sensitive in vitro. These antimicrobial sensiti
vities vary, and local patterns of bacterial resistance
should be monitored to select effective drugs. Note
that only diarrhoea associated with Shigella,11 V cholerae, 1!,13 giardiasis11 and amoebiasis15 are unequivocally
benefitted by antimicrobial therapy. It is important to
note that six well designed trials of antimicrobials for
uncomplicated Salmonella gastroenteritis all showed no
effect of antimicrobial therapy 5-’°. Some of the more
recently discovered organisms have not yet been sub
jected to controlled therapeutic trials.
In general a child with diarrhoea should receive
ORS. Current antidiarrhoeal preparations, despite
their long history of usage are ineffective or too toxic.
Although most diarrhoea in children is infectious, the
use of antimicrobials is currently justified only in those
children who have severe cholera or shigellosis. Fortu
nately, bacillary dysentery and cholera are relatively
easy to recognize clinically. Amoebiasis and giardiasis
can be identified with simple microscopy and also res
pond to antimicrobials. Nonspecific or unidentified
diarrhoeal disease is unlikely to improve with antibiotic
therapy.
In summary, current understanding of the pathoge
nesis of diarrhoea and recent careful studies of therapy
indicate the following:
(1) ORS is safe for all children with diarrhoea.
(2) Most antidiarrhoeal preparations arc ineffective,
some, such as Lomotil, are too toxic for child-
151
TABLE 1
Antidiarrheal Therapy
Example
Efficacy
Side Effects
Absorbents (2)
Kaolin, pectin,
attapulgite, bismuth salts.
0
absorption of antibiotics
and other drugs.
Anticholinergics
Atropine, hyoscyamine
0
Salivary, ocular, and
cardiac parasy
mpatholytic effects.
Opiates (3)
Codeine, tincture of opium,
Lomotil, Immodium
±
respiratory depression,
coma, prolongation of
shigellosis
Lactobacillus (4)
Curd
0
none
Absorption-increasing oral glucose-electrolytc fluids
±
~T~
Hypernatremia possible
Secretion-decreasing
(experimental)
Aspirin,
chlorpromazine
salicylate toxicity,
hypotension,
dyskinesia
UNDER THE LENS
Type
TABLE 2
Antimicrobial Therapy
Escherichia coli
cnteropathogenic
enterotoxigenic
Salmonella spp
(5-10)
Shigella spp (11)
V. cholerate (12, 13)
giardiasis (14)
amebiasis (15)
Selected Antimicrobials.
Decreased duration,
volume of diarrhoea
Decreased
duration of
positive culture.
±
ampicillin, T/S
± ■
? +
tetracycline, T/S
?+
0
0
chloramphenicol,
ampicillin
neomycin, amoxycillin
++
T/S, nalidixic acid
++
tetracycline, T/S
H—r
++
++
metronidazole
++
metronidazole
++
++
? = controlled studies have not been done in children
T/S = trimethoprim-sulfamethoxazolc
TREATMENT OF ACUTE DIARRHOEA IN CHILDREN
Organism
(reference)
UNDER THE LENS
(3) Only cholera, shigellosis, giardiasis and amocbiasis should be treated with antimicrobials.
The clinician’s problem is that he/she cannot know
the etiology of every case of diarrhoea, making thera
peutic choice difficult. I think this difficulty can be
cased somewhat by realizing that only a minority of
cases will be benefited by antibiotics. Therefore, the
clinician should use antibiotics only in those severe
cases which have a high probability of being caused by
one of the four organisms mentioned above. Thus no
mild case should receive antibiotics. Cases of very
frequent watery stools with vomiting which may be
cholera should be presumptively treated. Incidence of
cholera varies across this country and local patterns
will help a decision about cholera. (We at Vellore get
it in sporadic outbreaks). Severe bloody dysentery
with tenesmus and fever is probably shigellosis, and
should also be treated (Local patterns vary for dysen
tery also, amoeba are rare in Vellore). Chronic diarr
hoea may be giardiasis or amoebiasis and should also
be treated. These rules lead to the presumptive treat
ment of only a minority of diarrhoea cases.
References
1.
2.
WHO: A manual for the treatment of acute diarr
hoea. World health organization (WHO/CDD/Ser/
80.2) Geneva, 1980.
Portnoy BL, Du Pont HL, Pruitt D, et al: Antidiarrhoeal agents in the treatment of acute diarr
hoea in children.
J. Am. Med. Ass. 236: 844-846, 1976.
154
TREATMENT OF ACUTE DIARRHOE/X IN CHILDREN
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Du Pont HL, Hornick R; Adverse effects of
Lomotil therapy in Shigellosis. J.Am. Med. Ass.
226: 1525-1528, 1973.
Pearce JL, Hamiltion JR: Controlled trial of orally
administered lactobacilli in acute infantile diarr
hoea. J. Pediat. 84: 261-262, 1974.
Mac Donald WB, Friday, F, McEacharn M: The
effect ofchloramphenicol in salmonella enteritis of
infancy. Arch. Dis. Child 29: 238-241, 1954.
Petterson T, Klemola E. Wager O: Treatment of
acute cases of Salmonella infection with ampicillin
and neomycin. Acta. Med. Scand. 175: 185-190,
1964.
Effect of neomycin in non-invasivc Salmonella
infection of the GI tract. Lancet 2: 1159-1161,
1970.
Kazemi M, Gumpert TG, Mark MI: A controlled
trial of Sulfatrimethoprim, ampicillin and no
therapy for salmonella gastroenteritis. J. Pediatr.
86: 646-650, 1973.
Olarte DG, Trujillo SH, Agcndelo ON, et al: Treat
ment of diarrhoea in malnourished infants and
children. Am. J. Dis child. 127: 379-388, 1974.
Nelson JD, Kusmiesz H, Jackson LH, et al Treat
ment of Salmonella gastroenteritis with ampicillin,
amoxicillin, or placebo, Pediatrics. 65: 1125-1130,
1980.
Nelson JD, Kusmiesz H, Jackson LH, et al: Com
parison of trimethoprim—sulfamethoxazole and
ampicillin therapy for shigellosis in ambulatory
patients. J. Pediatr. 89:491-493, 1976.
Lindcnbaum J, Greenough WB. Islam. MR: Anti-
155
UNDER THE LENS
13.
14.
15.
biotic therapy of cholera in children. Bull WHO
37: 529-538, 1967.
De S, Chauduri A, Duta D, ct al; Doxycyline in
the treatment of cholera. Bull WHO 54:177-179,
1976.
Livi GC, de Avila CA, Neto VA: Efficacy of vari
ous drugs for treatment of giardiasis. Am.J. Trop.
Med. Hyg. 26: 564-565, 1977.
Rubidge CJ, Scragg JN, Powell SJ: Treatment of
children with acute amoebic dysentery. Arch Dis
Child 45: 196-197, 1970.
156
Cough sedatives and expectorant mixtures are probably
the most commonly prescribed preparations along with
tonics, and the sale of these forms the butter on the bread
of quite a few pharmaceutical firms.
—Sanjiv Cbugh
14
In Search of Appropriate Medicine
Cough Mixtures
Sanjiv Chugh
Cough sedatives and expectorant mixtures arc probably
the most commonly prescribed preparations along with
tonics, and the sale of these forms the butter on the
bread of quite a few pharmaceutical firms. This study
was prompted by our need for a cheap and effective
anti-tussive.
Indications for cough suppressants
Cough is a protective reflex which helps to expel irritant
matter from the respiratory tract. Indiscriminate arrest
of cough is not desirable. If the cough is due to the
159
under tut. lens
centre being too hypersensitive to reflex irritation from
the upper respiratory tract (larynx and above) and
where cough is of unproductive nature central depres
sants like opiates arc indicated. In children sedation at
night is more effective.
Utility of cough expectorants
Expectorants are used in the treatment of cough due to
irritation of the respiratory mucosa below the epiglottis
and respiratory conditions in which the secretion is
thick and viscid needing liquifaction. Commonly used
expectorants (Ammonium chloride, iodide, Ipecacunha)
are supposed to stimulate output of respiratory tract
fluid reflexly through irritation of gastric mucosa. For
this, simple steam inhalation is a much better, effective
and reliable therapy.
It must be remembered that except for dextrome
thorphan and codeine (centrally-acting cough suppres
sants) experimental proof of effectivity of other drugs
used in cough mixtures is totally lacking and the ratio
nale for their use can be debated.
With these facts in mind, we evaluated most of the
cough mixtures available in the market today and found
out some interesting facts.
(I) Most of the proprietary preparations available
as cough remedies generally contain a central cough
suppressant, an expectorant, an antihistaminic and a
brochodilator in pleasantly flavoured syrupy base. Com
bining the therapeutically incompatible cough suppres
sants and expectorants cannot be justified except for the
fact that it enables the pharmacy to sell their product
with a good margin of profit (cough sedative is costly
160
IN SEARCH OF APPROPRIATE MEDICINE
due to condeine content), when sold as a cough remedy.
it is interesting to note that a pure cough expectorant is
not cheaper than a pure cough sedative or cough sed
ative-expectorant mixture. It is also interesting to note
that the cough mixtures available in bulk (5 litre Jar)
are only cough expectorants and these are the pre
parations dispensed by a private practitioner as a cough
remedy in all cases of cough irrespective of their site of
irritation (even if the site is above the glottis).
(2) The average daily cost of taking a cough remedy
is:
Cough sedative-expectorant— 1.50 to 2.25 Rs./day
(40 ml. syrup)
Pure cough sedative—
about 1.10 Rs./day
Pure cough expectorant—
1.25 to 2.25 Rs./day
(40 ml. syrup)
Note:—The cost of cough mixtures with same in
gredients varies as much as 50%.
(3) Many available commercial preparations contain
drugs in either inadequate or excessive doses and some
of them contain drugs which are outdated and no
longer recommended.
These observations prompted us to evolve a sedative
mixture and an expectorant mixture containing only the
required drugs in adequate dose in a palatable base and
which would be reasonable priced. As we have no access
to the required drugs in their powder from which arc
available only in bulk, we arrived at approximate cost
by using tablets available in the market, so that cost
computed by us is necessarily higher than it would be
for the drug companies who buy the drugs in bulk in
161
UNDER THE LENS
their powder form. Still a difference can be made out
between the market price of commercial preparations
and the cost of the mixtures as prepared by us using
tablets bought in retail.
How to prepare cough mixture:
(1) Cough sedative
(i) Crush and make into powder
(a) 10 tablets of codeine phosphate
(100 ml.)
(10 mg.—6 paise each)
+ (b) 5 tablets of ephedrine HCI
(30 mg.—1.5 paise each)
+ (c) 5 tablets of chlorphcneramine maleate
(4 mg.—2 paise each)
(ii) Dissolve the powder in warm water and filter.
(iii) Dissolve 6 heaped tcaspoonsful of sugar
(66 gms. 20 paise)
in A cup of boiling water and add 1 drop of
pineapple flavour.
(iv) Add 0.5 gm (flat teaspoonful) of Na benzoate as
preservative to the filtrate and mix well with sugar
solution to make it 100 cc. total.
(1 teaspoonful flat=2.2 gms.)
Dose: 10 mI/6 hrly for adult
5 ml/6 hrly for children
Cost 56 paise per day.
(2) Cough Expectorant (100 ml.)
(i) Crush and make into powder.
(a) 5 tablets of chlorpheniramine maleate
(4 mg.—2 paise each)
162
IN SEARCH OE APPROPRIATE MEDICINE
(b) 5 tablets of ephedrine HCI
(30 mg.—1.5 paise each)
(c) less than one fiat teaspoonful of ammonium
chloride
(3 gms—3 paise)
(1 TSF flat=4 gms)
(ii) Dissolve in hot water and filter.
(iii) Dissolve 6 heaped teaspoonful of sugar (60 gms—
20 paise) in } cup of boiling water to which 2
drops of pineapple flavour arc to be added.
(iv) add 500 mg (4 teaspoonful flat) of Na benzoate as
preservative to the filtrate and mix it with sugar
solution to make 100 cc
Dose: 10 ml/6 hrly/day adult.
Cost: 16 paise per day.
Remember Na benzoate is added to avoid fungus
overgrowth. Those who wish to utilise the drug within
48 hours, need not add the preservative. Please preserve
in clean container to avoid fungus overgrowth.
163
A look at any drug directory will show that there are
dozens of companies producing herbal and herboniineral
drugs.
—Kamla'S. Jaya Rao
15
“Allo-Ayurvedopathy ” A non-scientific
Hybridization
Kamala S. Jaya Rao
A look at any drug directory will show that there are
dozens of companies producing herbal and herbomineral drugs. The drugs are perhaps manufactured accord
ing to ayurvedic or other non-allopathic principles of
therapeutics. The drugs are however not marketed as
traditional pills (“goli”), lehyas or powders. They are
marketed as tablets or syrups, a common mode of
manufacture of allopathic drugs. Obviously, the manu
facturers as well as the practitioners appreciate the case
of dispensing and consuming drugs in this form.
With the wide marketing of such drugs certain dis-
165
I1 Nl>1 R I 111. LENS
lurbing trends arc becoming evident. The drugs are
generally compounded only from herbs. However, there
is a small proportion where they are being mixed up
with allopathic drugs. Examples are given in Table!.
11 is not known whether any work has been done on
either the potentiating effect or adverse effects of one
group on the other. It is not known whether the Drugs
Controller has approved of such drugs. The question
arises, is this for use by traditionalists (the term tradi
tional is used here to include all traditional systems
using herbal medicines like Ayurveda, L'nani, Siddha
etc.) or by allopaths or is it the country's idea of inte
grating allopathy with traditional systems?
Although this cannot be condoned, by itself we may
try to ignore it. (The so-called quacks are anyway using
allopathic drugs like aspirin pencillin, quinine, etc.)
More serious, in my opinion, is the fact that some of
these are being used nonchalantly by allopaths. Mostly
these are used for infective hepatitis, urinary calculi and
piles. Is it because deep-rooted within us is the “ayur
vedic” culture; is it because of the wide advertising
(eg; Vinkola-12, Liv 52, Raktadoshantak, Jammis Liver
cure) or is it because these companies also employ
persuasive medical representatives?
I have no ready statistics regarding how widely these
drugs are used by allopaths. One company, The Hima
laya Drug Company, published two journals-Capsule
and Probe. From this, one can get an idea and I there
fore, use it as an example. The drugs are used by private
practitioners, doctors in general hospitals and in teach
ing hospitals. The drugs of this company have been
used in teaching hospitals from Kashmir and Kerala, if
166
A NON-SCIENTIFIC HYBRIDIZATION
one believes reports from Capsule and Probe. The medi
cal institutions include B. J. Medical College, Pune;
Osmania Medical College, Hyderabad, Tirupati Medical
College; Bunkura M.C. Bengal; Institute of Child
Health, Madras; SMS M.C., Jaipur, to name only a few.
Hybrid Herbal drugs
TABLE 1
Name
Ingredient
1. Spasmolin
Ephedrine, Caft’cin, Tine, bellandona,
(Addco Ltd.) vasaka,
long pepper,
kantikari,
Bamanbati, Nagaswar, 7-10% alcohol
2. Vinkola—12 Ferrous salt,
Copper Sulphate,
(Standard
B-complex vitamins.
Drakshrista,
Pharma, Ltd)
alcohol 10%
3. Malaria tablets Quinine, godanti bhasma
(Baidyanath)
What if these drugs are used? Yes, what if? I gave
the composition of three drugs; these are chosen be
cause all 3 have been used on children, by allopaths
(Table 2). Do the allopaths know the theraupctic and
toxic properties of all these ingredients? The allopaths
boast of a “scientific system” of medicine. Have proper
drug evaluations been carried out on these preparations.
If not, are the allopaths who used and use these drugs
quacks or are they indifferent to what happens to their
patient?
Do we know anything about drug evaluation and
clinical trials? Are we taught these in our pharmacology
classes?
167
UNDER THE LENS
(a) How is a new drug tested (b) When it is ready
for a clinical trial (c) How is a clinical trial to be con
ducted, etc.
TABLE 2
Name
Ingredients
Achillia millefolium, Capparis spinosa, Cassia
cccidentalis, cichorium intybus, Terminalia
Arjuna, Tamarix gallica, Solanum niger,
mandur bhasma.
Bonnisan Achillea millefolium, Capp, spinosa, Cass.
occidentalis, cich. intybus, Phyllanthus embica, Tamarix gallica, Term. Chebula, Tinospora cardifolia, Tribulus ferristus, long
pepper, cardamom.
Geriforte All ingredients of liv 52 plus—
Term, chebula, asparagus ascendes, Asp.
racemosus, casesalpinia digyna, withinia
somenifera, Glycyrrhizza glabra, centella
asiatic, Mucuna pruriens, Myristica fragrans,
Eugena caryophyllata, Carum coptilicum,
berberis aristata, Eclipta alba, Argyreo
speciosa, Celastrus paniculatus, Adhatoda
vasica, long pepper, mace, Cardomum,
Shilajit, Chyavanaprash, Abrak bhasma, Loha
bhasma Jasad bhasma, Kesar, amber, makardhwaj, haldi.
Liv 52
168
A NON-SCIENTIFIC HYBRIDIZATION
One may say that herbal medicines are being used
in allopathy—for instance serpasil, digitalis, belladonna
etc. So what is the harm in using others. Firstly these
are mostly single principles isolated from herbs and
secondly, they have been tested according to principles
of pharmacology. I do not question the efficacy of the
marketed ayurvedic drugs in treatment of particular
disease. I wish to emphasize that their use by allopaths
is quackery and at best, unethical. The results of these
trials arc even published in regular medical journals!
(Pediatric Clin. India 10:157, 1975 and Indian Pediatrics
14:197, 1977),
169
“Pulse strategy, based on the responsibility of health
institutions for immunization of local children, is likely
to achieve better coverage because the vaccine is taken
to the children, rather than vice versa.
—Vineet Nayyar, L Sharda
16
Appropriate Strategy For Childhood
Immunisation in India
Adapted from a series of three articles ofT. Jacob
John and M.C. Steinhojf
Vineet Nayyar and L. Sbarada
One-sixth of the world’s children are in India. Measles,
whooping cough, poliomyelitis and other immunizable
diseases continue unabated and are the major causes of
morbidity, mortality and deformity. The current system
of vaccine delivery has not achieved adequate coverage.
Of over 20 million children born in India, only about
6 million received their first dose of DPT1, whereas
the rest (14 million = 70%) remained unprotected. These
facts necessitate a fresh look into our immunization
171
UNDER THE LENS
strategy. The techniques and tactics of immunization
developed elsewhere may not be suited for our condi
tions. Hence, there is an urgent need to evolve a stra
tegy that is approriate for our conditions.
Recent experience with small pox vaccine has taught
us some important lessons. A shift from the traditional
strategy of systematic vaccination to surveillance and
containment vaccination resulted in the eradication of
small pox2. The first step in this achievement was the
assigning of high priority to the elimination of small
pox. To proceed, therefore, with the problem at hand,
it is important to assign priorities for vaccines in order
to achieve the maximum benefits. A simple and realistic
method of doing so is suggested, using available infor
mation.
A. Priorities
The overall importance of a vaccine in a country
depends upon:
(i) The characteristics of the disease to be prevented,
including both the incidence and the sequelae.
(ii) The effectiveness of the vaccine.
(iii) The safety and relative risks of the vaccine,
Each vaccine can be evaluated thus and scores
given. Vaccines can then be arranged in the order of
priority according to the total scores. This has been
done in Tables 1 and 2.
Diseases with a higher incidence c.g. tuberculosis,
or serious consequences c.g. poliomyelitis or both e.g.
Measles and ‘whooping cough’, receive high marks.
Similarly, diptheria, tetanus, measles, small pox,
172
APPROPRIATE IMMUNISATION STRATEGY
TABLE 1
Vaccine
Diphtheria
Whooping Cough
Tetanus
Polio
T.B.
Small Pox
Measles
Typhoid
Cholera
Nee:d
Efficacy
1
3
3
4
4
0
4
2
1
4
2
4
2 or 4*
1 or 2
4
4
2
1
Safety Product of
the three
4
2
4
4
3
2
4
3
3
16
12
48
64 or 32
24 or 12
0
64
12
3
’Depending on ‘cold chain’.
TABLE 2
(1) Measles
(2) Polio
(3) Tetanus
(4) T.B.
(5) Diphtheria
(6) Whooping coug h
rubella and mumps vaccines arc very highly efficacious
with protection rates of over 95% and therefore score
4 marks for efficacy. A vaccine causing very little un
pleasant reaction, and no risk to health or life e.g.
Measles, diptheria, tetanus, and polio, get the maximum
marks for safety.
From the Tables, it would appear that measles,
173
UNDER THE LENS
polio and DPT vaccines are the most important ones
for Indian children. Therefore, it is recommended that
these three should be considered the core vaccines for
routine use. There is low priority for typhoid, mumps,
rubella, tuberculosis and cholera vaccines for routine
use, although a more efficacious tuberculosis vaccine, if
discovered, would call for a revision of priorities.
Having thus sorted out the vaccines rationally, we
are in a position now to examine current practices, and
to suggest alternatives in our immunization policy.
B Immunization Schedule
Too many conflicting and confusing schedules arc re
commended by different experts for the immunization of
our children 6 to 11. Most of them recommend measles,
poliomyelitis, diphtheria, pertussis, tetanus, BCG and
small pox, but opinions vary regarding the number
of doses and timing of these vaccines. The country
needs a single schedule reflecting national policy. The
adoption of a single, realistic and need-oriented
schedule will provide a firm framework for health care
personnel to apply a uniform policy for teaching par
ents and immunizing children.
In formulating the schedule, epidemiological, im
munological and logistical considerations are relevant.
Epidemiological information has already been utilized
in identifying the vaccines necessary for routine use.
Immunological data suggest that 5 doses of OPV arc
necessary to protect 85-90% of infants and children
from poliomyelitis in India. It is obvious that these
5 doses are necessary prior to the period of maximum
risk i.e. 7 to 12 months of age. Similarly, on immuno
174
APPROPRIATE IMMUNISATION STRATEGY
logic grounds measles vaccine should be recommended
at or after 12 months of age and not earlier. For logi
stical reasons too, 12 months appears to be a better
age than 9 months as recommended by some schedules.
Again, for logistical lessons, there is a need to minimize
the no. of visits to achieve maximum acceptance. Both
DPT and OPV should be administered together at a
single visit, starting at 1| months, so that the child is
immunized against these diseases by 6 months of age.
Most of the recommendations for booster doses arc
based on conjecture or schedules deployed by other
countries. In our communities, because of more intense
circulation of various infectious agents, it is not in
conceivable that booster doses may be unnecessary.
Specific data on the benefit of one or two booster doses
is, however, lacking.
Unfortunately, current immunization schedules do
not seem to take any of the above mentioned facts into
account, and recommend as many as 20 visits at vary
ing intervals for complete immunization. Equally dis
tressing is the fact that higher priority items like mea
sles and polio vaccines are still imported although the
manufacture of polio vaccine in India, is expected to
commence a very soon.
Presently two factors impose severe limitations on
the usefulness of a schedule as a tool to achieve syste
matic and wide coverage of immunization—
(i) Parents should be well informed about the sche
dule, and be highly motivated to bring their healthy
children for immunization to an institution usually
meant for treatment of the sick.
175
UNDER THE LENS
The institution should procure vaccines and store
them throughout the year.
Therefore, it is necessary to consider alternative,
appropriate, community-based strategies of achieving
high immunization rates. Such new strategies should
not be bound down by an inflexible immunization sche
dule, but should be free to modify it, in order to im
prove immunization coverage.
C. Community-Based Annual Pulse Immunization
Recommended here are merely the modus operandi
for the government to make available a minimum num
ber of well chosen vaccines to every child in the coun
try. This strategy is an indigenous adaptation of the
mass immunization approach in contrast to the con
ventional strategy of clinic based sporadic immuniza
tion. The latter has been successful in developed or
authoritarian and highly disciplined or small countries
but in India, it has failed to make a meaningful impact
on the incidence of any disease. On the other hand,
pulse strategy, based on the responsibility of health
institutions for immunization of local children, is likely
to achieve better coverage because the vaccine is taken
to the children, rather than vice versa.
For reasons already discussed, a national pro
gramme of routine minimum childhood immuniza
tion should choose vaccines of high priority and
established need and efficacy. The need is to protect
every child against poliomyelitis, measles, whooping
coush. diphtheria and tetanus13. It would take 5-6
doses of oral polio vaccine, one dose of measles vaccine
and 3 doses for primary plus one booster dose of DPT
176
APPROPRIATE IMMUNISATION STRATEGY
per child to achieve this. In order to give these inocu
lations in the least number of encounters between
children and health care workers the schedule has been
simplified as shown below—
Planning for the annual pulse will be done at dis
trict and local community levels. The district level
planning will include the arrangements for obtaining,
storing and delivering the necessary vaccines. A central
vaccine store will be required to store vaccines and to
dispatch them in cold boxes with ice to the peripheral
points. Other materials such as syringes would also be
managed at the district level. In addition, the organi
sation and deployment of vehicles for transport of staff,
vaccines and other materials will be managed at the
district level. By staggering the dates of immunization
in different communities, a supply of cold boxes and
syringes may be used repeatedly, making the operation
economically viable.
Under the new scheme, unnecessary storage of
costly vaccine, sometimes beyond the expiry date, under
unfavourable circumstances existing in peripheral insti
tution (e.g. PHC) would be avoided. The vaccines
would be supplied fresh and in keeping with the de
mand; wastage would be avoided. This system of dis
patch of vaccine requiremements from a central store,
eliminates the weakest link from the cold chain, and
makes materials management simpler.
Planning at the peripheral level would be done by
PHC staff, VHW and community workers, who would
arrange the time and place of vaccination, children
eligible would be transmitted by a house visit, followed
by tom-tom announcements, 2-3 days before the appoin177
UNDER THE LENS
centre mobile teams and non-governmental organizations
have found enthusiastic responses when they have taken
DPT or other vaccines.
We believe that only where the conventional clinic
based immunization is supplemented by the suggested
community-based immunization, will a more fuller
coverage be achieved.
Refereces
1. Pocket book of Health Statistics of India. Central
Bureau of Health Intelligence, Ministry of Health
and Family Welfare, New Delhi, 1979.
2. Basu RN, Jezel Z , Ward NA: The Eradication of
small-pox from India, WHO New Delhi, 1979.
3. Chaturvedi UC. Mathur A, Singh UK. et al: The
problem of paralytic poliomyelitis in the urban and
rural populations around Lucknow. India J. Hyg
81:179, 1978.
4. Ashabai PV, John TJ, Jaybai P: Infection and dis
ease in a group of South Indian families. The
incidence and severity of whooping cough. Indian
Pediatr 6:645, 1969.
5. John TJ, Joseph A, George TI ct al: Epidemiology
and prevention of measles in rural South India.
Indian J. Med. Res. 72:153; 1980.
6. Manual on Immunization. Ministry of Health and
Family Welfare, New Delhi, 1978.
7. Choudhuri P: Practitioner’s column—Immunization
in children. Indian Pediatr. 14:65, 1977.
8. Banker DD: Modern Practice—Immunization.
Popular Prakashan; Bombay, 1980.
9. Ghosh S: The Feeding and Care of Infants and
180
APPROPRIATE IMMUNISATION STRATEGY
Young Children. VHAI New Delhi, 1977.
10. Ussova, Gujral, Ossipova, Behgal H: Prophylaxis
in children and its organisation. In: Some problems
in pediatrics in India and the Soviet Union. Kaiavati Saran Children’s Hospital, New Delhi, 1971.
11. Health care of children under Five. Tata McGraw
Hill, New Delhi, 1973.
12. John TJ: Antibody response of infants in tropics
to five doses of OPV. Brit. Med. J. 1:311. 197b.
13. John TJ, Devarajan LV: Priority for measles
vaccine (Guest Editorial). Indian Padiatr. 10:57,
1973.
14. John TJ, Joseph A, Vijayarathnam P: A better
system for polio vaccination in developing count
ries. Brit Med J 281:542:81.
15. MFC Bulletin—May 1981.
181
Even with limited financial resources, proper health
measures and improved rural and female literacy are
possible and that these may aid improving child health
and child nutrition.”
—Kamla S. Jaya Rao
17
Kerala: A Health Yardstick for India
Kamala S. Jaya Rao
This is based on an article published by P.G.K. Panikar,
Institute for Development Studies, Trivandrum1. The
paper shows that judged in terms of conventional health
indices, Kerala stands out from the rest of India. The
paper tries to analyse the possible reasons for this. It
shows that ‘given proper policies and priorities, lack of
resources need not be an impediment to improvement of
health status. Following the presentation of Panikar’s
data, I have tried to analyse the nutritional status of
Kerala’s children and its role in child mortality.
The Crude Death Rate, Infant Mortality Rate (IMR)
and Toddler Mortality Rate arc considered to be im-
183
UNDER THE LENS
portant indicators of the general health status of a
community. With lack of protected water, poor sani
tation and inadequate medical care, morbidity and
mortality in rural areas are high. Therefore, the level
of health indicators of the rural population would give
a more accurate picture of the health status of a country
like India. National averages not only mask the wide
variations between states but also mask the differences
between the rural and urban population.
The Crude Death Rate in India is 16 per 1000; it
ranges from 8.5 in Kerala to 22.0 in U.P. The rate
TABLE 1
Crude Death Rates in India
Rural
Urban
Total
Kerala
Punjab
Haryana
Karnataka
Maharashtra
Gujarat
Bihar
A.P.
Tamil Nadu
Rajasthan
Assam
Orissa
M.P.
U.P.
8.6
12.2
12.9
13.4
13.7
16.0
16.0
16.9
17.0
17.3
17.7
18.4
18.6
23.0
7.4
8.9
8.5
7.7
9.2
11.4
11.2
10.5
8.7
9.1
9.7
11.3
10.9
13.5
8.5
11.5
12.2
11.8
12.3
14.8
15.5
15.8
14.5
15.8
17.0
17.9
17.5
21.8
All India
17.3
9.8
15.7
184
kerala: a health yardstick for india
among the rural population is higher, sometimes almost
twice that of the urban population (Table 1). The differ
ence is hardly much in Kerala.
IMR in India is about 120 per 1000 live births. In
Kerala it is only 64. Although this is much higher than
in developed countries, it is the lowest in India. U.P.
has the highest IMR of 179 (Table 2).
TABLE 2
Child Mortality in India (Rural)
Infant Mortality
Rate
Underfive mortality
Rate
Percent of
per 1000
Total
Deaths
Kerala
Haryana
Punjab
Maharashtra
Karnataka
Tamil Nadu
A.P.
Orissa
Assam
M.P.
Gujarat
Bihar
Rajasthan
U.P.
61.4
79.0
99.1
101.2
102.0
112.5
118.9
133.7
137.9
141.4
146.8
152.4
162.6
179.0
24.0
34.2
37.0
45.1
46.4
53.7
47.1
59.6
46.7
62.5
71.9
36.6
77.5
86.4
39.0
50.9
46.1
47.7
47.5
42.8
43.4
—
49.2
—
59.5
—
30.4
59.2
All India
138.3
61.7
53.2
185
UNDER THE LENS
The mortality rate among children under five years
is disterssingly high in India, It ranges from 24 in Kerala
to S6.4 in U.P., with a national average of 62 per 1000
(Table 2). According to Panikar, if the under-five death
rate for the whole country were to drop to 24 (the rate
in Kerala) the crude death rate will come down from 16
to 12. This argument may not be completely correct.
Though the under-five death rate is low, as can be seen
from the Table, the proportion of deaths is this age
group compared to total deaths is still very high. It
appears that the rate has fallen down because the crude
death rate has come down. If the crude death rate in the
country were to come down to 8.5, under-fivc death rate
will come down to 28 from 62. Therefore, the fall in
childhood mortality appears to be due to general im
provement of conditions. In Kerala and not particularly
due to improvement of child health.
The expectation of life at birth in India is 50 years
for males and 49 for females. In Kerala it is 61 and 62
years, respectively. Note the longer life expectancy of
females in Kerala.
Kerala is one of the economically backward states in
India (Table 3). Yet, 100% of Kerala’s total expenditure
is on medical and health services. In most other states
it is 6-8%. There are, however, some states where the
expenditure is higher, despite which mortality rates are
high. The doctor-population ratio and bed-population
ratio in Kerala arc also not the highest in the country
(Table 3).
What makes Kerala’s achievement in the health field
particularly significant is that the rural population enjoy
a much better health status than even the urban popu-
186
KERALA: A HEALTH YARDSTICK FOR INDIA
TABLE 3
Measures of Medical Facilities in India
Per
Per
Capita capita
State Expen
Domestic diture
Product on
(Rs) Health
(Rs)
Punjab
Haryana
Maharashtra
Bengal
Gujarat
Tamil Nadu
A.P.
Kerala
U.P.
Karnataka
Rajasthan
Assam
M.P.
Orissa
Bihar
1190
924
839
814
791
691
600
573
573
554
554
554
530
511
443
8.32
8.67
8.85
8.81
9.28
8.65
9.09
6.93
7.88
7.85
11.06
9.09
10.62
8.24
6.62
Popu Beds Per
lation
per cent
served 100 Hos
by one Popu pitals
doctor lation in
rural
areas
5863
—
2592
1747
4900
1988
4922
4742
7672
5300
12662
3139
21663
7008
6083
77
56
68
90
43
70'
45
92
39
85
51
44
38
38
26
10
—
4
32
22
61
26
57
35
23
39
27
28
57
27
lation in several states. Even in 1965 57% of Kerala’s
hospitals were in rural areas. In most other states this
was only 22-38% (Table 3). But, the mere presence of
hospitals in rural areas does not bring down death rates.
The proportion of rural hospitals is equally high in
187
UNDER THE LENS
Orissa and Tamil Nadu but the death rates are nearly
double.
Panikar points out the obvious—that more than the
availability of health services, it is the extent of their
utlisation that really matters. According to him the
success of Kerala is due to the fact that as much
emphasis is given to promotivc and preventive measures
(such as provision of protected water, massive compaigns against communicable diseases, public health
education using all media of mass communication, etc.)
as to curative medicine.
Good antenatal care, a high proportion of insti
tutional deliveries and infant care through home visits
by ANMs have contributed to the low maternal and
infant mortality. Other important measures arc triple
vaccination, distribution of iron-folic acid tablets to
pregnant mothers and ^ntenatal immunization against
tetanus. While the female population of Kerala is 4% of
the total population in India, maternal deaths in Kerala
account for only 1% of total maternal deaths in the
country.
Panikar argues that the health consciousness of the
public is an important factor in the utilisation of health
programmes. Kerala’s literacy rate is as high as 60%
compared to the all India average of 30%. In 11 States
it is less than 30 and in 10 others it ranges from 30-40.
Rural literacy in Kerala is 59%, in 10 States less than
25% and in 10 others between 26-32%. More significant
ly, female literacy is very high in Kerala. Rural female
literacy is 53%. In 20 States, it is less than 20%; in U.P.,
M.P., Rajasthan and Bihar it is 4-7%. Apart from
governmental efforts, the matrilinear system of inheri-
188
KERALA: A HEALTH YARDSTICK FOR INDIA
tance might have significantly aided rural female literacy
in Kerala. Panikar suggests, perhaps rightly, that the
high general literacy and.education of the females may
have contributed most to the improvement of the health
of infants and children in Kerala.
Though childhood mortality is the lowest in Kerala,
it is still very high. Also while the under-fives form
only 15% of the total population deaths in this group,
as mentioned earlier, account for nearly 40% of total
deaths. Why is child mortality still very high in a state
with an otherwise impressive health record? Two factors
mainly govern childhood mortality in developing coutrics—infections, and nutrition.
Unfortunately, I am unable to get a state-wise
break-up of the incidence of infections in Indian child
ren. I have, therefore, considered the data available for
the whole population regarding the two most common
childhood ailments, namely, diarrhoeas and respiratory
diseases. The incidence figures in Kerala are much
lower than in other States (Table 4).
When it comes to nutrition, Kerala is in very bad
shape. It has one of the lowest energy and food intakes
in the country. While the mean caloric intake of adults
in other States is 2000 or more, in Kerala it is around
1,800. Kerala also has the lowest intakes of iron, Vita
min A and Vitamin B-Complex. Consequently, the
proportion of individuals receiving adequate energy is
also the lowest in Kerala (Table 5). Only 28% of the
children have a normal growth status. Yet, surprisingly,
this figure is higher than in other states. Further, the
incidence of protein-calorie malnutrition is also lower
than in many States. Thus, though food intakes are
189
UNDER THE LENS
very low in Kerala, the growth and nutritional status
of the children is not any worse than in other States,
and perhaps even better.
TABLE 4
Deaths by Disease (Per cent of total deaths)
Diarrhoea Respira Fevers
Dysentery tory
Cholera Diseases
Total
Kerala
Gujarat
Tamil Nadu
Maharashtra
Karnataka
A.P.
U.P.
Assam
Punjab
Bihar
Haryana
M.P.
Orissa
2.2
1.6
5.0
4.4
4.1 .
4.0
5.8
12.1
1.3
3.4
1.5
5.4
7.1
9.1
4.4
8.8
15.5
9.8
7.4
11.7
10.1
12.0
2.2
14.1
11.4
2.5
9.3
24.0
22.2
16,8
27.5
30.9
25.1
26.0
50.0
57.0
57.5
56.0
64.7
20.6
30.0
36.0
36.7
41.4
42.3
42.6
48.2
63.3
62.6
73.0
72.8
74.3
All India
4.6
9.2
32.9
46.7
Note: The figures should not be taken as absolute
because errors in reporting are known. This is
only to show the trend.
190
KERALA: A HEALTH YARDSTICK FOR INDIA
TABLE 5
Nutritional Status of Children
Per cent adequate Per cent Per cent
in energy
children incidence
Adults * Children
with
of
normal
PCM
growth
Karnataka
**
Andhra Pradesh
Gujarat
Maharashtra
Tamil Nadu
Orissa
Madhya Pradesh
West Bengal
Uttar Pradesh
Kerala
75.3
69.2
62.8
61.0
55.6
52.7
50.8
50.3
50.3
10.8
63.4
33.3
53.6
35.5
41.7
—
48.0
34.4
33.0
21.9
9.9
15.3
10.1
8.9
14.9
14.5
11.7
11.0
18.8
28.0
9.2
5.1
6.1
6.8
1.4
0.9
0.5
3.7
5.0
0.7
* These figures should not be considered absolute,
since there arc some different calculations involved.
This is to show the trend.
** Data available for only these States.
How does one explain this paradox? In most States
the proportion of adults getting adequate food energy
is much higher than the proportion of children getting
enough energy (Table 5). This means that food is eaten
preferentially by adults, perhaps the wage-earners. In
Kerala, the picture is reversed showing a better distri
bution of food within the family. Perhaps, female lite
racy is again responsible for this.
191
UNDER THE LENS
It would appear that malnutrition may be greatly
responsible for the high childhood mortality in Kerala.
Kerala is a poor State with high rates of unemployment
and underemployment. Thus poverty may be the major
operative factor in the high childhood mortality. It also
appears that even in conditions of poverty, education
of the women may help in improving the nutritional
status and health of the children. Perhaps Kerala is
the right place to organise and experiment with supple
mentary feeding programmes.
In other states, apart from poverty, infections,
inadequate rural health services, ignorance, and maldis
tribution of food within the family appear also to play
important role in the high childhood mortality. The
experience of Kerala shows that even with limited
financial resources, proper health measures and im
proved rural and female literacy are possible and that
these may aid improving child health and child nutri
tion. Kerala can therefore be considered a yardstick
forjudging health status in the country.
Reference
P.G. Panikar, Economic and Political Weekly,
14:1803, 1979.
192
“Knowledge of nutrition and health can become an effec
tive tool for the economic fight by the poor. This way the
benefits to the poor and their health might be more than
through health work alone."
—Abhay Bang
18
Food Requirements as a Basis for
Minimum wages
Abhay Bang
Chetana-Vikas is organising rural labourers for their
legal right to work and for lawful wages’. During
this, we faced the question—what should be the mini
mum wages for a rural labourer? This article is the
result of an enquiry into this very important issue. The
study may appear specific to Maharashtra, but can very
well be generalised.
The prevailing minimum wages for agricultural
labourers in Maharashtra are based on the recommen
dations of a Study Committee appointed by the Govt.
of Maharashtra under the chairmanship of Mr. Page2
195
UNDER THE LENS
One finds that the Committee has made many
errors in its method to decide the wages, and these
errors form the ‘scientific’ secret of the low wages offer
ed to about six million landless labourers and an even
larger number of small farmers in rural Maharashtra
for the last many years.
What standard of life should be considered as
“minimum”, when minimum wages are decided? Any
definition of ‘Minimum standard of life’ would be
highly controversial. I shall stick to the minimum
necessities as understood by the above Committee and
to the basic method evolved by the Committee to cal
culate the cost of minimum living for deciding mini
mum wages. In this article an attempt will be made to
point out some serious errors in certain assumptions
about the food requirements used in this method, to
correct them and to calculate the corrected minimum
wages, using the same formula which the above Com
mittee has established. To make it more relevant for
the readers of MFC Bulletin, I shall elaborate only on
the nutritional aspect of my enquiry and make only
brief reference to the economic part of it.
The Mlethod Established by Page Committee
The report says, ‘Minimum wages must be in some
way related to the cost of living. The workers must be
able to meet minimum requirements of food, shelter,
clothings, medicine and education’ (page No. 118). We
should agree to this fundamental principle.
The method used by the Committee to calculate the
cost of such living is as follows:
“The wages should be fixed in quantity of one kind
196
FOOD REQUIREMENTS FOR MINIMUM WAGES
of staple grain, i.e. jowar in Maharashtra.”
“The wages should be calculated in kind first and
then converted to cash at a price at par with the sell
ing price of first quality jowar at ration shop”.
“For fixing the wages in kind, we have considered
the following factors” (page No. 106).
“An average working man requires at least 2000
to 2200 calories for which 625 gms of staple food
is a necessity. We are assuming a family of 3| units
e. husband, wife and three children. Their require
i.
ment will be 21874 gms This would be the staple food
requirement of the average family.”
“Normally, we are advised, that staple food require
ments arc 40 to 50% of the total budget. Working on
this basis of 40% which is in favour of the labourer, the
total budget would come to 5468 gms of jowar. Mak
ing some allowances for one weekly holiday, we can
safely assume that a poor worker’s family budget would
be 6000 to 6400 gms Normally 6 kgs should be earned
by 2 persons”.
“We were advised that 3 kgs can be assumed as the
daily wages in kind for an adult.”
The minimum wages and E.G.S. rates decided by
the Government of Maharashtra were based on these
recommendations. Three kg jowar was converted into
cash as Rs. 4 which thus became the minimum wages
for the rural labourer.
Errors in the Committee’s method and necessary
corrections
I. The calorie requirements'of the labourers—
The biggest mistake is to accept 2000 to 2200 calo-
197
UNDER THE LENS
ries as the calorie requirements of ‘average working
man’. This is insufficient even for a sedentary man. For
a male rural labourer it is 3900 calories/day.
The figure of 2000 to 2200 calories for working
man was based on 3 supports (personal discussion with
Mr. Page).
(i) Average of National Sample Survey for 10 years.
(ii) The poverty line accepted by Dandekar and
Rath3.
(iii) Advice by nutrition expert.
Let us examine these one by one:
1. The National Sample Survey (N.S.S.) figure is
the amount people actually purchase and consume on
an average. In India, about half of the population live
below the poverty line and don’t get enough food. It is
ridiculous to consider the average consumption of such
semistarved people as their biological requirement.
2. The poverty line defined by Dandekar and Rath3
is based on 2250 calories, average calorie consump
tion per capita per day, this being considered “nutri
tionally adequate”. Unfortunately the authors are
silent on how this figure has been considered “nutri
tionally adequate”.
Further, the food consumption figures given by
N.S.S. and the poverty line accepted by Dandekar and
Rath are the average figures of various age, sex and
occupational groups. It is well known that the calorie
requirements of different age, sex and occupational
groups grossly vary. Hence to accept such an average
as the calorie requirement of a ‘working man’, as done
by the committee, is not correct.
198
FOOD REQUIREMENTS FOR MINIMUM WAGES
3. The nutrition expert, mentioned by Mr. Page,
is actually a diabetes specialist of Bombay. There is
obviously some gross error in the ‘expert’ advice.
(Has he assumed that rural labourers need the same
amount of calories as his obese upper class diabetic?)
My conclusion is that the figure of 2200 calorics is
not applicable to the labourer.
For the purpose of minimum wages and Employ
ment Guarantee Scheme (E.G.S.) we are dealing speci
fically with manual labourers: hence the calorie require
ments of this specific group should be taken into
account and not the ‘average’.
The Indian Council of Medical Research (ICMR)
is the highest body in the field of medical research in
India. Based on WHO recommendations and scienti
fic research in India, ICMR gives us the nutritional
requirements of various age, sex and occupational
groups in India'1. These figures are accepted and
used in the medical field all over India as authentic
figures. Page Committee should use these figures,
Calorie needs of rural labourers
The ICMR Nutrition Expert Group has classified
adults in various occupations into 3 categories—seden
tary, moderate and heavy work, on the basis of their
Calorie needs. The calorie requirements are as
follows:—
Male (55 kg)
Female (45 kg)
Sedentary
2400
1900
Moderate
2800
2200
Heavy
3900
3000
In which category, should the agricultural labourers
199
UNDER THE LENS
me ask; led E.G.S. labourers be pct? This is a very
■crucial cmsum. and needs close examination.
Let nte make one observation here about the present
me cfstiemmc knowledge. In a predominantly rural
.■cumry like ours where 70% of the labour force is
engaged in agriculture! work, scientists and experts are
net •’•cry certain, about the calorie needs of the agricul
tural labourer- Not that the answer is very difficult,
er 'eeycnd scientific research. But the plain fact is
act -num pains have been taken so study this supremely
m perms r issue. There are very -* i7» studies and many
assets ire still mtans- erm. This is obviously an area
vsicii mmm urgent attention from the researchers in
:iie 5eic m nutmticn.
FA? "■■EC Committee puts many farm worItacs :n. me Ttitbemttiy active’ category. Obviously, the
iinnmimm his mechanised farm workers in mind beeaiiBr m mry active’ category are iztiuc’ed 'unskilled
iiiiuiumm
cgticu'mrai workers. seme farm wor;am e-.nenm,.;. peasant agriculture.’3 sc cur agricnl-.unti! mm.mm mi unskilled E.G.S. labourer should
conn .'nt''veti mis;’ category.
'— - ~r comma used to determine the calorie needs
n: nr' :>rmr.m'cmi group is to break into 3 equal
i,0®s e®£^1
occupational work, off-duty
v n.’t. tike bouse mid work etc. and sleep.
-it. vm;mm m calorie needs of ditiereni cccups.inu..: gr.'tns is because ot tne diffiereoce in the calorie
rnnmiitinu-e darinp the S hours of ocmapationa’l work.
-it. m.nrie expenditure for the other 16 hours is the
ra‘-’>deraie or 'heavy' occupational groups.
tie.!., v. u i.j concentrate on the rare of energy expen
200
FOOD REQUIREMENTS FOR MINIMUM WAGES
diture during occupational work.
The ‘heavy work’ taken for ICMR calculations is
one which needs 5 cal. per kg body weight per hour
while ‘moderate’
means 2.5 cal/kg./hour.c There
is evidence to prove that most of the work done by
the agricultural and E.G.S. labourers involve expendi
ture of calories either more than or equal to 5 cal/kg/
hour.
There are two authentic studies7 8 referred to
by the ICMR Nutrition Expert Group. The calories
expenditure in various types of agricultural and other
unskilled operations as found in these and some other
studies varied from 4.5—10.0 cals/hour/kg body
weight.
A question can still be raised that no labourer con
tinuously works for all the 8 hours of occupation. They
rest intermittently. Hence actual energy expenditure
in 8 hours of work might be less.
The above mentioned two studies have actually
recorded the minute-to-minute activity of the labourers
during the working hours (for 3 months in one of the
studies). Thus the relaxing intervals were also covered.
The hours spent in various types of activities were
available from this record. The energy expenditure of
the labourers during the 8 hours of work was then cal
culated on the basis of time spent and the rate of
energy expenditure in various types of activities. The
energy expenditure for 24 hours was 3,020 calories for
agricultural labourers and 3,025 for unskilled labourers.
The average body weight of the labourers (all male)
in these studies was 44 kg to 46 kg If we correct the
figures for the reference body weight (55 kg according
201
UNDER THE LENS
and unskilled E.G.S. labourars be put? This is a very
crucial question and needs close examination.
Let me make one observation here about the present
state of scientific knowledge. In a predominantly rural
country like ours where 70% of the labour force is
engaged in agricultural work, scientists and experts are
not very certain about the calorie needs of the agricul
tural labourer. Not that the answer is very difficult,
or beyond scieutific research. But the plain fact is
not much pains have been taken to study this supremely
important issue. There are very few studies and many
aspects are still unanswered. This is obviously an area
which needs urgent attention from the researchers in
the field of nutrition.
(1) FAO/WHO Committee puts many farm wor
kers in the ‘Moderately active’ category. Obviously, the
Committee has mechanised farm workers in mind be
cause in ‘very active’ category are included ‘unskilled
labourers, some agricultural workers, some farm wor
kers especially peasant agriculture,’5 so our agricul
tural labourer and unskilled E.G.S. labourer should
come in ‘very active’ category.
(2) The method used to determine the calorie needs
of any occupational group is to break into 3 equal
parts, 8 hours each of occupational work, off-duty
work like house hold work etc. and sleep.
The variation in calorie needs of different occupstional groups is because of the difference in the calorie
expenditure during the 8 hours of occupational work.
The calorie expenditure for the other 16 hours is the
same for ‘moderate’ or ‘heavy’ occupational groups.
Hence we will concentrate on the rate of energy expen-
200
FOOD REQUIREMENTS FOR MINIMUM WAGES
diture during occupational work.
The ‘heavy work’ taken for ICMR calculations is
one which needs 5 cal. per kg body weight per hour
while ‘moderate’ means 2.5 cal/kg./hour.0 There
is evidence to prove that most of the work done by
the agricultural and E.G.S. labourers involve expendi
ture of calories cither more than or equal to 5 cal/kg/
hour.
There are two authentic studies7 8 referred to
by the ICMR Nutrition Expert Group. The calories
expenditure in various types of agricultural and other
unskilled operations as found in these and some other
studies varied from 4.5—10.0 cals/hour/kg body
weight.
A question can still be raised that no labourer con
tinuously works for all the 8 hours of occupation. They
rest intermittently. Hence actual energy expenditure
in 8 hours of work might be less.
The above mentioned two studies have actually
recorded the minute-to-minute activity of the labourers
during the working hours (for 3 months in one of the
studies). Thus the relaxing intervals were also covered.
The hours spent in various types of activities were
available from this record. The energy expenditure of
the labourers during the 8 hours of work was then cal
culated on the basis of time spent and the rate of
energy expenditure in various types of activities. The
energy expenditure for 24 hours was 3,020 calories for
agricultural labourers and 3,025 for unskilled labourers.
The average body weight of the labourers (all male)
in these studies was 44 kg to 46 kg If we correct the
figures for the reference body weight (55 kg according
201
UNDER THE LENS
to ICMR) and for the faecal losses, the calorie require
ments of the male agricultural labourer will be 4150
calories and of the unskilled labourer, 3977 calories.
It is important to quote from one of the studies “How
ever it would be wrong to conclude that this is the
optimal calorie requirement of Indians engaged in
heavy activities. Such a conclusion would be permis
sible only if it is established that the activities investi
gated represent the maximal efficiency and output. It is
possible that the output of work in the subjects investi
gated in the present study might have been better, had
their calorie intake been higher’’3. In other words, even
this figure is likely to be an underestimate because it is
calorie expenditure at the present level of intake which,
because of severe economic constraints is very low and
limits maximum working capacity.
The energy requirements for males in ‘heavy work’
as advised by ICMR are 3900 calorics and those in
‘moderate work’, 2800 calories. Obviously the agricul
tural and unskilled E.G.S. labourer’s calorie needs arc
at least those of the heavy worker and not those of the
moderate worker.
2.
Calorie requirements of children
Another mistake of the Page Committee is to assume
that the calorie requirements of the family arc equival
ent to 31 units: 2 units for husband and wife, and i
unit for 3 children.
The per capita ‘average’ given by N.S.S. or Dandekar and Rath includes all the age groups. If the Com
mittee accepted that figure as the average requirement,
it should have at least used the same average figure for
202
FOOD REQUIREMENTS FOR MINIMUM WAGES
all the family members.
Further, the assumption of the Committee that the
calorie requirement of child is half of the adult is purely
a guess without any scientific support. Because of their
growing age, children require quite large number of
calories.
3. Per capita calorie
labourer’s family
requirements
of the rural
ICMR. gives calorie requirements of various age and
sex groups’. By taking into account the proportion
of various age and sex groups in the population, the
average per capita calorie requirement at the national
level was also calculated. It has been assumed that all
adults are moderate workers but we should consider
the calorie requirements of the adult working popula
tion (age group 19 to 59) as those of heavy workers.
If we do this, we get a per capita recommended
intake per day of 2560 cal. This figure is much
more scientific and true to the real needs of the
workers than the one calculated by Page Committee
“°OX3-5_1540C«l). This is also closer to the figure
5
of 2400 cal. per capita per day calculated as minimum
requirement for the rural areas by the Perspective
Planning Division of the Planning Commission of
India9.
4.
The family size of the poor
The family size taken for calculations by Page Com
mittee is 5. Assuming that the rural labourers come
from the lower 50% of the rural strata, which they
203
UNDER THE LENS
surely do, the average family size of this section of rural
population is 5.6'°.
Calorie Requirements of a labour-family
The real calorie requirements for a family of 5.6 would
be 2560x5.6 or 14336 calories/day. This corrected
figure is much higher than the one calculated by the
Page Committee (2200x3.5=7700 calories/day).
5.
The types of foods in the labourer’s diet
The next error in the Committee’s calculation is the
assumption that all the calorie requirements are met
by jowar only. The diet of any labourer should
contain:
1. Cereals and pulses.
2. Other types of foods—Fats, Jaggery, Milk, Vege
tables etc.
To calculate the staple food requirements of the
family, we must deduct the calories provided by the
other types of foods from the total.
ICMR recommendations of a balanced diet for
a ‘‘heavy work” man include milk (250 ml.) fats and
oil (65 ml) sugar (55 gm) vegetables (170 gm)4. Con
sidering that our economy to-day cannot provide all
these things in this ideal proportion, we shall for the
time being take into account how much food of this
type the poor actually eat to-day. In doing so the poor
are probably left with deficient supply of minerals and
vitamins. The rural people living at the level of poverty
line obtain 200 calories per capita per day from these
’other types of food’3. So a family of 5.6 persons
204
FOOD REQUIREMENTS FOR MINIMUM WAGES
would obtain 200X5.6=1120 calories from these foods.
The remaining calorie requirements (14336—1120=
13216) will be met through cereals and pulses. It is
necessary that the diet also provides the amount of
pulses recommended by ICMR which for a family of
5.6 works out to 280 gms per day. It must be borne in
mind here that ICMR recommendation for pulses is
with the assumption that milk is provided in the ideal
proportion. As we have not provided for these, the
requirement of pulses should be increased to cover the
proteins. Hence in our given situation, this figure of
pulses is an underestimate. It must be noted that the
ICMR has recommended that at least 25% of the total
calorics should come from non-cereal sources.
This amount of pulses will provide about 980 calo
ries per day to the family. To cover the remaining
(13216—980)= 12236 calories, the jowar required is
3500 gms (II). Thus the food requirement of the labou
rer's family are not 2.187 kg jowar as calculated by
the Committee, but 3.5 kg jowar and 0.28 kg pulses.
In calculating this, we have taken into account ICMR
recommendations for calories and pulses only. For
other types of foods in the diet, we have, for the pre
sent, accepted the existing reality and not the optimum.
6.
Other Wastages
These are requirements of a healthy population. Indi
viduals who suffer from worm infestations, diarrhoeas,
other infections may have increased food requirements.
The majority of the rural poor suffer from one or more
of these illnesses, making their real food requirements
higher. But we have no method at present to calculate
205
UNDER THE LENS
this wastage and so we shall leave it uncovered.
There are various losses between the retailer’s shop
and human consumption. FAO/WHO Committee (19)
and ICMR consider that 10% allowances should be
given for such losses20. Thus to provide 3.5 kg jowar
and 0.28 kg of pulses for actual consumption, the
purchaser must be 3.85 kg of jowar and 0.308 kg of
pulses.
7.
Provision for other necessities
The Committee has assumed that 40-50% of the family
expenses are on staple foods, and remaining on the
other necessities of life i.e. other types of foods, house,
fuel, clothing, medicine, education etc. This is well in
agreement with National Sample Survey and with
Dandekar and Rath.
Taking into account the fact that a labourer has to
earn in 6 days' amount needed for 7 days, the Page
Committee calculated the daily requirement to be 6.4
kg of jowar (This the Committee unnecessarily ‘round
ed off" to 6 kg). Using the same method but using the
daily food requirements of 3.85 kg jowar and 0.308
kg pulses the total requirement to cover the minimum
cost of living will be 11.27 kg jowar and 0.90 kg
pulses per day.
Conversion of wages into cash
Without going into the details of the errors involved in
using issue price of jowar at ration shops for convert
ing wages in kind into cash it should suffice to say that
market price of jowar should be used for conversion
because the issue price of jowar in ration shops does
8.
206
FOOD REQUIREMENTS FOR MINIMUM WAGES
not reflect the general price rise. The prevailing market
rates are:
Jowar—11.27 Kg. X 1.75 Rs. = Rs. 19.70
Pulses— 0.9 Kg. X5Rs. = Rs. 4.50
9.
Total cost of living of the family and wages
Thus the total cost of minimum living for the labourer’s
family is Rs. 19.70 + Rs. 4.50 = Rs. 24.20 per day. By
the Committee’s own guiding principles, a labourer’s
family should get this much amount as wages to cover
the minimum necessities of life.
This amount is to be earned by a couple. Assuming
equal wages are given to male and female, it should be
Rs. 12.10 per day.
10.
Earning Members
Tn the organised sector the salary of white collar
workers (Eg. Lecturers, bank employees, Govt. Officials
etc.) are so decided that one member should earn all
the family requirements. But for the rural labourer, the
Committee assumes two persons earning the family
requirements thus reducing the wages to half—to be
earned equally by male and female.
We must also remember that at present there is no
provision for the days lost due to sickness, pregnancy
and delivery.
Cost of living is the cost of production of the labourer
Thus Rs. 24.20 is the cost of minimum living for a
labourer’s family. In other words it is the cost of pro
duction of labour power i.e. the cost that a labourer
couple has to incur to produce one day’s labour-power.
207
UNDER THE LENS
Il is a widely supported principle now that the farmer
should get the cost of production for his produce.
Similarly the labourer also should get the cost of pro
duction of his labour-power.
Wage rates and justice
This rate (Rs. 12.10) may appear too high to some
people, only because we are accustomed to a very low
and unjust figure of Rs. 4.
These new wages are calculated to provide the
necessary calories and proteins (only partly) from the
cheapest sources (jowar and pulse) and to provide other
necessities of life at the present level of actual consum
ption by the poor (and not the ideal level). Hence they
are the minimum.
Four things must be borne in mind while thinking
about these rates.
(i) Rs. 24.20 per day X26 days of work per month
= Rs. 627 per month will be the income of a family of
5.6 persons i.e. Rs 112 per capita per month. This is
still within the limit of our average per capita national
income (Rs. 142 50 per capita per month)12. Our
economy can provide such wages provided the exhuberent incomes of few other people are slashed down.
This is, after all, a question of political will.
(ii) The wages for the rural labourers in Kerala,
Punjab, Haryana arc already more than Rs. 10 per day.
(iii) Minimum wage in E.G.S. are not merciful relief
or dole offered by the Government to the labourers.
This is a legal right of the labourers and a pledge and
responsibility of the Government of Maharashtra.
(iv) Many persons argue, “but labourers don’t eat
20S
FOOD REQUIREMENTS FOR MINIMUM WAGES
the amount that has been recommended by ICMR, and
still they are not hungry”. Here one must remember
what ICMR experts said—
‘‘Unfortunately, experience has shown that human
beings can adapt themselves, at a low level of vitality
and with their powers impaired, to an insufficient ration
without realising that that they are underfed’’.11
Conclusion
(1) In spite of having accepted many limitations
posed by the Page Committee’s frame work (Eg. require
ments of other types of foods, number of earning mem
bers in a family, wastages of calories and time due to
illness etc.) the minimum wages for rural labourer work
out to Rs. 12.10 per day instead of Rs. 4 per day.
(2) The level of scientific accuracy is extremely low
in the calculations of a high power committee like the
Page Committee, whose report decided the daily wages
for more than 10 million people. One tends to wonder
whether these mistakes were innocent or motivated.
We learn from this exercise that no report from such
‘authentic’ committee be accepted blindly.
(3) There is an urgent need to do more research on
the calorie expenditure and nutritional requirements of
the agricultural labourer. The insufficient material pre
sently available also speaks about the research priori
ties in our country.
(4) Knowledge of nutrition and health can become
an effective tool for the economic fight by the poor.
This way the benefits to the poor and their health might
be more than through health work alone.
209
UNDER THE LENS
It is a widely supported principle now that the farmer
should get the cost of production for his produce.
Similarly the labourer also should get the cost of pro
duction of his labour-power.
Wage rates and justice
This rate (Rs. 12.10) may appear too high to some
people, only because we are accustomed to a very low
and unjust figure of Rs. 4.
These new wages are calculated to provide the
necessary calories and proteins (only partly) from the
cheapest sources (jowar and pulse) and to provide other
necessities of life at the present level of actual consum
ption by the poor (and not the ideal level). Hence they
are the minimum.
Four things must be borne in mind while thinking
about these rates.
(i) Rs. 24.20 per day x 26 days of work per month
= Rs. 627 per month will be the income of a family of
5.6 persons i.e. Rs 112 per capita per month. This is
still within the limit of our average per capita national
income (Rs. 142 50 per capita per month)12. Our
economy can provide such wages provided the exhuberent incomes of few other people are slashed down.
This is, after all, a question of political will.
(ii) The wages for the rural labourers in Kerala,
Punjab, Haryana are already more than Rs. 10 per day.
(iii) Minimum wage in E.G.S. are not merciful relief
or dole offered by the Government to the labourers.
This is a legal right of the labourers and a pledge and
responsibility of the Government of Maharashtra.
(iv) Many persons argue, “but labourers don’t eat
208
FOOD REQUIREMENTS FOR MINIMUM WAGES
the amount that has been recommended by ICMR, and
still they arc not hungry”. Here one must remember
what ICMR experts said—
‘‘Unfortunately, experience has shown that human
beings can adapt themselves, at a low level of vitality
and with their powers impaired, to an insufficient ration
without realising that that they are underfed’’.11
Conclusion
(1) In spite of having accepted many limitations
posed by the Page Committee’s frame work (Eg. require
ments of other types of foods, number of earning mem
bers in a family, wastages of calories and time due to
illness etc.) the minimum wages for rural labourer work
out to Rs. 12.10 per day instead of Rs. 4 per day.
(2) The level of scientific accuracy is extremely low
in the calculations of a high power committee like the
Page Committee, whose report decided the daily wages
for more than 10 million people. One tends to wonder
whether these mistakes were innocent or motivated.
We learn from this exercise that no report from such
‘authentic’ committee be accepted blindly.
(3) There is an urgent need to do more research on
the calorie expenditure and nutritional requirements of
the agricultural labourer. The insufficient material pre
sently available also speaks about the research priori
ties in our country.
(4) Knowledge of nutrition and health can become
an effective tool for the economic fight by the poor.
This way the benefits to the poor and their health might
be more than through health work alone.
209
UNDER THE LENS
References
I.
2.
3.
4.
5.
6.
7.
S.
9.
10.
11.
12.
Government of Maharashtra has passed an act by
which it ensures employment to every rural un
skilled labourer through the Employment Guaran
tee Scheme.
Report of the study Committee on Employment
conditions of Agricultural Labour in Maharashtra
State with Reference to Minimum Wages, Govt.
of Maharashtra, (July 1971).
Dandekar, V.M., and Rath, N. (1971) Poverty in
India, Indian School of Political Economy, Pune.
Recommended Dietary Intakes for Indians (1981).
Indian Council of Medical Research, New Delhi.
Energy and Protein requirements, Report of a Joint
FAO WHO Expert Committee (1973), Rome.
Patwardhan, V.N. (1960) Dietary allowances for
Indians, Special Reports Series No. 35, Indian
Council of Medical Research, New Delhi.
Ramana Murthy, P.S.V. and Balavady, (1966)
Indian J. Med. Res. 54:977.
Ramana Murthy, P.S.V. and Dakshayani, R(1962)
Indian J. Med. Res. 50:104.
Majumdar, K.C. and Datta, K.L. Comparative
Calorie defficiency among different states presen
ted at the Seminar on ’Poverty, Population and
Hope’. Pune 10-12 June 1981.
Computed from Table no. 1.7 in Ref. 3.
Gopalan, C e: al (1971) Nutritive value of Indian
foods. ICxMR. New Delhi.
World Bank estimate, published in its report of
1981, circulated by A.P. from Washington on 10th
August.
210
"‘Health and nutrition insurance cover for women and
children of the families must form an integral part of the
programme. With both parents at work children below
5 are bound to suffer. Therefore, the landlord must be
required to deposit Rs. 5/- every month for each labourer
(male or female) employed by him, in the local bank for
this purpose."
—C. Gopalan
UNDER THE LENS
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Government of Maharashtra has passed an act by
which it ensures employment to every rural un
skilled labourer through the Employment Guaran
tee Scheme.
Report of the study Committee on Employment
conditions of Agricultural Labour in Maharashtra
State with Reference to Minimum Wages, Govt.
of Maharashtra, (July 1971).
Dandekar, V.M., and Rath, N. (1971) Poverty in
India, Indian School of Political Economy, Pune.
Recommended Dietary Intakes for Indians (1981).
Indian Council of Medical Research, New Delhi.
Energy and Protein requirements, Report of a Joint
FAO/WHO Expert Committee (1973), Rome.
Patwardhan, V.N. (1960) Dietary allowances for
Indians, Special Reports Series No. 35, Indian
Council of Medical Research, New Delhi.
Ramana Murthy, P.S.V. and Balavady, (1966)
Indian J. Med. Res. 54:977.
Ramana Murthy, P.S.V. and Dakshayani, R(1962)
Indian J. Med. Res. 50:104.
Majumdar, K.C. and Datta, K.L. Comparative
Calorie defficiency among different states presen
ted at the Seminar on ‘Poverty, Population and
Hope’, Pune 10-12 June 1981.
Computed from Table no. 1.7 in Ref. 3.
Gopalan, C et al (1971) Nutritive value of Indian
foods. ICMR, New Delhi.
World Bank estimate, published in its report of
1981, circulated by A.P. from Washington on 10th
August.
210
“Health and nutrition insurance cover for women and
children of the families must form an integral part of the
programme. With both parents at work children below
5 are bound to suffer. Therefore, the landlord must be
required to deposit Rs. 5/- every month for each labourer
(male or female) employed by him, in the local bank for
this purpose."
—C. Gopalan
19
Nutritional Basis of Minimum Wages
C. Gopalan
(The December 1981 issue of the Bulletin carried an
article by Abhay Bang on nutritional requirements as
basis of deciding minimum wages of agricultural labou
rers. Dr. C. Gopalan, the renowned nutritionist, has at
our request sent his comments on this article—Editor).
1. The energy requirement of 3,900 Kcals for heavy
work, is for the reference man with a body weight of 55
kg. Studies from the National Institute of Nutrition
(1,2) have shown that the body weight of poor labou
rers engaged in heavy manual work is 44 to 46 kg. and
their daily mean energy expenditure is 3,025 Kcals.
Thus, even with the current low body weights, the
213
UNHIJt I HI. LfcJ.Ii
energy requirement of a male agricultural labourer will
be 3,100 Kcals. We may assume that he is laid off work
for 3 months in a year, when his energy requirement
will be 2,200 Kcals (sedentary work, corrected for body
weight). Thus, he needs 3,100 Kcals daily for 9 months
and 2,200 daily for 3 months, or on an average 2,900
Kcals daily throughout the year.
2. Similar calculations for the adult female (correc
ted to 40 kg. body weight) will yield a figure of 2,200
Calorics per day.
3. The minimum wage can only provide for a family
size consistent with our national policy of a small family
norm, namely only two children. We may assume both
the children to be below 12 years. The energy require
ment figures will, therefore, be 1200 for the child below
5 years and between 1500 to 2100 (mean—1800) fora
child between 5 to 12 years of age. The total energy
requirement for the children will work out to 3,000
Kcals (12004-1800).
4. The total energy requirement per day for the
family will be 8,100 Kcals.
5. I would suggest that the cost of this diet be based
not merely on the price of the staple cereal but on a
least cost balanced diet. In 1979, for an urban area, the
average cost for such a diet providing 2,400 Kcals was
Rs. 2-90 without including fuel expenses (3). On this
basis the total family diet of 8,100 Kcals will cost Rs.
10-11.
6. We may accept two-thirds of total income as a
reasonable and realistic level for food expenditure. Thus
the daily minimum wage for the family will be Rs. 16-00.
7. We must make an allowance for lack of wages for
214
NUTRITIONAL BASIS OF MINIMUM WAGES
90 days since agricultural and rural labour are usually
laid off for such a period. We also have to provide for
short periods of sickness. Therefore, the daily wage will
be 16x4/3, or about Rs. 22-00 per day for family. It
may be pointed out that many of the assumptions in the
above calculations are based on an appreciation of the
hard current realities and not on “idealistic” conside
rations.
8. From the above calculations, we may accept the
minimum daily wage of Rs. 22-00 for family. If we
assume that both the man and his wife will work, the
minimum daily wage will be Rs. 11-00 per person.
However, certain realities must be accepted. The output
of work of women in an occupation involving manual
labour will be less. Therefore, the landlords may feel
reluctant to engage women for the same wages. It may,
therefore, be prudent to suggest a minimum daily wage
of Rs. 12/- for the man and of Rs. 10/- for the woman
on the basis that different types of agricultural opera
tion are involved. It must be clearly emphasised that
this is valid only if both the man and the woman in the
family are provided employment for at least 270 days in
the year and preferably for 300 days.
The minimum wage proposed should automatically
fluctuate with the cost of living index, using 1981 as the
base year.
9. The prescription of a minimum wage must also go
hand in hand with fixing a minimum norm for produc
tivity and discipline. This is what has really made Japan
prosperous. Those who vociferously demand higher mini
mum wages rarely talk of productivity. The norms for
productivity must however take into account the small
215
j tiu of Uie ‘.^Mite:.
'- t
*—v-cce®Hrt
\ f ^5yc
: ' , 7 here ehoafa be
a raoil family norm. Trt ■.:....r^. '^.. -
■yte’Mi tikett '>n\j k
'.- - ----- -
-■
. r_
,.■ rQZ
'
>osj;dera‘ion in
■
of'the 2 child far.m.y :. "■'■'■
—
‘
'
. ,
.- -__ -'-=. - rrrm
>.
r.ot the rich. In my ri^.n '.n,...------- - — - ---~
for all, irrespective of rsligor titte
—
r.'.mic status.
\\. Health and nutrition insurance c.mr
cad children of the families must term
.z'.tzs.
1
rA the programme. With both parent:?
coilcren
below 5 arc bound to suffer. Therefore,
.aro.ord
must be required to deposit Rs. 5 —sslo for
each labourer (male or female; emplos ei by birr.
the
local bank for this purpose. One Health ~ crier per 100
families could be employed, to provide special health
and nutrition cover to the family, reinforcing the exist
ing health structure. A creche for underfives can also be
set up.
12. On its part, the State must of course provide
safe drinking water, reasonable environmental sani
tation and basic health care.
13. There is also another aspect to this. If the cost
oi agricultural labour operations are increased to very
high levels, this is bound to be reflected in increased
prices of food grains. This may disrupt the economy to
the eventual disadvantage of the labourer himself. One
way of overcoming this is to propose that half the
•> ages may be paid in the form of food grains, at pre
vailing prices.
'
216
NUTRITIONAL BASIS OF MINIMUM WAGES
It has been the sad experience that there is often a
wide disparity between what the rural labourer is
supposed to get and what he actually gets. The pre
scription of a “minimum” wage will have only acade
mic value if there is no machinery for strict enforce
ment. This is really the crux of the matter.
(The original note does not contain the emphasesEditor).
References
1. P.S.V Ramanamurthy and R. Dakshayani (1962).
I.J.M.R. 50:804.
2. P.S.V. Ramanamurthy and B. Belavady (1966) I.
J.M.R. 54:977.
3. Ann. Rep. Nat’l. Inst. Nutrition, Hyderabad 1980.
217
Rural women do on an average eight hours of domestic
labour (collection offire wood, fetching water, cooking,
carrying husband's food, livestock grazing) expending
1010 Calories per day on this work alone. Obviously,
even on unemployed days, the labourers need more calo
ries than a sedentary person.
—Abhay Bang
20
Food Requirements and Minimum Wages:
A Rejoinder
Abhay Bang
I read with great interest Dr. C. Gopalan’s comments
on my article ‘Food requirements as a basis for minimum
wages.' I am very encouraged to note that—
(1) The issue has interested an eminent nutritionist
like Dr. Gopalan.
(2) The final figure of minimum wage arrived at by
Dr. Gopalan’s calculations is almost same as that
of mine.
(3) The balanced way in which he has reacted is quite
a lesson for us in MFC who often react in a very
aggressive and emotional fashion which creates
more heat than light.
219
UNDER THE LENS
Even though the final figure is the same, I dare to
differ on some points with Dr. Gopalan.
(1)
Energy Requirements
Dr. Gopalan assumes that the average body weight of
male labourers is 44 to 46 kg. as assumed by ICMR as
reference body wight for Indian man. He has taken
this figure from 2 studies. The sample size in these
studies is 6 adult males in one and 30 in another. These
studies were primarily designed to measure the calorie
expenditure of male labourers by doing metabolic
studies. For such tedious studies obviously the sample
cannot be too large. Hence these studies are useful for
knowing the calorie expenditure of labourers of the
given body weight, Dr. Gopalan is not justified in using
the average weight of the small sample from this study
as the average weight of crores of Indian males.
I do not know why ICMR has taken 55 kg. as refe
rence weight for Indian males. I am also not aware of
any study which gives average body weight of Indian
labourer, taking a wide sample on the National level.
Hence I am not in a position to comment what is the
average weight of Indian labourers but obviously the
above two studies cannot be used for this purpose.
The second question which crops up is, are we going
to provide food for the existing low body weight and
thus seal the fate of the Indian labourer at the present
low body weight? As the studies at NIN have shown,
Indians, by heredity or constitution, are not destined
for a low body weight as was prviously thought and if
provided with adequate food and other care, an Indian
child matches the Western standard of growth and
220
FOOD REQUIREMENTS AND MINIMUM WAGES
development. Hence it is chronic undernutrition which
has resulted in our present underweight ‘pigmy’ popu
lation. Unless this class is provided with more food,
underweight will persist. So one should provide the
food required for a person of optimum body weight
(55 or 65 kg) to break the present bottle-neck and allow
the labourer’s children to grow to their fullest physical
potential. When treating a child with marasmus, do we
ever say that he should be given calories according
to his present body weight? On the contrary he is given
nutrition according to the expected body weight for his
age so that he can grow to that optimum level.
While calculating the calorie requirements for the
unemployed period of the labourers, Gopalan has
assumed that their calorie requirements are those of
sedentary persons. The off duty work and house hold
work that labourers, specially females, have to do is
much more strenuous than a sedentary person has to do.
The ASTRA study of rural energy patterns has shown
that rural women do on an average 8 hours of domestic
labour (collection of fire wood, fetching water, cooking,
carrying husband’s food, livestock grazing) expending
1010 Calories per day on this work alone. Obviously,
even on unemployed days, the labourers need more
calories than a sedentary person. Batliwala has recently
(EPW, Feb. 27) proposed an interesting approach to
bridge the energy deficiency by cutting down domestic
labour by providing amenities like electricity, watersupply, easy fuel to the rural people so that this huge
energy expenditure on domestic work is saved.
Dr. Gopalan has also not made any allowance for
pregnancy and lactation. As Kamala Jayarao has shown
221
UNDER THE LENS
in her article, “Who is malnourished; Mother or the
woman?’’ an average woman spends about half of her
reproductive life (15 to 45 years) either in pregnancy or
lactation.
Thus it appears that Dr. Gopalan has underesti
mated the calorie needs of the labourers. This under
estimation is further aggravated severely by the small
family size of 4 assumed by him.
(2)
Family Size
Dr. Gopalan supports his calculation of food allow
ances for a small family by saying that it is consistent
with National policy. Who decided this National
policy? How is this figure of two children decided?
Has any thought been given to why the poor need and
produce more children? When 25 to 30% children
die before the age of 5 years-and this average figure will
be still higher for the poor class-how can we enforce
that the poor should stop at 2 only? It is now fairly
accepted that poverty is the main reason, for the higher
birth rate. Hence slogans like ‘Development is the best
pill’.
If food allowances are made only for 2 children be
cause such is the National policy now, what will the
poor do with their already existing extra children?
starve and kill them? Incidentally many of these ‘sur
plus’, children were born when the National policy was
of 3 children or when there was no National policy.
By making allowances for a smaller family of 4(when the reality is that the poor have a family size of
5.6),) the allowance 4 will be distributed over 5.6 per
sons, obviously frustrating Gopalan’s efforts to provide
222
FOOD REQUIREMENTS AND MINIMUM WAGES
minimum standard of life to the poor and perpetuation
of poverty will frustate all the efforts to achieve the
‘National goal’ of family size of four. It is a self defeat
ing proposition.
While one should agree with Gopalan that small
family norms should be achieved, the methods have to
be dfferent. Even though I am not proposing an inde
finitely large family, let me just point out that for the
purpose of land ceiling or urban wealth taxes, there is
no limit on the family size. The rich have the facility to
have more children to save their wealth. In the organis
ed sector, the wages arc calculated for a family of five.
In such context, restricting the minimum wages of the
poor so that they can maintain only a family of four
does not seem justified.
While Dr. Gopalan states at one place that "many
of the assumptions in the above calculations are based
on the appreciation of the hard current realities and
not on "idealistic” consideration,” one fails to under
stand why he doesn’t accept the hard fact about the
existing family size.
(3)
Balanced diet
Dr. Gopalan has aimed at providing a balanced
diet to the labourers. It is most welcome. As I was
operating within the framework of the Page committee,
I couldn’t venture to ask for balanced nutrition and
argued only for cereals and pulses. But let me point
out that the cost of the balanced diet taken into account
by Gopalan is one prevailing in 1979. By’82, the costs
have scaled up at least by 40%. For calculations of
minimum wages today, prices of 1982 have to be
used.
223
v>TEZ THE LENS
*. Less vxjej f-r
--- - mtmte f- - zziz for males and females proposed
~7 <7z-zzLzzz i.: mat justified on the basis of difference in
~trk zzzzzz t-emmse men and women do different types
z: ~zfsz. Mr: zz physically strenuous work while
~tmrz. f: mere ■killful and tedious types o: operations.
let zzzzzz after different categories cannot be com
pared. 2.'. -art: usually put less hours of labour
they zz late to fields cue to their domestic dunes) and
at th-j Erorttd unequal division may be considered.
~z. Qzzzlzz hzs touched the heart of the whole
zzzzzzz ~ztz he stated ‘'The prescription of minimum
—T have only academic value if there is no
mazbimary f:r strict enforcement.” In our area we are
farms fimam res in trying to enforce even the existing
zzzzz~-z.zz.~-zz? act of4.5 Rs. per day. How can the
zz7z:.~zzz --zz? of 12 Rs. be actualised? But then this is
zz? next inescapable logical step of all this exercise.
May be ether people can take over this responsibility
zzzzz zz~. the medicos.
Editors remarks
1. The average body weights of rural adults are
-z-z'. kg males) and 40-44 kg. (females): National
N'tmr. .Mmitoring Bureau, 19S0. The figure 55 kg. was
nxed by ICMR arbitrarily when data on Indian adults
were r.tt available. Now ICMR has attempted to make
smitable alterations.
2 The comparison of energy provision for adults and
zzz a marasmic child is not correct. Since children possess
growth potential, their requirements are calculated on
“ideal " eight.” For adults, since maximum growth has
stopped, calculations are made for “actual weight”.
224
“The question is not whether supplementary feeding pro
grammes improve nutritional status of the children. The
point is, unless they are a part and parcel of an overall
economic programme they should not be taken up ”
—Kamla S. Jaya Kao
21
How Successful are Supplementary
Feeding Programmes?
Kainala S. Jaya Rao
It is very well known that undernutrition among
children is a major public health problem in India as
well as in other developing countries. With a view to
mitigate this problem, many governments sponsor large
scale supplementary feeding programmes. Imrana
Qadeer had discussed in one of our earliest issues the
relevancy or irrelevancy of these programmes (I) The
programmes have been going on and supplementary
feeding is presently a major component of the Integra
ted Child Development Services (ICDS) of the govern
ment of India. A question often raised is, how success
ful arc these programmes?
227
UNDER THE LENS
The impression gained from listening to seminars
or through personal discussions with various people is
that the programmes do not really improve the nutritio
nal status of beneficiaries in any substantial way. How
ever, when one goes through the relevant literature, the
position is not as clear. As Gopalan said, “With no
built-in machinery for scientific direction or evaluation,
the position with regard to many feeding programmes
is truly chaotic” (2).
Recently the UNICEF had commissioned Beaton
and Ghassemi to write a report on this subject. The
report says, “while food distribution programmes of
many types have been introduced in many countries
relatively few have been examined or evaluated in a
manner that produces usable information for the present
assessment of past experience” (3).
Types of Feeding Programmes :
Before evaluating the programmes, let us consider the
two main types of feeding programmes. The first is
the on-the-spot feeding or supervised programme. The
children are assembled at a Balwadi or some such
central location and are fed once a day. This entails
that,
1. the young, preschool child has to be brought to
the centre by an older sibling or parent:
2. the centre must be reasonably close to the house,
to ensure regular attendance;
3. the centre needs personnel to cook and serve the
food;
4. the child has to eat the entire amount of food at
one sitting;
228
SUPPLEMENTARY FEEDING PROGRAMMES
5. since no organisation can run throughout the
year without breaks or holidays, the feeding in
effect generally takes place only for 250-300 days
in a year.
The second type of feeding programme is the TakeHome distribution programme. Food, adequate for a
week or more, is distributed at the centre and it can be
carried home.
1. This needs less frequent visits to the centre and
proximity of the centre to the house becomes less
important.
2. The presence of the beneficiary child at the centre
is not essential.
3. The food can be given to the child whenever it is
hungry, and in divided amounts, if so desired.
4. The child will receive the food for all the days in
the year.
5. The centre does not have to keep utensils for
cooking and serving the food.
In the take-home system, there is the risk of sharing
of food by other members of the family. However in
most studies where this was noted, it was observed that
the sharing occured with siblings under 10 years of age
and not with adult members. This partly depends on
the nature of food distributed. Any food identified by
the community as children’s food was generally not
consumed by the adults.
To overcome the problem of sharing, in one study
conducted in Colombia, South America, enough food
was given to take care of the energy gap among all
members of the family (4). The targets were however
229
UNDER THE LENS
pregnant and nursing mothers, and young children. The
food ingredients are those commonly used by the local
population, such as bread, oil etc. It was however
found that the total calorie intake of beneficiaries had
not increased. It was concluded that either part of the
food was being sold in neighbouring, control villages or
the money spent otherwise on food by the family was
now being used for buying other necessities.
The Problem of Substitution
Thus in the above study, the intended supplement was
being used as a substitute. This problem of substitution
is seen in both supervised feeding and in take-home
programmes. In the former, the time of feeding is fixed
according to the convenience of the organisers. It was
felt that if the gap between this and the normal meal
time at home was not much, the child may not eat its
usual quota. However, the process of substitution even
in the take-home programme believed this assumption.
■‘The overall impact of these programmes, of cither
type, in filling the apparent ‘energy gap’ of young
children is disappointing”. “For most programmes the
supplement was designed to meet about 40-70% of
established energy gap. In point of fact, only 10-25% of
the gap was closed.”
“On the basis of these data alone, one would have
to question the effectiveness of food distribution pro
grammes in effecting satisfactory net increases in energy
intake among target population” (3).
However, the results of some individual studies have
been more encouraging. Thus, according to the Project
Poshak, the food was used as a complete supplement
230
SUPPLEMENTARY FEEDING PROGRAMMES
in children between 1-2 years and mostly as a supple
ment, and only to a small extent as a substitute in those
between 2-4 years. The supplement was hardly ever
given to infants below 1 year (5).
A strong component of health and nutrition educa
tion is necessary for the parents, particularly where the
take-home system operates. This may ensure, to some
extent, that the supplement is not utilised as a substitute.
The extent of substitution will also depend on the eco
nomic pressures and financial liabilities of the family.
In the take-home system, if all the children of the
family are not included, sharing will become inevitable,
unless the supplemental food is the same as the staple
consumed in the family. In on-the-spot programmes
too, sharing cannot be avoided in the poorer families.
The food from the family pot which would have nor
mally been the share of the beneficiary child, may now
be offered to the older siblings. In many instances, the
person accompanying the child to the feeding centre
happens to be an older sibling and she has to be in
cluded in the programme both for psychological and
ethical reasons. A strict bureaucratic attitude of in
cluding only preschoolers, whatever their vulnerability
from the nutritionist’s point of view, will not help in
the long run.
Improvement in Nntritional Status
The above conclusions were drawn mostly from diet
survey data. Results of nutrition surveys, on the other
hand, are more encouraging. It is well recognized that
individual diet surveys, particularly of young children
is a difficult task. The errors can therefore be great. In
231
UNDERjTHE LENS
this respect, nutrition survey data are more accurate.
Evaluation of a Special Nutrition Programme orga
nised for tribal children showed that in villages where
the programme was on, there was no grade III malnu
trition. Incidence of grades II and I was less compared
to that in unsupplemented, control villages. It is not
known how long after the implementation of the scheme,
these changes could be seen. The evaluators attributed
the success of the programme, which was on-the-spot
type, to the fact that the villages were compact, locals
were employed as helpers and food material was directly
supplied to the organisers (6). Other studies also showed
that when planned and operated properly, supplemen
tary feeding can result in improvement of the growth sta
tus of the malnourished child. By and large, it appears
that success depends, as in any such programme, on the
dedicated involvement of the organisers and in the
continuous operation of the programme. Such of those
voluntary agencies or research projects have been
successful because a single agency operates the pro
gramme continuously in the same villages.
An important observation made in one of the studies
was that although all malnourished children benefitted,
those severely malnourished benefitted most, the incre
ments in heights and weights being more in these child
ren (7). In any large scale feeding programme, almost
all children of the community are included, irrespective
of their nutritional status. If a striking improvement
is seen only in the severely malnourished, then these
will be missed in the calculations of means, averages
etc. of the whole group. It is therefore necessary that
children with different grades of malnutrition are classi
232
SUPPLEMENTARY FEEDING PROGRAMMES
ficd separately before the start of the programme and the
effects on both food intake and body growth arc calcu
lated separately for each group. Such an analysis may
provide a more accurate picture. If supplementary
feeding programmes are then found to help reduce grade
III malnutrition and prevent others from sliding into
grade III, the programmes cannot be deemed unsuccess
ful.
I will not go into the cost-benefit effectiveness of
the programmes. Firstly, there are not many, or perhaps
any, such evaluations. Secondly, I am not competent
to make such assessments. The question that how
ever, needs to be asked is, even if these programmes
do mitigate malnutrition to a some extent, how long
should they be continued?
The ICDS Programme
Every nutrition programme, when taken up is referred
to as short-term measure, the implication being that
such measures are needed till socio-economic condi
tions improve. However, neither administrators and
planners nor politicians define this word, ‘short-term.
One wants to know how long will the short term
be? In view of the programmes being termed short
term, they are started as ad-hoc programmes; the
definition of short-term is restricted to this and unfor
tunately no attempt is made to link it with a long term
goal, or, may be the truth of the matter is that our
developmental plans have no specific goals. The mam
moth ICDS programme is a case in point (8-10). No
where is it mentioned as to how long the supplementary
feeding will be a part of the comprehensive programme.
233
UNDER THE LENS
The whole ICDS project is actually termed an experi
ment and yet an experiment whose duration is not
mentioned. A strange way indeed of starting an experi
ment. Although the ICDS was conceived by the Fifth
Planning Commission, it does not seem to have been
linked with any economic programme. The latest evalu
ation report of the ICDS attributes the improvement in
the nutritional status of the children solely to the pro
gramme since there were absolutely no changes in the
socio-economic conditions in those study areas. This
may be very well as far as the success of the ICDS is
concerned. The ICDS covers large parts of the country
and more areas are coming under its purview. In view
of this, that statement needs serious consideration.
How long will a country be able to feed children, who
may number 100 million or more, without any socio
economic improvements? Was the ICDS programme
started in areas where the Planning Commission also
launched some new economic programme? If not, the
whole programme will be a collossal burden and the
country will become more and more dependent on
foreign aid, whether that comes directy from donor
countries or through international agencies. Assuming
that we save young lives through ICDS, what is the next
help the child will get in terms of food in late child
hood, education, vocational training etc? One finds no
answers
As Dr. Gopalan said, “In the long run, we can
hope to improve the nutritional status of our preschool
children only through improvement in the economic
conditions of the community to a level at which families
can afford balanced diets. Organised state-sponsored
234
SUPPLEMENTARY FEEDING PROGRAMMES
feeding programmes cannot be the permanent answer
to the problem”
“The need for supplementary feeding programmes
for preschool children will be inverse proportion to
our success in the matter of removal of socio-economic
disparities and improvement of economic and living
standards of our people” (2).
The question is not whether supplementary feeding
programmes improve nutritional status of the children,
The point is, unless they are a part and parcel of an
overall economic programme they should not be taken
up. The success of the programme should be measured
in the context of the success of the overall-economic
programme. If not they should be restricted to only
two situations. Firstly, in emergencies like acute
natural and man-made calamities. Secondly, in extre
mely poor and backward areas where the administrators
and planners are able to state categorically that signi
ficant improvement in socio-economic conditions will
not be possible in a specified period of time, for what
ever stated reasons.
References
1. Imrana Qadeer. MFC Bull: 14.
2. C. Gopalan. Proc. Nutr. Soc. India. 15 (1973).
3. G. H. Beaton and H. Ghassemi. Amer. J. Clin.
Nutr. (Suppl.) April 1982.
4. J. O. Mora et. al. Nutr. Rep. Intcrnt’l. 17:217
(1978).
5. Project Poshak. Vols 1 & 2. CARE INDIA; New
Delhi: 1975.
6. D. Hanumantha Rao ct al. Indian J, Med. Res,
235
UNDER THE LENS
63:652 (1975).
7. D. Hanumantha Rao and A. N. Naidu. Amer. J.
Clin. Nutr. 30:1612 (1977).
8. ICDS: A co-ordinated approach to children’s health
in India. Lancet 1; 650 (1981).
9. B. N. Tandon et. al. Indian J. Med. Res. 73:374 &
385: 1981.
10. ICDS. Progress Report after Five Years. Lancet 1;
109 (1983).
From the Editor’s Desk
Malnutrition and Intelligence
Among all the known aspects of malnutrition, none has
made as deep an impression on doctors, scientists and
the lay public alike as brain damage. This has had very
serious implications. Firstly it is believed that all
malnourished children, irrespective of the degree of
malnutrition, become mentally retarded and turn
out to be idiots. Secondly, since it is the poor that
suffer from malnourishment, the poor are idiots. There
fore, reservations in educational institutes and jobs are
futile, because they are malnourished and mentally re
tarded. When such dangerous convictions are held by
the privileged classes, it is important that this issue is
examined in its proper perspective.
It is true that when psychological tests were per
formed, children who had suffered from kwashior
kor scored poorly compared to apparently normal
children from the same community. However, it must
236
SUPPLEMENTARY FEEDING PROGRAMMES
be emphasised that these are children who suffered
from the most severe form of malnutrition, namely,
kwashiorkor. At any time point only 1-2 per cent of
the under-five suffer from such severe malnutrition. The
rest suffer from mild to moderate forms of malnutrition.
There are no studies to show that mental retardation
occurs in these conditions. Considering that other
physiological functions were found not to be affected
in such children, one may, until proved otherwise,
assume that brain damage also doesnot occur in mild
and moderate malnutrition. Therefore one is not justi
fied to say that mental retardation is a consequence of
malnutrition, without stating the degree of malnutrition.
Even in the severe forms where mental deficiency
has been demonstrated, it is not conclusively proved
that the deficiency is the result of malnutrition alone.
At least two studies, one from India (I) and the other
from Mexico (2), indicate that the lack of adequate and
timely environmental stimulation is as important a
causal factor, if not more, in leading to poor mental
performance. It was found that the mothers were poorly
motivated and showed no interest in the development
of the children. For a child’s intellect to develop a close
interaction with surrounding individuals is necessary
and normally the mother has a predominant role to play
in this. These children lacking this maternal interaction
and interest perhaps suffer both from severe malnutri
tion and lack of intellectual development.
The mother’s apparent lack of interest can be appre
ciated when one realizes that parents in highly im
poverished families have varied and tremendous burdens
to bear. The woman has to work outside the house,
237
I'NIM.K Hit: LENS
despite which the family income docs not help ends
meet. There arc never ending debts to be paid off.
Perhaps another pregnancy (with no wherewithal to
terminate even if unwanted), perhaps a drunkard hus
band, an ill-treating mother-in-law, the constant illness
of the children, and her own failing health. There should
therefore be little wonder that the mother shows no
interest in her children, family or her own life, although
this may be difficult to grasp for the economically
privileged classes.
Environmental stimulation is very important in
intellectual development and families suffering from
severe poverty and therefore malnutrition, also do not
provide enough intellectual stimulation for the children.
An interesting study on tribal children of Maharashtra
(3) has not received the publicity due to it. It showed
that 45 per cent of children with normal nutrition fared
badly on intelligence tests and 30 per cent classified as
malnourished performed normally, showing that malnu
trition is not the only factor determining intellectual
performance.
Even in those children who suffer menial damage
due to malnutrition, is the damage permanent? Some
follow-up studies indicated that even in later childhood
these children performed poorly on intelligence tests (4).
However this was not a permanent deficiency but a
delayed development; that is, a 16 year old performs
only as well as a 12 year old but does not stay put at
the 6 year level or the 12 year level. Age anyway is a
relative factor. This would only mean that a child may
finish school at 20 years instead of 16. Does this really
matter to children to whom schooling is any way denied?
238
SUPPLEMENTARY FEEDING PROGRAMMES
How important is it for a community that is engaged in
traditional occupations? And perhaps, experience has
taught the community how to teach these children the
traditional skills. Who has ever really examined this?
Moreover, it must be remembered that children
followed into adolescence, have continued to live and
grow in an environment that has hardly changed from
childhood. The same socio-economic pressures, the same
lack of parental interest and no proper school environ
ment. Therefore one cannot say that the poor perfor
mance on intelligent tests during adolescence is the
residual effect of childhood malnutrition. On the other
hand, when malnourished Korean orphans were adop
ted by foster parents in America, they showed no resi
dual mental deficiency in later years (5).
The last, but not the least important, aspect is the
appropriateness of the intelligence tests used. It is true
that attempts were made to ‘adapt’ the tests to local
conditions. But, how ‘appropriate’ are the investigators
themselves? We, with an urban education and an urban
style of living and thinking, to what extent have we
truly ‘adapted’ ourselves to the ‘local conditions?’ Even
if the mother tongue of the investigator and the investi
gated is the same, the dialects are so different. There
are so many cultural variations...the way a question is
put, the way answer is received all make a difference
in assessing mental performance. If the tests were so
designed to include chores and life styles to which the
child is daily exposed, would the performance be dis
tinctly better?
In summary, there is no strong evidence to say that
there is permanent brain damage due to malnutrition.
239
UNDER THE LENS
Although children with severe malnutrition perform
poorly on intelligence tests the environment may play
an important role in this. There is no evidence that the
delayed ‘mental development’ cannot be rectified by
proper training even in young adulthood. Lastly, we
do not know whether the urban-based investigators are
truly competent to offer the intelligence and psycho
logical tests. If the roles were reversed, how well will
the present investigators perform on those intelligence
tests?
References
1. S.G. Srikantia and C.Y. Sastry. Proc. 1st Asian
Congress of Nutrition, Nutr. Soc. India, 1978.
2. J.C. Cravioio, Proc. Nutr. Soc. India 22:1, 1978.
3. B.D. Patel et al in Early Malnutrition and Mental
Development. Swedesh Nutr. Foundation, Uppsala
1974.
4. S. Champakam, S.G. Srikantia and C. Gopalan,
Amer. J. Clin. Nutr. 21:844, 1968.
5. M. Winick et al. Science 190:1173, 1975
240
It is a matter of regret that there is not a single study on
the health problems of the workers of an industry involv
ing material whose hazards are well documented.... The
Medical Inspector of Factories has passed over the res
ponsibility of producing a “prima facie evidence" on to
us.
—Dhruv Mankad
22
Health Problems of Tobacco
Processing Workers
Some Impressions
Dhruv Mankad
The tobacco processing industry of Nipani (Karnataka)
employs around 6,000 workers, most of them women.
Given the apalling conditions under which they work
and live—the latter not being very much different from
that of other workers of the unorganised sector—it
would be unscientific not to suspect the presence of a
variety of work-related diseases amongst them.
When I started working for a dispensary run by an
institution in close association with their Union,
Chikodi Taluka Kamagar Mahasangh, I began to look
243
UNDER THE LENS
for correlations between the symptoms presented by the
workers and the nature of their work. After working
for around two years what I observed is a 1S^.nC
pattern in the diseases and health problems that a ict
these workers. Although I have not done any systematic
study as yet, I have been able to form some impressions
which I wish to share.
The process of converting raw tobacco into process
ed zarda or beedi zarda consists of a number of part
manual, part-mechanical operations of winnowing,
sieving and pounding. At times all these are done with
the help of machines. Finally, various grades and kinds
of tobacco are blended into a mixture as required for a
particular brand of beedi. The whole process, parti
cularly winnowing and blending, causes a lot of fine
tobacco dust to fly up into the air of the closed rooms
that pass-off as factories. For a newcomer it is impos
sible to stand there even for half a minute without
retching or getting a bout of coughing and sneezing.
New recruits often feel giddy and vomit while working.
The whole process also entails direct contact of the
skin with tobacco. During the blending which is done
with legs, the heat generated by constant sprinkling of
the tobacco zarda with water is a problem added to the
risk of constant skin contact.
Initially, my colleagues and I had formed tentative
ideas about the work-related diseases (I hesitate to call
them occupational diseases for want of any evidence of
correlation between the work and the disease) we were
likely to come across. We expected that the workers
would be suffering from the following:
1. Respiratory diseases: Chronic bronchitis, emphy244
PROBLEMS OF TOBACCO PROCESSING WORKERS
sema, bronchial asthma etc. due to constant inhala
tion of tobacco dust.
—Malignancies of the respiratory tract.
—Laryngitis, Laryngeal tubercle etc.
—Increased proneness to tuberculosis.
2. Skin diseases like contact dermatitis and allergic
disorders,
Although based on my subjective experience, I can
say with some confidence, and relief too, that some of
the conjectures were probably wrong:
(a) Respiratory disorders like chronic bronchitis,
emphysema etc. are not as widespread as we had
expected, though probably more common than en
countered elsewhere.
(b) We have not come across any patient with malign
ancies of the respiratory tract, which is somewhat
perplexing as constant contact with tobacco in
other forms have been associated with malignancy.
We had three patients with oral cancer but they
had a history of tobacco chewing.
(c) Bronchial asthma too, does not seem to be any
more common than elsewhere. But in at least two
out of eight patients taking regular treatment from
our dispensary, the onset could be correlated
directly with the work.
(d) Tuberculosis too, does not seem to be any more
widely prevalent than in other areas. In fact, 11 of
the 13 T.B. patients under our treatment so far,
have been beedi rolling workers or their family
members. Only one woman patient was working
in a tobacco factory and the other was her daughter.
245
UNDER THE LENS
This is a very perplexing epidemiological fact
requiring further investigation. Many occupations
involving inhalation of various kinds of dusts make
the workers vulnerable to T.B. e.g., slate pencil
industry, stone breaking etc. It is also a well
known fact that beedi workers are more prone to
T.B. No causative factors have been identified as
yet, though.
(i) Laryngitis is quite common especially after the
mixing operation which as mentioned above
causes a lot of tobacco dust to rise. In many
women and men, voices have changed and some
even lost them altogether.
(ii) Skin problems like dermatitis, urticarial rashes
etc. are quite common. Many women complain
of fissures in the soles.
Many problems not considered earlier have been
encountered:
(a) The incidence of dyspeptic symptoms, hyperacidity
and we suspect even peptic ulcer may be quite
high. Almost all the tobacco workers who have
attended the dispensary have one time or the other
suffered from these symptoms. One factor which
we have not considered is the habit of tobacco
chewing which is quite prevalent.
(b) The commonest complaint that the workers have
is low backache and pain between the shoulder
blades. This problem seems almost universal among
the tobacco workers. To this, one can add the
problem of painful and stiff knee joints. Many
operations like pounding and sieving require the
246
PROBLEMS OF TOBACCO PROCESSING WORKERS
worker to squat on her legs for hours together.
This awkward posture must take its toll. That most
of these problems are caused by muscular strain is
borne out by the fact that relief is obtained by
massaging the affected part with or without a
counterirritant. Liniment turpentine is perhaps the
most frequently used drug in the dispensary. Of
course, low nutritional status, housework and fre
quent child birth cannot be ruled out as other
possible causative factors without a thorough
study.
This problem seems to be more acute in beedi
rolling workers. They complain of pain and stiff
ness of neck, too. They sit in even more awkward
position—with straight back and legs stretched out
in front of them and stooping over the tray con
taining tobacco and beedi leaves kept over the
legs.
(c) Chronic dacryocystitis seems to be more common
than encountered elsewhere. It may be because of
chronic inflammation as a result of tobacco induced
irritation, blocking the nasolachrymal duct, or as a
result of physical blockage of the duct by tobacco
dust.
The experience so far raises certain questions which
we are trying to solve by a systematic study of some of
these problems:
1.
What are the relative incidences of the diseases noted
above in the workers and control subjects—sexwise
and age group wise. If the results confirm the sub
jective experience so far then,
247
UNDER THE LENS
2. Why is the incidence of both pulmonary tuberculosis
and malignancy of the respiration tract so low? Has
it anything to do with the fact that most of the
workers arc women?
3. Are the muscular problems related to posture during
the work or are they due to other causative factors
noted above?
It is a matter of regret that there is not a single
study on the health problems of the workers of an
industry involving material whose hazards are well
documented. The National Institute of Occupational
Health could help me with only a single reference to a
study on hazards to agricultural workers involved in
tobacco farming. Dr. Gupta of the Department of
Occupational Health, Central Labour Institute, Bombay
did promise to initiate a study on an official request
from the Medical Inspector of Factories. In turn the
Medical Inspector of Factories has passed over the res
ponsibility of producing a “prima facie evidence” on to
us.
Is this callousness on the part of the authorities due
to the fact that these workers belonged till recently to
the so-called unorganised sector or is it because most of
them are women? I do not think any systematic study is
required to answer this particular question.
From the Editor’s Desk
Dhruv Mankad needs to be congratulated for the syste
matic work he has undertaken. The article is based on
248
PROBLEMS OF TOBACCO PROCESSING WORKERS
his personal experience. Although he is careful to say
this is not a systematic study, his results compare very
well with those reported by the National Institute of
occupational Health, Ahmedabad (NIOH).
The symptoms described such as nausea, vomiting,
dizziness, headache etc. belong to a syndrome known as
green tobacco sickness. This was first reported by Gehlback from the U.S. (JAMA 229, 1880, 1974). This was
described in those who work on tobacco fields in North
Carolina state and hence the name green tobacco sick
ness. The authors stated that though the symptoms were
known to the workers for many years, they were never
described till then in medical literature. .This was
considered to be of a recurrent, self limiting nature.
Symptoms occurcd a few hours after starting work and
was described as a combined dermal-respiratory ex
posure. Gehlback also found that smoking protected
against the symptoms, perhaps due to an increased tole
rance to nicotine.
In our country, tobacco is mainly cultivated in
Andhra Pradesh and Gujarat. There were said to be 1.2
lakh workers in the organised tobacco industry as of
1974. Studies by NIOH on those harvesting tobacco as
well as handling cured leaves confirmed the findings of
Gehlback. They also described difficulty in breathing,
breathlessness, dry cough etc. In 1980 NIOH did a study
on tobacco processing workers in Nadiad, Gujarat. The
work included pulverising dry leaves, sizing and fillingup in the bags. Symptoms were found in 70 per cent of
the workers but most commonly only after heavy dust
exposure or during hot summer months. Symptoms
persisted only for a few hours and were considered by
249
UNDER THE LENS
2. Why is the incidence of both pulmonary tuberculosis
and malignancy of the respiration tract so low? Has
it anything to do with the fact that most of the
workers are women?
3. Are the muscular problems related to posture during
the work or are they due to other causative factors
noted above?
It is a matter of regret that there is not a single
study on the health problems of the workers of an
industry involving material whose hazards are well
documented. The National Institute of Occupational
Health could help me with only a single reference to a
study on hazards to agricultural workers involved in
tobacco farming. Dr. Gupta of the Department of
Occupational Health, Central Labour Institute, Bombay
did promise to initiate a study on an official request
from the Medical Inspector of Factories. In turn the
Medical Inspector of Factories has passed over the res
ponsibility of producing a “prima facie evidence” on to
us.
Is this callousness on the part of the authorities due
to the fact that these workers belonged till recently to
the so-called unorganised sector or is it because most of
them are women? I do not think any systematic study is
required to answer this particular question.
From the Editor’s Desk
Dhruv Mankad needs to be congratulated for the syste
matic work he has undertaken. The article is based on
248
PROBLEMS OF TOBACCO PROCESSING WORKERS
his personal experience. Although he is careful to say
this is not a systematic study, his results compare very
well with those reported by the National Institute of
occupational Health, Ahmedabad (NIOH).
The symptoms described such as nausea, vomiting,
dizziness, headache etc. belong to a syndrome known as
green tobacco sickness. This was first reported by Gehlback from the U.S. (JAMA 229, 1880, 1974). This was
described in those who work on tobacco fields in North
Carolina state and hence the name green tobacco sick
ness. The authors stated that though the symptoms were
known to the workers for many years, they were never
described till then in medical literature. .This was
considered to be of a recurrent, self limiting nature.
Symptoms occurcd a few hours after starting work and
was described as a combined dermal-respiratory ex
posure. Gehlback also found that smoking protected
against the symptoms, perhaps due to an increased tole
rance to nicotine.
In our country, tobacco is mainly cultivated in
Andhra Pradesh and Gujarat. There were said to be 1.2
lakh workers in the organised tobacco industry as of
1974. Studies by NIOH on those harvesting tobacco as
well as handling cured leaves confirmed the findings of
Gehlback. They also described difficulty in breathing,
breathlessness, dry cough etc. In 1980 NIOH did a study
on tobacco processing workers in Nadiad, Gujarat. The
work included pulverising dry leaves, sizing and fillingup in the bags. Symptoms were found in 70 per cent of
the workers but most commonly only after heavy dust
exposure or during hot summer months. Symptoms
persisted only for a few hours and were considered, by
249
UNDER THE LENS
the investigators to be mild in nature.
The NIOH study also found a slight increase in the
incidence of tuberculosis and also hypertension. Dhruv
Mankad has raised the question as to why the incidence
of tuberculosis and cancer were not high in those
studied by him. As far as tuberculosis is concerned,
unless the incidence in the general population is known,
it is difficult to state why there is no increased incidence
in the beedi workers. After all, tuberculosis is an in
fectious disease and other factors described by Dhruv
can only be precipitating factors. As far as cancer is
concerned, it is not so easy to find a correlation bet
ween occupation and the disease. A large number of
workers have to be studied, their ages known and also
the length of exposure to tobacco should also be known.
Therefore, by a small study like this one cannot cate
gorically say whether the incidence of the two diseases
is high or not in these workers.
I am glad that Dhruv has given us these findings on
an industry regarding the health problems of which, as
he rightly says, we do not have much information. I
also hope this will enthuse other members to share their
own experiences, although the studies may not always
compare with those taken up by established research
workers and centres.
250
The Chingleput study once again underscores the point
that vaccines are but of secondary importance in the con
trol of disease in a highly endemic area. Unless concomi
tant and sincere efforts are made to control and improve
the environmental factors, benefits from immunization
programmes may not be commensurate with the money
expended.
—Kamla S. Jaya Rao
23
Is BCG Vaccination Useful ?
Katnala S. Jaya Rao
The efficacy of BCG vaccination has never been ques
tioned by most clinicians. We have perhaps assumed
that the function of a vaccine is protection and there
fore BCG vaccine will protect against tuberculosis. The
protection, however, has never been complete. As
WHO report says “BCG vaccine has been used exten
sively in tuberculosis control programmes since the
early 195O’s, when, for many countries it was the only
feasible antituberculosis measure. At that time, it was
known that protection from BCG vaccination was not
complete, but there was little quantitative information
in that respect. For this reason, several controlled field
253
I'Nbr.ll I III. LliNI
trials were undertaken. The results of these trials were
contradictory, protection varying from nil to 80%.
The main hypotheses put forward to explain this varia
tion were that in some trials a vaccine of low potency
had been used, and that infection with mycobacteria,
other than mycobacterium tuberculosis had provided
some natural protection against tuberculosis, thus mas
king the effect of BCG vaccine” (1).
BCG vaccination continued to be recommended as
an antituberculosis measure nevertheless. It was how
ever soon recognized that no field trial was undertaken
in developing countries. Therefore the ICMR. with
assistance from the WHO and the American govern
ment, conducted a 72 year carefully controlled trial in
Chingleput, Tamil Nadu. The study was planned some
time around 1968.
Chingleput is highly endemic for tuberculosis. It
also has a high incidence of leprosy and filariasis. It
was not covered extensively by the national BCG pro
gramme. The initial survey or “intake” comprised
among other things tuberculin testing, X-ray exami
nation and sputum examination. Of those identified as
eligible on basis of x-ray examination nearly 3,50,000
people were included in the study and all except infants
below one month were tuberculin tested.
Two batches of tuberculin, PPD-S and PPD-B, were
used for skin testing. Prevalence of the disease, as
assessed by a reaction of 12 mm or more to PPD-S,
was 54% in males and 46% in females. The prevalence
increased with age upto 25-35 years; and in males by
25 years of age it was 80% and in females, by 35 years
it was 70%. Taking a reaction of 10 mm or more to
254
IS BCG VACCINATION USEFUL ?
PPD-B as evidence of infection, after the age of 15 years
almost everyone was a reactor. It is believed that “this
massive sensitizaion is caused by environmental myco
bacteria, which however, rarely cause living disease in
man” (2).
On the basis of x-ray findings, the prevalence of
pulmonary tuberculosis was 1429/100,000 in males and
978/100,000 in females. Those with two cultures posi
tive, who are definite bacillary cases were 598 males and
205 females, per 100,000. Those with a single culture
positive were 994 and 237, respectively. According to
the experts, the latter cases are considered to be mostly
‘early cases’, but there may be some false positives also.
The population was then administered one of the
two strains of vaccine chosen for the study. As men
tioned earlier, the study was carried for 7} years and
follow-up was done at 21 years and 4 years, also.
The results showed that BCG vaccination, over
71- years, had no effect in offering protection against
development of pulmonary tuberculosis. There were
four salient findings in this study:
1. A very low disease to infection ratio.
2. Men were affected four times more than women.
3. The large majority of cases occurcd among those
already infected at intake.
4. An almost universal skin sensitivity to PPD-B.
The study report concluded that after taking all
possible reasons into account, “The high incidence of
infection, the low incidence of disease among non
reactors associated with a high incidence of disease
among reactors suggest that a large proportion of cases
occur not as a result of primary infection but as a
255
UNDER THE LENS
result of either endogenous reaction or exogenous rein
fection” (2) ‘‘it appears therefore, that while the infec
tion rate is high in this study population and possibly
not declining, newly infected persons develop disease
less frequently. Tuberculosis is highly prevalent, but only
among the middle-aged and especially, elderly men—
individuals who must have been infected many years,
even decades ago. It is possible that it is not the pri
mary infection but rather superinfcction in the host
already allergic from a previous infection that is the
case of the ‘adult’ type of lung tuberculosis” (3).
The study thus shows that in an area of high endemicity, adults and older children may not be protect
ed against tuberculosis by BCG vaccine. However, the
reports warn that the results of the study may not be
extrapolated to infants, since infant tuberculosis was
not observed in this trial. The field trial was not de
signed to test the efficacy of BCG in infants and children.
The relevant information on children is thus frag
mentary.
In view of the high cndemicity in many parts of the
country, it is perhaps a correct view that BCG vacci
nation of infants should not be given up. The serious
forms of childhood tuberculosis, namely, miliary tuber
culosis and tuberculous meningitic, are said to be often
fatal, even if chemotherapy is given. Let us assume that
unlike in the already infected adults, BCG vaccine will
afford protection to infants and young children. The
question that needs to be settled is, under these circum
stances, till what age will the child remain ‘a good
candidate’ for protection? Ideally, BCG vaccine has to
be administered in the neonatal period. However, con
256
IS BCG VACCINATION USEFUL ?
sidering that most births occur at home with no trained
health personnel at hand, and in view of the various
bottlenecks in . the health delivery system, this ideal
situation will not be achieved. The Chingleput study
showed that the incidence of disease even among the
1-4 year olds in the control or placebo population was
nearly 2%. There is, therefore, an urgent need to know
whether in a highly endemic area infants will be firstly
protected and if so, till what age they respond. BCG
vaccination is now a part of the ICDS programme and if
we do not get an answer to this question early enough,
the money spent on it may merely go down the drain.
The Chingleput study once again underscores the
point that vaccines arc but of secondary importance in
the control of disease in a highly endemic area. Unless
concomitant and sincere efforts are made to control and
improve the environmental factors, benefits from im
munization programmes may not be commensurate with
the money expended. (The word environment is used
in a broad perspective which includes socio-economic
factors). I will not further dilate on this issue, since
I have already done so in my editorial in Bull No. 79
(July 1982).
References
1. Vaccination Against Tuberculosis. WHO Tech. Rep.
Ser. No. 651; 1980.
2. Trial of BCG Vaccines in South India for tuber
culosis prevention. Indian J. Med. Res. July Supple
ment; 1980 (for abridged version see; IJMR 70; 349;
1979).
3. Bull, WHO 57: 819; 1979).
257
UNDER THE LENS
From the Editor’s Desk: Tuberculosis
This is the centenary year of the discovery of the
tubercle bacillus. Every medical student knows tuber
culosis by its eponym, Koch's disease. Robert Koch, a
German physician and Louis Pasteur, a French chemist
were pioneers in the field of bacteriology. Koch first
discovered the anthrax bacillus and later, in 1882, the
mycobacterium tuberculosis. No student of bacteriology
can be ignorant of Koch’s postulates for establishing
the pathogenicity of an organism: the presence of the
organism in the body, ability to culture it in vitro and
reproducibility of the disease when injected into an
animal. Koch travelled wide, investigating cholera in
Egypt, plague in India, rinderpest in South Africa and
malaria in Java. Koch was in Garrison’s words (Intro
duction to the History of Medicine, Saunders, 1929)
“one of the greatest men of science his country has
produced.” His one failure, if it can be called one, was
his premature optimism that “tuberculin” will cure
tuberculosis.
The problem of tuberculosis is colossal and cannot
be tackled easily. No one group can be blamed for our
inability to reduce the incidence of tuberculosis. But
neither is there place for complacency. I hope that this
centenary year will be used as an occasion to take stock
of the situation in the country.
The disease is as prevalent today as two decades ago.
The annual incidence is 3 per cent. There are approxi
mately 8-9 million cases of radiologically active pulmo
nary tuberculosis, of whom 25-30% are infectious cases
(ICMR Bulletin, Sep. 1975). Among communicable
258
IS BCG V,\CCINATION USEFUL ?
disease, tuberculosis stands fourth in S.E. Asia and is
also the fourth important cause of death in the region
(WHO Chronicle, 31:279, 1977). It is another significant
cause of death for children between 2-5 years of age
(ICMR Bulletin, sept. 1975).
The rate of infection is the same in the rural and
urban areas. If you are living in a city and travel a fair
distance to work you may come into contact with 500
people every day, during travel, at place of work and
while marketing. Thus every day you can come into
contact with about 9 cases of pulmonary tuberculosis,
of whom at least two will be infectious cases.
To what extent have we made an earnest attempt to
reduce the disease? The WHO had stated that “the first
aim of a bacteriological service in a developing country
should be to perform sputum examinations by micro
scopy on a large enough scale to permit the accurate
bacteriological diagnosis of every smear positive case
and next to follow the progress of chemotherapy ’’
(WHO Tech. Rep. Ser. No. 552). To what extent has
the country taken steps to implement this? Do we have
these facilities in every hospital and PHC? One must
remember that for every smear positive case there is a
smear negative, culture positive case. In other words,
do we have adequate facilities even to detect half the
cases?
Nagpaul has very lucidly traced the epidemiology of
tuberculosis (J. Ind. Med. Assn. 71:44, 1978). He says,
there is a clear cut and “gradual change from a com
paratively acute and extensive disease among the young
to a more chronic, less extensive disease among the
elderly. It is significant that very similar changes were
259
UNDER THE LENS
noticed in countries where tuberculosis has definitely
declined.’’ He says that every infectious disease starts
as an epidemic which later declines or becomes endemic.
Though the picture today in India is similar to that in
countries where there is a definite decline, the disease
is not on the decline but has become endemic; “there is
a considerable incidence of fresh disease, sizeable selfhealing, and death.” I do not know whether this indi
cates that there is every danger of a fresh epidemic,
when the young will be more extensively affected.
That the socio-economic nature of a disease should
be understood by all truly interested in health, has been
MFC's major tenet. Nagpaul has stated very significant
reasons for our inability to control tuberculosis: “En
vironment is a fundamental factor in the ecological
triad of tuberculosis. Socio-economic conditions can
alter the epidemiological situation powerfully. Since
BCG vaccine has no influence on the naturally infected
population and chemotherapy merely eliminates some
cases but cannot prevent cases from occuring, a tuber
culosis control programme has a low potential for in
fluencing the epidemiological curve. So far, no report
ed study has successfully demonstrated the prime influence
of antituberculosis programmes in controlling the disease,
without a concomitant marked improvement in the stan
dard of living of the people.” (Emphasis mine).
It is therefore little wonder that the seven-year Pre
vention trial study by ICMR, with assistance from
WHO, has failed to show the expected beneficial effect
of BCG vaccine (IJMR, Suppl. July 1980). One wonders
whether the above quoted important factor was taken
into consideration in this study. Apparently not. Scien
260
IS BCG VACCINATION USEFUL ?
tists and doctors in this country have all too often taken
the view that changes in socio-economic conditions are
not within their purview and that they must work out
solutions within the existing socio-economic framework.
Many health programmes, including several nutrition
and feeding programmes, were worked out and carried
out with this attitude. The outcome—the failure—
should not have been unexpected. Like men, very few
diseases are non-respecters of economic status. Small
pox was one such exception. Hence its successful eradi
cation even without any perceptible change in the exist
ing socio-economic conditions. We have had enough
experience. The lesson is all too clear for those who
wish to learn. Without any parallel attempts to improve
socio-economic conditions, no health programme—
whatever the input in terms of money and personnel
can really succeed.
261
Throughout the underdeveloped areas of the world, the
great philanthropic foundations became aware that
'medicine was an almost irresistible force in the colo
nization of non-industrialized countries'.
—Zafrullah Choudbury
24
Research: A Method of Colonization
Zafrullah Chowdhury
Bangladesh, we say, has suffered from wars, poverty,
overpopulation and natural calamities. Now we arc
coming to see that it has suffered as much if not more
deeply, from “invested aid,” or, aid given to primarily
benefit the wealthy country. Let us look specifically at
what has been developing in the area of medical re
search.
In 1905, Gates, main administrator of the Rock
efeller assets, and a former Baptist minister, informed
Rockefeller that “Quite apart from the question of per
sons converted, the more commercial results of missio
nary effort to our land is worth a thousandfold every
263
UNDER THE LENS
year of what is spent on missions—our export trade is
growing by leaps and bounds Such growth would have
been utterly impossible but for the commercial conquest
of foreign lands under the lead of missionary endeavor.
What a boon to home industry and manufacture.” (1)
Medicine: Force for Colonization
But it did not take long for these concerned imperialists
to see that medicine could accomplish even more for
them than the missionary. Throughout the underdeve
loped areas of the world, the great philanthropic foun
dations became aware that ‘‘medicine was an almost
irresistible force in the colonization of non-industrialized
countries.” (2) But this medical care must remain in
their control if it was to continue primarily for their
benefit. In the Rockefeller international health pro
grammes, it was assured that ‘‘the entire control of all
the money would be held by our people and not the
natives.” (3)
Now a new age has set out to “reclaim” a new re
public, Bangladesh. In the past, as now, the glutted
American market cried out for colonies to consume its
goods. The medical research situation in the United
States today contains the same urgency to find regions
for expansion.
The Third World as a Laboratory
The procedure is somewhat standardized. The large
university offers job opportunities and attractive side
benefits to young professionals, and approaches the
underdeveloped, overpopulated country with a plan re
lated to health, nutrition, and family planning, financed
264
RESEARCH : A METHOD OF COLONIZATION
in large part, if not entirely, by the United States.
Government officials from the host country, while main
taining their government offices, are employed by the
U.S. university project, in limited number. This gives the
project, the necessary “in” with the local government,
while at the same time not being required to sacrifice
any real control. No national is trained to the point
where he could assume responsibility for the project,
independent of the foreign power.
Avoiding Solutions
What arc the benefits accruing to the underdeveloped
host nations? In the line of scientists trained to carry on
the work, it is nil. Further, the preponderance of foreign
research stultifies any growth of local efforts, making a
monopoly of health science. The population is used,
while effective solutions to the problems of health and
family planning arc subtly avoided. This avoiding the
real solution is an art that American medical researchers
are often forced to practice in the U.S. Incredible sums
of money are spent seeking cures for such killers as
hypertension and cancer, cures which the scientist knows
must be avoided, for, in the U.S. as here, discovering the
real solution would lead to a radical change of the life
style and economic system, and place in a rather un
comfortable position, the men who control research.
Johns Hopkins Again
A medical man with a missionary background and some
former members of the Cholera Research Laboratory
presented the Government of Bangladesh with a pro
posal for an International Institute for Health, Popu265
UNDER THE LENS
laiion and Nutrition Research. The Government has
been asked to consider the proposal in light of the fact
that funds for the Cholera Research Laboratory will no
longer be forthcoming.
The proposal for the Institute is a clear example of
national interests in the areas of health, population, and
social services being absorbed into the control of a
foreign state. Let us look more closely at the proposal
itself which step by step illustrates how the Institute,
primarily planned for the benefit of U.S. researchers,
will cripple any attempt on the national level for an
effective, independent health and family planning pro
gramme. Bangladesh will serve as a laboratory whose
population may or may not benefit from the experiments
and all will be done in collaboration with, under the
management of and through funds and personnel in the
control of the U.S.
In the Interests of U.S.A.
The proposal contains the following quote: “Establish
ment of a training programme for young investigators
from developed countries such as the U S. will require
development of direct institutional ties with U.S. or
other university and training institutions. These ties
should be encouraged in order that young scientists
from the developed countries can gain the skills and
expertise necessary to address health, population, aud
nutrition problems in the developing world.”(4)
It is not experienced scientists who arc being sent to
offer expertise. It is young men, needing experience,
and who, if they follow the pattern of the Cholera Re
search Laboratory scientists, will only be speaking
266
RESEARCH : A METHOD OF COLONIZATION
English when they address the health problems of the
developing world.
The proposal goes on to say that, “The key to the
development of the proposed research programme will
be the recruiting of expatriate scientific manpower to
conduct the research programme.” and that “This re
search programme docs not envision the requirement
for expanding the local technical and supporting staff.”
It then notes that “There are very few other Bangla
deshi professionals that can be recruited in the requisite
careers.” It fails to further elaborate that there arc
three Bengali scientists at the lab who were trained
elsewhere before the inception of CRL. However, the
quotes do indicate quite clearly what has happened in
regard to the CRL training of Bangladesh scientists, and
what will happen with the new proposal. In both in
stances,—nothing. If during the 1960’s alone over 100
US scientists were trained at the CRL, why, after the
16 years of its existence are there no Bengalis trained
for the required positions. Certainly not because capable
people can’t be found. The intent of the lab had never
been to train Bengali scientists. And neither is it the
intent of the new proposal. The new proposal intends
to maintain the hospital and field work as these are
areas where the Bengali staff can be absorbed and they
need not infringe on the scientific end.
Weight with government will come from other
areas. The proposal tells us “Unrestricted funds must
be available, so that the scientific staff can be recruited
from any nation where they may be available.” The
programme is envisioned as operating with “multiple
sources of funding from a variety of international
267
UNDER THE LENS
agencies and governments” with over 50% of the
funds, all of which will be controlled by the ‘inter
national’ board, coming from the U.S. This is real
power and weight with any government. Further, the
proposal reads that “’Crucial to the successful opera
tion of the lab is adequate administrative back up
support in the U.S. for management procurement, ship
ping of supplies, and equipment, as well as of manage
ment activities related to the expatriate staff.”
Why Bangladesh?
‘‘In conjunction with studies of immunological res
ponses to naturally acquired infection,” the propo
sal tells us, “there will be a program of studies of the
human response to artificial immunization by a variety
of routes.” The study has begun with animals in the
U.S. The next step will be the human population of
Bangladesh.
Why is it that Americans, so fond of the “sacred
rights of individuals” see only masses when they are
looking east? Bangladesh, too, is a country whose
people have individual longings and fears and even
individual rights.
Once the individual is lost sight of, medical research
becomes pointless. There is no one to serve, only the
ego addressing statistics. Further, once the individual
is lost sight of, scientific truth cannot be maintained.
Perhaps we should have known it all along, but now
the “proposal” spells it out for us.
And then one comes across this statement: “improv
ing the nutritional status of lactating women will lead
to shortening of the period of amenorrhea resulting in
268
RESEARCH : A METHOD OF COLONIZATION
birth at shorter intervals. This would not only be
detrimental to the welfare of the infant, but would also
lead to rising birth rates and more rapid population
growth. Chronic malnutrition may be effective in
suppressing fertility by prolonging the duration of lac
tational amenorrhea...” What is the author trying to
convince us of? That we should strive to maintain a
malnourished Bangladesh? It is hardly sick people, or
hungry people, that is the concern here.
Unapplied Research
The older cholera vaccine has proven virtually ineffec
tive in preventing the disease. A later experiment with
a cholera toxoid vaccine has proved equally ineffective.
Now a study is being conducted that will further ob
serve the two ineffective vaccines! 50% of all deaths in
the nation arc due to diarrhoeal disease. Over 60%, in
the case of children. The major achievement of the
CR.L is simplified oral theray, but this remains unavail
able, throughout most of Bangladesh, to patients in
serious condition. Intravenous fluids for cholera were
introduced in the 1830’s but remain unavailable to
rural Bangladesh even today. It has also been noted
that villages whose water is contaminated by material
from Matlab cholera hospital have attack rates for
cholera and diarrhoeal disease that is 20 times higher
than the average. It illustrates the efficiency of research,
that can create and perpetuate an endemic area in
which to observe the ineffective vaccines.
And all of this accomplished on an annual budget
of 1.7 million dollars. One million going toward finan
cing the home leaves, vacations, education, recreation,
269
UNDER THE LENS
elaborate homes and furnishings, etc., of seven expa
triate staff, while the treatment of diarrhoeal patients
and a Bengali staff of 770, share the remainder.
Because of the framework of the proposal and exis
ting institutional links with Ford Foundation, World
Bank, and USAID, all research in areas covered by
the Institute have to pass through the programme.
Monopoly is the result. A monopoly of science stifling
any growth of the Bangladesh scientific institutions.
And the institute is not primarily, nor secondarily con
cerned with training Bengali scientists.
The large amount of foreign funds remaining in the
full control of foreign groups will serve, consciously
or unconsciously, as a pressure on government and
state institutions. The result is freedom in Bangladesh
for American research universities, and freedom in
Bangladesh for American exporters of medicine and
medical equipment, who may be researching new pro
ducts for undesirable side-effects.
The Johns Hopkins Fertility Research Project in
Bangladesh found in one of their own studies in Matlab
on Depoprovcra, that it disturbed menstruation radi
cally, and lessened lactation. In another area of Bangla
desh, it came up in the same indications in regard to
menstruation and lactation. However, the Johns Hop
kins Project, delected facts pertinent to the point of
decreased lactation among Bengali women.
The Experts
Recently in Dacca airport, I met an acquaintance who
said to me in the course of brief discussion that he had
counted 72 Experts in Dacca on that one day alone.
270
RESEARCN t A METHOD OF COLONIZATION
And yourself, I asked, “73”, he admitted. For a long
time to come we will continue to credit foreign exper
tise unquestioningly with any knowledge it may lay
claim to.
Who arc these experts that come from thousands
of miles away with the perfect plan for a village they
have never seen, and a culture they have never lived?
One such expert on smallpox eradication qualified as
a motor mechanic. But then, he was a foreigner.
Our “western trained medical profession...sanitary
inspectors’ origination in the British Empire, the mala
ria program established by WHO...the Rural Health
Centres devised by western public health experts, and
most recently, the family planning programs,” (5) all
forms of expatriate expertise that have left the health
and family planning system of Bangladesh crippled,
confused, and utterly dependent.
The present split of the health and family planning
ministries is the result of “expert advice” from World
Bank and USAID planners who felt the population
problem would be effectively met in this manner. Now
we have the doctors being hired for family planning
work and paid 39% higher than the health ministry
doctor who is working in the same rural area within
another narrow field. One can foresee the difficulties
that will arise here without too much imagination. We
will have family planning office in each union, and a
sub-centre in each union, and offices for the health
ministry. There arc 92 maternity centres with twelve
rooms each, and 205 Rural Health Centers. In another
five years there is to be another 150 RHC’s, but these
with their 30 rooms each cannot be used for the family
271
UNDER THE LENS
planning work. Nor can the Lady Health Visitors who
are working in the Maternity Centres and are designa
ted as family planning workers, be able to count on
the doctors of the RHC for the back-up and support
needed if their work is to be effective.
It is accepted that Bangladesh needs barrfoot
doctors, people trained in the village to meet the needs
of the villagers, but the World Health Organization
experts proposed an elaborate 3 year programme to
produce medical assistants. This training will take
plarc in the towns and most of the students will have
a background of 12 years formal education. In the
centre visited, 65 out of SO enrolled had had twelve
years or more educational background, and nearly all
felt that the course itself should be four years or more
if the programme was going to equip them to “better
serve the people.” Serve, no doubt in Dacca, or Libya
as experience attests. But the expert advisors of WHO
refuse to see any other way.
These are the experts. They have been with us, as
was noted earlier, for sometime. Will we sell ourselves
out to them unconditionally now? There are real experts,
however, and there is such a thing as appropriate aid.
And neither is it impossible to discern the real from
the “invested aid”. Does the plan provide for local res
ponsibility in the foreseeable future? Does it reach the
real problems with realistic solutions? Is it honest in
assessing its weaknesses as well as its strengths? The
Companyganj Integrated Health Project in Noakhali is
an example of appropriate aid. Now, under Bengal lea
dership which has been capably trained to assume
the responsibility, it is meeting real health needs in a
272
RESEARCH : A METHOD OF COLONIZATION
practical way.
The nutrition and women’s programmes of UNICEF
were also attempts in the right direction.
And as we acknowledge the truly beneficial and
helpful work of certain foreign assistance, neither can
we fail to accept the fact of our own weaknesses, which
surely exist. Yet we do not want to compound and
nourish these weaknesses by importing others.
Death Blow to Bangladesh Health Care
But “inappropriate” aid is concerned with its own
purposes. The proposed institute will give researchers
free rein to use the people of Bangladesh and the
institutions of Bangladesh to further the purposes that
suit them. And it may well be the death blow to our
own health system, whether scientific research or deli
very of service.
The proposal threatens the sovereignty of Bangla
desh. It perpetuates the image of starving baby syn
drome and basket case Bangladesh, to attract funds
for foreign researchers. It disregards the fact that there
is talent and ability in Bangladesh, and there is a dignity
both among our professions who will no longer tolerate
being treated like school boys, and among our people
in general who will not much longer tolerate being
treated as mere statistics at the cost of their better
health.
[Courtsey-Bangladcsh Times]
References
1. F.T. Gates in J.D. Rockefeller, Dec. 12,1910, (Re
cord Group 2.) Rockefeller Family Archives.
273
UNDER THE LENS
2. E. Richard Brown, Ph. D, “Public Health in Im
perialism: Early Rockefeller Programs at Home and
Abroad.”
3. J.H. White to W. Rose. Aug. 14,1915, and W. Rose
to J.H. White Aug. 17, 1915, International Health
Commission files, Rockefeller Foundation.
4. W.H. Mosley, “Proposal for a Five-Year Research
Program for the Cholera Research Laboratory
Dacca, Bangladesh” April 1976.
5. Colin McCord, “What’s the Use of a Demonstra
tion Project” 1976.
274
“This angry young man instead of asking “Why should
there be so much of unemployment at all? starts blaming
the small partner in this diminishing cake. The result is
the caste war amongst the unemployed themselves."
—Anant Phadke
25
Caste War By Medicos
Anant Phadke
The recent outrage by caste-Hindu medicos of Gujarat
against reservation of seats for the Scheduled castes has
brought to the fore the question of reservation of seats
in general and of the philosophy behind the policy of
reservations. Though the specific demand of the medi
cos was restricted to the abolition of reservation of
scats for post-graduate medical education, there is a
wide-spread feeling amongst non-dalit medicos against
reservations for S.C. as such. It would not, therefore be
inappropriate to discuss in some detail the issues of
reservation of seats in our Bulletin.
277
UNDER THE LENS
Why Reservations?
Anybody who has even a rudimentary understanding of
the history of India would no doubt agree that the
untouchables (now called Scheduled Castes) were the
most oppressed stratum of our society. They were
systematically forbidden from acquiring any education
or property. Anybody amongst these dalits trying to
rise up in the social, educational hierarchy was ruth
lessly suppressed. During the British rule and after
Independence, the dalits had a chance to rise up in the
social hierarchy. But this cold be done only by getting
educational degrees since traditionally, the dalits owned
neither property nor trade. For them, education was
the only way to rise up in this modern competitive
society. At the time of Independence almost all dalits
were extermely poor and what is more important were
culturally at a considerable disadvantage. Centuries of
oppression had shaped their culture. Getting educated,
mixing with others as equals was unprecedented in
most dalit families and there was hardly any encourage
ment from the family and the community to the new
generation of dalits. Dalits had to be given a push if
they were to get out of their educational-social back
wardness. It was not enough to give scholarships and
other economic help to the dalits because the question
was not of mere economic backwardness but cultural
backwardness was equally important. Dalit students
could not compete with, say, Brahmin students coming
from educated well-placed families even if they got
financial help.
Today’s world is based not on co-operation but on
fierce competition. In this society, the competition bet
278
CASTE WAR BY MEDICOS
ween a dalit student and a high-caste Hindu student
would not be a fair and just competition because the
high-caste student is already a few miles ahead because
of his family background. If any competition has to be
a fair one the, competitors must start from an equal
base. Since the dalits had lagged behind, (thanks
to our history) it was necessary to exempt the dalits
from competition with the non-dalits and reserve seats
for them in proportion to their share in the general
population. In the absence of this reservation, the dalits
would have been almost excluded from the modern
organized sector that has developed in India after Inde
pendence. Modern India must undo the injustice per
petrated on the dalits by ancient India; non-dalits have
to pay a price for the injustice done by their ancestors.
In the immediate post-independence period this price
was not much because the economy was growing and
unemployment amongst the educated was not such a
burning problem. There was therefore not much resis
tance to the policy of reservation of seats for the dalits.
Reservations and Unemployment of Non-Dalits
A non-dalit (Hindu or otherwise) who fails to get a job
or a seat in medical college thinks that he would have
got a seat had there been no reserved seats for the
dalits. But this is an erroneous feeling. Reserved seats
are hardly an important cause of unemployment.
Official statistics show that unemployment amongst
educated youth (those who have completed their 11
years of schooling) jumped from 9.1 lacs in 1966 to 49
lacs in 1976 i.e. more than fivefold (1). This has happen
ed because there has been an economic crisis from 1966,
279
under the r.p:<s
<nc> .fence. employment the organized sector has been
.’.icreasing very siosv’y. For exam pie in 1975, our of? 93
■ <c registered •memp'.oyed. or.iy
got employment
n he organized sector. Out of .-hose 4 liases,-only 59(559
*.
ver.
Scr.ed red Caste;. O-.tr of these S.C. merely 24703'
got , v.t ■•.eeaase o3 reserved se.tts (21. (There are no
reserved sea,:
di. ;; ’■• :-,e
o.->?,-...-:.i..f sector)
y,.: -.e >vre<r oiame the 24'15 da!';-; >hc rdt
. - - -, .--... l.» ,■>. •. iSe - .S -. .-'... —y ,0. .... e !,
3 i .,.'
o-’
e:.;-iat-sd .seeker
*.?
rs
■<
"•'i‘ ■■■•'■■ '■ s-x. .•.'?•
?.» r-r u.ti'sLe
•• ■
■
Co ; ■■■
s.; ;
sstpis Ctm
•.
<_• ;.o • ' ■.?_ V, ‘.:.s
as ac
•• >•.•
of
T:.:. aog.-v jcarr
ww tosfcswJ of si^siog "Why ahotild there be so ww
*
star;-, blaming the smaili
;;>..•■•■'.d.r
C,;s '■/rot.-.ng cake. The resuli Ls th
* caste
s r a.Ttosgs’. i;.e -unemployed themselves.
k -..
among st the deprived is uitimately in
< : e in'-erett of :he ruling classes in India. Even if the
a.ro abolish the reservation of seats is accepted,
.’. v... !■',• reduce the unemployment amongst the highcestes to any significant extent. The statistics for 1975
c-ioied above tell us that abolition of reservations
wo j.'d reduce the unemployment of the educated only
fay 5%. Please remember that the vast majority of the
non-dajit section is really not going to be benefitted by
this demand.
Objections against reservations for S.C. are raised
by giving different kinds of arguments. Let us examine
these briefly one by one.
280
CASTE WAR BY MEDICOS
Substandard Doctors
One of the objections against the reservation policy
is "Because of the reservation-policy, we are producing
substandard doctors and are thus playing with the lives
of the people.”
It is forgotten by the anti-reservationist that all
S.C. students have to pass the final examination like all
others before they start clinical practice. How can you
call a doctor as substandard when he has passed his
final examination? It might be argued that most S.C.
students just manage to get passing marks. Firstly no
objective, statistical basis has been provided for this
statement. But even if this statement is true, how does
it substantiate the charge of “sub-standard” doctors?
Even if we want to make distinction between "quali
fied and good” and “qualified but not so good” doctors,
can this distinction be made on the basis of marks
obtained at the final examination? Is it true that those
who get good marks provide a better quality care? MFC
has been rightly stressing all these days that our medi
cal education and the structure of medical practice is
such that doctors cannot effectively help to guard the
health of the vast majority of the poor population of
our country. Any medico who thinks a little critically
would agree that knowledge of medicine is not of
central importance in general practice today, and the
quality of care being offered to the community today
cannot even be called “satisfactory”. Against this
background can we seriously talk about deteriorating
quality of medical care due to S.C. doctors?
Why Should I Pay The Price
One objection against the reservation-policy is "May
281
UNDER THE LENS
charge. However, the term laziness is quite relative.
Thus for example, it took not a inconsequential degree
of will and effort on the part of a dalit student to pursue
his studies upto the college level given his cultural and
economic background. However, after having reached
this level and knowing that he is going to get a job
even by acquiring only passing marks at his degree
examination (thanks to the lack of severe competition
amongst S C for the reserved seats) he would not try
his best in his studies. It is true that this was a reality
a few years ago. But this kind of “laziness” was also
present (though to a lesser extent) amongst the nondalits in the immediate post independence period. Jobs
were easy to come by for a graduate in those days and
hence a non-dalit student in those times would not try
his best, the way a student in the year 1980 is trying his
best to get better and still better marks.
The picture is however, changing very rapidly.
Unemployment and hence competition amongst S. C.
is increasing very rapidly. According to official statis
tics there were only 3254 unemployed S.C. graduates
in 1965, but this number rapidly rose to 64563 at
the end of 1977, a 20 fold rise (3). Though a part of this
rise is because of better statistical coverage, there is no
doubt that there is phenomenal increase in unemploy
ment and hence competition amongst the S. C. gradu
ates. S. C students therefore must now try^hard to get
as many marks as possible at their degree examina
tions. It is true that the competition amongst S. C. is
not as severe as that amongst the ncn-dalits. This is
because of the fact that the literacy rate amongst S. C.
is still much lower compared to the high-caste hindus,
284
CASTE WAR BY MEDICOS
and the drop-out rate from schools and collleges is still
higher. It is however certain that now there is very
little scope for the S. C. students for being 'lazy (5).
This however, does not mean that had there been
no reservations, there would never have been any scope
for S. C. to be indulgent. On the contrary, the reality
was such that in absence of reservations, the S. C.
would have been in a completely hopeless position.
They would have got demoralized because it was almost
impossible for them to compete with the high caste
Hindus because of the huge educational-cultural gap
that existed in the immediate post-independence period,
between the dalits and the caste-Hindus. It is be
cause of the policy of reservations that a section of the
dalits have to a certain extent come out of their in
feriority complex, lack of self-confidence.
Reservations for How Long?
How long arc the reservations for S. C. going to
continue?
This depends on the socio-political atmosphere. But
rationally speaking, reservations for S. C. must be con
tinued till the S.C. are no more a socially, educationally
backward caste. Today, take any major indicator of
social educational development, like literary rates,
drop-out rates etc. wc find that S. C. arc still a back
ward caste. When these differences will be no more,
then caste background will not be a factor in deciding
the fate of competition between two students or job
seekers: the fate would depend entirely on the individual
merit of the students-job seekers concerned. (This of
course presumes that both come from the same econo
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mic background and that the examiner is not casteist).
We cannot tell how much time this will take. We
are however sure that the S. C. cannot (even if they
want to) remain permanently backward to get the
advantage of reserved quotas. This is because of the
increasing unemployment and hence competition
amongst themselves referred to above.
Introducing Economic Criterion
The time has however come to introduce an economic
criterion along with the caste criterion in the reserva
tion-policy. Those scheduled caste students whose
parents’ income is above say the minimum level beyond
which income tax is levied, should not be given seats
through the reserved quota. Most of the well-to-do
S.C. are educated because by and large S.C. do not own
property. At least the father in a well-to-do S.C. family
is usually well educated and understands the import
ance of education. A student coming from such a S.C.
family will not be at much disadvantage, vis-a-vis a
high-caste student. Today, majority of the reserved
scats are probably going to those S.C. students who
come from a comparatively well-to-do, white-collar,
educated S.C. family. The students coming from poor
and uneducated S.C. families really require support.
Introduction of an economic criterion will achieve this
effect.
Likewise a proportion of seats should be reserved
for poor non-dalits. This would leave very few open
merit scats. But that does not matter at all. What is
important is that the competition should be fair, it
should only compare between the individual efforts and
286
CASTE WAR BY MEDICOS
intelligence by discounting the effects of social back
ground and culture. A student has no control over his
social background and hence if a competition has to be
a fair competition, the effect of differences in social
background has to be eliminated as far as possible.
Reservation-system does this job and hence has to be
continued as long as significant differences exist
amongst various communities in our society.
Reservations and Social Upliftraent
It is sometimes argued that reservations have failed to
achieve the desired effect of upliftment of the S.C.
community. It has only created a “Babu-layer” amongst
the S.C.; a layer which is least concerned about their
poor, backward community.
This argument is misdirected. If only a few people
amongst the S.C. benefitted through reservation-policy,
it is not the fault of the reservation-policy but of the
strategy of economic development adopted after Inde
pendence. This strategy has lead to a very truncated
and uneven modernization besides extreme inequality in
all spheres of life. That most of the educated and well
to do S.C. families do not bother about their own
community is again not the fault of the reservation
policy but of commercialization of our life. Moreover
selfishness is not exclusive to educated S.C. families.
How many high-caste well-to-do persons bother about
the vast majority of poor people belonging to their own
caste? Like in any other caste or community, a small
but important section of educated S.C. have thrown
their lot with the struggle of the poorer dalits and have
provided leadership to their struggles. This would not
have happened to any significant extent in absence of
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the reservation policy.
All said and done, it must however be emphasized
that the qestionof reservation of seats for S.C. should
not be equated with the uplift of the whole S.C. com
munity. Most of the S.C. are working as unskilled
labourers. Their major problem is that of controlling
the products of their labour. This is forgotten many
times by dalit leaders coming from an urban and middle
class background.
Reservations at Post-graduate Level
This has become THE burning issue today in Gujarat.
I do not know concretely and in detail what arguments
have been put forth by the anti-reservationist medicos
in Gujarat against post-graduate reservations. I also do
not know the exact severity of the problem caused by
the carry-forward system. But judging from reports in
the Times of India, it does not seem that the anti-reser
vationist have any strong case for the abolition of
reservations at the post-graduate level. The carry-for
ward system needs to be abolished. But there is no
rational basis for abolition of reservations as such at
the post-graduate level.
The argument about “playing with the lives of the
people” will not do. If reservations at graduate level
does not produce substandard doctors (equivalent of
“playing with the lives of the people”) as shown above,
why should reservation at post-graduate level mean
playing with the lives of the people? What is so heaven
ly about post-graduate education?
It is sometimes argued that it is enough to give a
push to a S.C. person through various forms of pro288
CASTE WAR BY MEDICOS
tcction till his graduation. After this he should stand on
his own. The trouble with this argument is that it draws
the line quite arbitrarily. Likewise it can be argued that
it is enough to give a S.C. person special concessions
till he passes out of school; this much push is enough
and at college level he should stand on his own. A
similar argument can be given against reservations for
jobs after graduation. All these lines are arbitrary,
S.C. collegians (premedical) as a social layer (we arc
not concerned here with individuals) are backward
compared to high-caste Hindu collegians as a social
layer. To offset this effect of social history, they there
fore require protection from open competition with the
high-caste Hindus. Similarly an average S.C. graduate
is backward compared to average high-caste-Hindu, for
reasons beyond his control and hence needs protection
from competition with average high-caste Hindu
graduates.
The Times of India, 21st February reports that the
Gujarat Junior Doctors’ Association has suggested that
there should not be any reservations at post-graduate
level for S.C. Instead they should be given 20 marks
extra this year and this figure should be reduced to zero
in 4 years. This figure of 20 grace marks (or any other
figure) is arbitrary. Why not 40, why not 5 ? As ex
plained above, there is a principled basis for reservation
policy—the principle of fair and just competition. Laws
should be made according to this principle of eliminat
ing the effect of differences in social, historical back
ground, and comparing only individual effort and intelli
gence. Arbitrary figures violate this principle.
Would it be futile to extend the following appeal to
the non dalit medicos? “Please do not fall prey to
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casteist, racist, irrational propaganda; think scien
tifically; find out the real cause of the problem and
struggle against it. Please do not engage in a castewar
which is not going to solve the problem of vast majority
of non-dalit or of dalit student.”
References
1. “Basic Statistics Relating to the Indian Economy”
published by Centre for Montitoring Indian Eco
nomy. Bombay, Vol. 1, December 1976, table 12.8.
2. 24th Report of the Commissioner for Scheduled
Castes and Scheduled Tribes, 1976, appendix XI.
3. 15th Report of the Commissioner for S.C. and S.T.
1966, Page 22; and 25th Report, appendix IX.
290
"Under all circumstances a man may get stuck, lose
himself and have to turn round and go back a long way
to find himself again. Only under certain socio-economic
circumstances will be suffer from schizophrenia”.
—Ramana Dhara
“Constantly I get this feeling that I am
perfectly normal and that I am wasting my
money coming here!’’
26
The Attitude of Society and the
Psychiatrist Toward Madness
Ramana Dhara
Most people seem to take a mad person for granted.
Accompanied by a joke or two about his crazy be
haviour, the general impression is that he has a “screw
loose” somewhere. Few people realise that no individual
behaves in such a way without a reason. Fewer still
understand that “going mad” is not instantaneous but
the result of a process which has been going on for a
long time. It is only when the person is unable to live
with this process anymore that he breaks down and
gives himself up to the fantasies of his mind.
For a person confronted with emotional breakdown,
what are the alternatives that present themselves?
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Rather, what is likely to be done with him by the people
he lives with? This largely depends on the economic
status and cultural practices followed in the community.
In our communities the tendency is cither to diagnose
the crazy person as being possessed by a devil (and
various religious and supernatural methods arc employ
ed to extract this devil) or a person who is “plain mad”,
is left to his own devices which invariably means emo
tional and economic deterioration.
It is only in the urban areas that the alternative of
the mental hospital presents.
This article deals with how psychiatry looks at the
phenomenon of madness and tries to show that instead
of being liberating for the individual, it is actually an
agent of suppression. One look at any mental hospital
will reveal the bizzare and inhuman results that modern
medicine has effected upon people. Patients stare at
you blankly, each one with his own stormy history.
There is little personal association between the staff
and patients, only a cold neutral, suspicious wall. In
fact there is a lurking fear in many doctors and nurses
that too close an association with patients may result
in they themselves going mad and funnily enough this
is a standard joke about psychiatrists.
How does a psychiatrist elicit a history, diagnose
and treat someone with abnormal behaviour? Largely
from the symptoms. Taking a common example, when
a person exhibits disturbed behaviour, it is usually a
member of the family who brings the person to the
psychiatrist stating that she/he is behaving oddly. After
a brief interview which consists more of asking about
what the patient has been doing rather than how and
294
THE ATTITUDE OF SOCIETY
why he is doing so, the psychiatrist arrives at one or
other of the following conclusions: either a psychosis
(where the person is out of touch with reality) or a
neurosis (in touch with reality).
Little emphasis is placed on the existential situation
in which the person breaks down. At best it is men
tioned as a precipitating cause of his illness. No attempt
is made to go into the details of his family back-ground,
of the relationships of the various family members with
one another and the family unit as a whole. No enquiry
is made whether the person’s moods of sadness, anger,
frustrations, despair are a product of his interaction
with the family. No attempt is made to increase the
understanding and awareness of the patient and cer
tainly no encouragement is given to him to act on his
genuine feelings and desires and thereby attempt a
solution to his problems. In short, instead of trying to
view the patient’s problems, the patient himself is con
sidered a problem. That personal change is very neces
sary for the patient is over-looked by the psychiatrist,
who through his technical understanding of the dis
turbed behaviour, views the patient as “one in whom
madness resides.” The commonest diagnosis arrived at
is schizophrenia, or “split personality”. Could we not
view this condition as the adoption of false roles by
people whose true roles have not been allowed to deve
lop or have been consistently rejected by the people
around them? If we view it in this manner, we begin
to perceive the relationship between the individual’s
madness and society. If an individual’s sense of reality
and experience (consciousness) is negated by the people
around him (usually the family which unconsciously
mirrors social values) then his consciousness becomes
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“unreal” in contrast to the “real” consciousness of the
others. The latter have been powerful enough to im
pose their consciousness upon the former. Disturbed
behaviour exhibited by the individual is a response re
action to his isolation and alienation. Drug addiction
is another manifestation of his isolation, where the drug
is used as an escape mechanism. In the power equation
between the two sides “reality and unreality” the
psychiatrist invariably acts on the side of “reality.”
The central theme running through academic psy
chiatry is that there is something inherently wrong
with the person that causes him to feel and behave in
an abnormal way. In other words, a person is either
born or destined (genetically, bio-chemically etc.) to
become mad at some stage of his life. This is some
what analogous to the Hindu theory of Karma. Trans
lating Karma into psychiatry ! “it is impossible to
escape from the cycle of one’s own genes and amino
acids since they have been pre-determined.” This sort
of pre-judgement of human behaviour makes it easier
for the psychiatrist to rationalise his suppressive
therapy on the person who has broken down, and also
later explain away the relapses which occur. What
evidence exists to prove that schizophrenia is determin
ed genetically or biochemically? As yet there is no con
clusive evidence. Every few years a “revolutionary”
break-through is announced that some chemical or
other is responsible for the abnormal states experienced.
Such discoveries usually end up being disproved. For
example, when a chemical cousin of LSD was discover
ed in the brain it was hypothesized that its fluctuation
was responsible for hallucinatory mental states. This
theory was popular until it was shown that this fluctua
296
THE ATTITUDE OF SOCIETY
tion occured in normal people too.
That disturbed behaviour does seem to run in certain
families is true and this is probably responsible for
generating the notion that schizophrenia is hereditary.
Recent work on genetic transmission of schizophrenia
has thrown doubt on this notion. On the other hand,
it is increasingly being recognised that certain patterns
of family interaction can be disturbing and thus gene
rate disturbed behaviour. It is important to take note
of this since it can afford a key to this much mystified
disease. By placing the disturbed behaviour of the
individual in the context of his family, it is possible to
study the emotional dynamics and situations which
produce such bizzarre behaviour, which when seen
alone seems utterly incomprehensible.
A mad person is oppressed by his situation and his
madness is a result of and reaction to his being unable
to live any more with this oppression. In a bid to free
himself from this oppression he perpetrates an explod
ing violence upon others or an imploding violence upon
himself. In the former case, he will be branded by psy
chiatrists as a homicidal maniac and in the latter a
suicidal depressive. We also begin to sec why women
are doubly oppressed. Society, operating through the
family, places many more restrictions and constraints
upon women than men, thus oppressing them both
socially and sexually.
Standard forms of psychiatric therapy are directed
towards suppression of symptoms and feelings. In the
main they consist of electro-shocks, tranquillizers and
surgical resection of part of the brain. Who has the time
to sit and talk to a guy who is “nuts”? A good cure
is one where the patient is quiet and polite. David
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son’s renowned Textbook of Medicine reinforces this
view saying that schizophrenics should be “allowed to
participate inconspicuously on the fringe of group
activities.”
Even though these suppressive measures have been
proved to cause irreversible brain damage by destroying
brain cells, therapists have not heeded these unfortu
nate side effects saying that the treatment is in the best
interests of the patients. These modes of treatment are
dc-humanising, de-personalising and rob the individual
of the capacity to feel and act. They are largely carried
out in mental institutions and asylums. Consequently it
is in these asylums that we see people suffering from
the most serious side effects, vegetating away in their
meaningless existence.
It is not surprising that so dehumanising a form of
scientific therapy should exist in the society in which
we live. The economic framework of society which
generates unemployment, poverty, competition turns
life into a never ending rat-race for survival. This social
insecurity reflects upon the individual through the
family, the family being the representative unit of
society. The social problem becomes an emotional
problem for the individual, as he begins to view his
existence as an unwanted and rejected one by his family
and therefore by society.
Take the following situations—
— A child who is the victim of emotional tensions
existing between his parents who have been forced
to marry, live together and reproduce because it is
socially correct to do so. He develops psychological
problems due to the anxieties of his formative
years
298
THE ATTITUDE OF SOCIETY
— A girl trapped by the rigidities and orthodoxy
of a joint family finds that she has no control over
what to do with her life and ultimately the only
control she does have is to decide whether to live...
— A man unable to find employment and feed his
family seeks refuge in the dullening effects of alcohol
and drugs in a bid to forget about the problems he
faces
— An old man unable to work any more becomes
economically un-productive and a burden on the
family and drifts off into senile psychosis
— The competition to survive alienates man from man
and ultimately man from himself.
In this apparently hopeless situation what are the
alternatives available for people who have become
alienated to find themselves again? It must be empha
sised that alternatives are present and must be actively
sought for by the alienated. Basically it lies in becoming
aware of the oppressive situation one is entrapped in
and acting to change the situation both at an indivi
dual and social level. “We must change the world in
order to change ourselves” writes Christopher Caudwell
in his critique on psycho-analysis. Groups like the
Radical Therapists (MFC Bulletin No. 5; May—1976)
seem to advocate and implement this ideology in
therapy which consists of groups of patients engaging
themselves in various activities directed towards revolu
tionary social change concurrent with discussion and
reflection and action upon their individual problems.
R.D. Laing, the anti-psychiatrist believes that the
schizophrenic experience is a “voyage” which has to
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occur without hindrance and through which the person
has to be helped and guided. This voyage comes to its
natural termination over a variable period of time and
acts as a self-healing process if allowed to occur freely.
To sum up a quotation from Laing’s “Politics of the
Family”:
“Marx said: ‘under all circumstances a Negro has a
black skin, but only under certain socio-economic
conditions is he a slave'. Under all circumstances a man
may get stuck, lose himself and have to turn round and
go back a long way to find himself again. Only under
certain socio-economic circumstances will he suffer
from schizophrenia.”
300
“Doctors in India should of course strongly preach family
planning in the interest of the health of our womanhood.
But one should not be under the impression that we are
making any dent in solving the problem of resources by
carrying out family planning programmes."
—Anant Phadke
27
Family Planning and the Problem of
Resources
Anant Phadke
Kamala Jayarao, in her editorial to the 65th issue (May
1981) of the Bulletin, has made a remark that there are
not enough resources in the world to sustain an increase
in the population at the present rate. I would like to
debate this point because such a view is quite wide
spread. I would argue that it is not the increase in
population which has posed the problem of inadequacy
of natural resources. What is really important is the
wasteful and reckless utilization of resources by ad
vanced capitalist countries.
Take the example of food. The per capita consump
tion of food in the underdeveloped countries (UDCs)
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was 506 pounds per capita per year. This is only an
average, which hides gross inequality in consumption
of food amongst different strata of our population. If
everybody in the UDCs got 506 lbs. of grain then there
would not be any hunger in these countries. The per
capita annual consumption of food in the U.S. however
is 1760 lbs. i.e. more than three times as much as in
the UDCs. (These figures are 10 years old. But that
does not affect my argument). Nine-tenths of it is the
form of meat, poultry or dairy products—thanks to the
“American Way of Life,” which breeds overnourish
ment leading to diseases like cardiac ischaemias, hyper
tension, etc. Americans get their grain via pigs and other
animals, that too in a highly processed and concen
trated form—thanks to the giant agro-business compa
nies and their advertising. This is a very costly way of
getting one’s food since it takes about 20 lbs. of grain
to produce one lb. of beef and seven or eight lbs. of
grain to produce one lb. of pork. The costs mount if
you take into consideration the cost of sophisticated
medical care to look after the problems created by
ingestion of so much of animal fat. The American
Medical Association has recommended a one-third
reduction in the meat consumption of the American
population. In a matter of 10 years (1966 to 1976) the
average American has added 350 lbs. of grain in his
annual diet! This addition has merely increased the
profits of the agro-food business (ninth largest in the
US) and of the medical profession.
This increase has been achieved by the use of in
creasing amounts of synthetic fertilizers. It has been
estimated that merely to maintain an average yield of
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FAMILY PLANNING
150 bushels of maize, nitrogen fertilizer has had to in
crease from 129 to 480 lbs. per acre, (see “How the
Other Half Dies”, 1977 Pelican, page 305). American
companies could squander natural resources in this
manner because resources throughout the world are at
their command—thanks to the system of Neo-imperialism and the power of the American army. Robert
McNamara until recently the President of the World
Bank, has himself pointed out that the U.S. has about
6% of the world’s population but consumes over 35%
of world’s resources.
Take the case of energy about which so much is
being talked about. The World Bank figures show that
“on as average, one billion people in the countries with
per capita annual income below 200 dollars consume
only about I percent as much energy per capita as the
citizens of the U.S.” Schumacher in his famous book
“Small Is Beautiful” makes an interesting calculation.
He has shown that in 1966, the “rich” countries
accounted for 31% of the world’s population but con
sumed 87% of the energy utilized in the world. He now
argues—suppose their population grows only at the rate
of li% per year, suppose the population of the poor
countries grows at the rate of 21% per year, further
suppose that the fuel consumption per head increases
at the rate of 2i% and 41% per year in the rich and
poor countries respectively. With this increase in popu
lation and per capita energy consumption, till the year
2000 A.D. the world would require an additional 1707
million tonnes of coal equivalent i.e. more than thrice
as much as the world was consuming in 1966. Out of
this increase, more than two thirds would be consumed
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by the rich countries!
The threat to the world resources then is not from
the increasing population [which is mainly taking place
in the ’‘poor” countries] but from the reckless, waste
ful use of resources [which is mainly taking place in the
“rich” countries]. Yes, American economy has been
using energy in a reckless manner. For example, the
per capita consumption of energy in the U.S. is twice
as much as in the West Germany though the standard
of living of the people in both the countries is almost
the same.
The way to solve the problem of resources lies in
rejecting the “American Way of Life” [which creates
unnecessary problems and spends resources on solving
them]: finding out ways to lead a modern but sensible
way of life. Doctors in India should of course strongly
preach family planning in the interest of the health of
our womanhood. But one should not be under the im
pression that we are making any dent in solving the
problem of resources by carrying out family planning
programmes.
306
It is significant to note that though research on male
fertility control was regarded as a priority area, less
than 10 percent of the total research budget for new
methods was allocated for this. The trials were entirely
in the area offemale methods.
—Mahtab Banerji
28
Male Contraception
Mahtab Banerji
Though family planning ought to be the concern of
both man and woman, the burden invariably falls on
the latter. The factors responsible for this are: (a) the
prevalent socio-cultural-political attitudes towards man
vis-a-vis woman, (b) man’s preoccupation with his
sexuality and fear of losing libido by any intervention
and (c) non-availability of suitable and convenient
reversible methods of controlling male fertility. In the
last three decades, tremendous efforts have been made
to understand the physiology of female reproduction.
Effective hormonal methods and intrauterine devices
for controlling female fertility, in a reversible manner
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have been developed. Compared to the understanding
of female reproductive biology, knowledge of male re
productive biology is very deficient, because few in
vestigators have considered it be an important area
of research. Suppression of ovulation appears to be
easier than complete suppression of sperm production.
Though several agents (sex hormones and chemicals)
are known to produce oligospermia and influence sperm
motility, the relationship between the magnitude of
these changes and infertility is difficult to assess.
Less Research on Males
Condom, coitus interruptus and vasectomy are the only
male methods of contraception currently available. The
failure rate with condom is considered to be too high to
make it a reliable method. Surprisingly, little effort has
been made to improve the conventional condom to
nakc it more reliable. A simple innovation like a thin
bi-layered condom with a powerful spermicidal agent
sandwiched between the two layers may improve its
effectiveness just as the combination of diaphragm and
jelly provides better protection in the woman than
diaphragm alone. A more sturdy and yet a thin, reus
able condom would reduce the problems of disposal.
Materials research in this direction is required.
Male fertility is regulated by several factors such as
(a) hormones which regulate steroidogenesis and sperma
togenesis, (b) the male accessory glands and organs which
are under strict hormonal control and which are res
ponsible for the production of seminal plasma and
(c) the psychogenic determinant which controls mascu
line behaviour and libido. For a male contraceptive
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MALE CONTRACEPTION
to be acceptable, it should be safe, reliable and should
not interfere with male libido. The psychogenic com
ponent is the most difficult to manage as far as the male
is concerned.
In the last decade, an opinion that men should
share the burden of family planning has been created
through pressure from women’s groups. The World
Health Organisation under its Expanded Programme
for Research in Human Reproduction (HRP—an impor
tant funding body for research in family planning)
considered the development of oral and injectable birth
control drugs for use by men, as a priority area for
research and a task force on “Methods for the Regula
tion of Male Fertility” was created in 1975. HRP has
two types of programmes. Through its net-work of
collaborative centres for clinical research and training,
it carries out multi-centred studies on safety and accep
tability of the existing, improved and new methods of
fertility regulation, to assist the national family plann
ing programmes in developing countries. It also funds
research on development of new methods of fertility
regulation. The 1975 annual report of HRP lists ten
such task forces out of which nine deal with female
fertility and only one with male fertility.
It is significant to note that though research on
male fertility control was regarded as a priority area,
less than 10 percent of the total research budget for
new methods was allocated for this. The trials were
entirely in the area of female methods. The composi
tion of task forces and the pattern of funding by WHO
has been more or less similar from 1975 to 1980. Under
the task force on Regulation of Male Fertility, Phase
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I & Phase II clinical trials were initiated on five com
binations of progestogen/androgen formulations and
Cyprotercne acetate—an antiandrogen with some progestogenic properties. These agents limit spermato-genesis
without affecting libido. The task force also funded
basic research in other areas of male fertility such as
Inhibin (a naturally occuring testicular substance which
selectively inhibits spermatogenesis, without interfering
with testesterone production), Androgen Binding Pro
tein and some other areas dealing with sperm matura
tion in epididymis.
The difficulties
The clinical trials were handicapped by the difficulty
in finding volunteers. Basic research was thought to
be too expensive to sustain and by 1980 the task force
on male methods was phased out on the recommenda
tion of the advisory group. The following gives the
state of art with regard to hormonal/pharmacological
methods for male contraception [WHO 9th annual
report, 1980.]
“Following the recommendation of the Advisory
Group to the Programme, research in the Task Force
on the Regulation of Male Fertility was phased out
in 1980. The Advisory Group had recognized the need
for new methods of birth control for men but consi
dered that this could not be achieved without a very
considerable effort in basic research which would be
very costly and time-consuming. Such efforts were
being sponsored by research councils in several deve
loped countries. This research is being closely monito
red by the Programme for breakthroughs that might
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MALE CONTRACEPTION
provide a base for mission-oriented research by the
Task Force.”
HRP continues to fund some work on male methods
for fertily regulation in a task force on “Plants for
Fertility Regulation”. A computerised data base has
yielded over 170 plants for the control of male fertility.
Bioassays are being carried out on few of these from
the priority list. WHO is also supporting research on
gossypol, a toxin from cotton seeds with antifertility
effect in males. The People’s Republic of China puts
great emphasis on male contraception and has carried
out clinical trials with gossypol in over 10,000 men.
Though the Chinese experience so far has been encou
raging, it is unlikely that many other countries will
intiate trials with gossypol because of its toxicity in
several species of animals. In man, gossypol produces
hypokalemia but this can be counteracted by oral
potassium supplements. Gossypol analoguge without
toxicity will have to be developed for wider acceptance.
Vasectomy or male sterilization is effective, safe and
simple. Its acceptance is claimed to be increasing in
developed and developing countries. The most signi
ficant complication of vasectomy is sperm granuloma,
an inflammatory reaction to the extravasation of sperm
from either the vas or the epididymis into the surround
ing tissues. However in most cases sperm granulomas
remain asymptomatic with no adverse effect on the
man’s health. Another sequel of vasectomy is the deve
lopment of sperm specific antibodies. The clinical im
plications of these antibodies are yet to be understood.
Studies have shown that sperm antibodies do not lead
to autoimmune disease, nor do they reduce the chance
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of successful vasovasectomy (reversal of vasectomy. A
recent report claimed that antisperm antibodies in
vasectomised male monkeys aggravated atherosclerosis.
Further invesigation is needed to establish this.
Mentally healthy, sexually well adjusted men do not
experience psychological problems after vasectomy, but
some men of neurotic temperament complain of im
paired health and libido. This problem can be mini
mised by educating the man regarding the nature of the
surgery before the operation and by reassuring him.
In conclusion, the goal of developing chemical/hormonal male contraceptive remains elusive, chemical and
physical devices to occlude the vas and immunological
approaches have been thought of, but are still at the
experimental stage. With improved surgical techniques
for vasectomy and vasovasectomy and proper educa
tion, it may be possible to increase the acceptance of
vasectomy. The conventional condom should be im
proved upon to decrease the failure rate and to make it
reusable.
Literature Cited
1. Regulation of Male Fertility. Clinics in Andrology,
Vol. 5 (1980) Ed.
G.R. Cunningham, W-B Schill & E.S.R. Hafez.
Martinus, Nijhoff Publ.
2. Gossypol: A possible, Male Antifertility Agent
Report of a Workshop.
Research Frontiers in Fertility Regulation, May 1981,
Vol. no. 4.
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MALE CONTRACEPTION
3. Alexander, NJ. Carkson T.B. Vasectomy increases
the severity to diet-induced atherosclerosis in
Macaca fascicularis. Science 201:538.
4. World Health Organization. Expanded Programme
of Research, Development & Research Training in
Human Reproduction. Annual Reports Nos 4-9,
1975-1980.
315
29
Medico Friend Circle
Perspective
The medico friend circle is a group of socially cons
cious individuals, interested in the health problems of
our people, mfc is trying to evolve an appropriate
approach towards developing a system of health and
medical care which is human and which can meet the
needs of the vast majority of the population in our
country.
The existing system of medical care, we have reali
zed, is not geared towards the needs of the people. It
requires a fundamental change. Such a change would
occur as part of a fundamental change in the total social
system in the country, since the medical system is only
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a part of the total social system, mfc believes that the
potential created by modern medical science cannot be
realized fully without a fundamental change in the
social system.
What is wrong with the existing medical systems in India ?
Though after independence there has been a rapid
growth of the medical services organised by the Govern
ment, Private Practice remains the dominant feature
of medical care in India. In private practice, medical
care like any other commodity in the market is available
only to those who have money to pay. The medical
profession resembles any other commercial sector and
therefore has been dominated by concern for money
rather than for people. Commercial competition and
personal interests of doctors lead to numerous mal
practices.
This behaviour is encouraged and promoted by pro
fit oriented durg companies which dump many useless
or even harmful drugs onto the consumer by co-opting
the doctors, through their sales promotion techniques.
mfc upholds the interests of the people and
* wants medical care to be available to every one
irrespective of his/her ability to pay.
* wants to develop methods of medical intervention
strictly guided by the needs of our people and not
by commercial interests.
Since purchasing power is mainly concentrated in
urban areas, commerical medical practitioners are also
concentrated in cities and towns. This over-crowding
of doctors is partly responsible for the overgrowth of
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MEDICO FRIEND CIRCLE
specialists. This has resulted in the denigration of the
role of a basic doctor to just a “cough and cold” doctor.
The training of doctors has also been influenced by this
situation. Hospital based training by Western and
Urban oriented specialists produces a graduate condi
tioned to urban and hospital practice. Therefore even
after prolonged training in a medical college, such a
graduate is not capable of dealing with the situation in
rural areas.
nifc would work towards
* a pattern of medical care adequately geared to the
predominantly rural character of our country and.
* towards a medical curriculum and training tailored
to the needs of the vast majority of the people in
our country.
To further their narrow professional interests, doctors
have established a monopoly control over medical know
ledge and medical practice. Medical knowledge has
been jargonised and a halo has been created around it.
This monopoly and mystification opens the door for
domination by the medical profession over patients and
by doctors over nurses and other paramedics.
mfc stands for
* popularization and demystification of medical
science and
* believes that different categories of medical pro
fessionals be regarded as equal members of a
democratically functioning team.
Commercial interests demand a growing market for
drugs and medical therapies and this is partly responsi319
UNDER THE LENS
ble for medical practice being reduced mainly to cura
tive services. It denigrates the primary role of preven
tive and social measures. Drugs, surgery, even vaccines
have so far contributed marginally to the improvement
in people’s health in different countries. In spite of the
primary role of socio-economic development in impro
ving health of a people, a wrong belief is promoted that
medical intervention—use of drugs, surgery etc.,—is
primarily responsible for improvement in the people’s
health.
* mfc realizes the importance of curative technology
in saving a person's life, alleviating suffering or
preventing disability but
* stresses the primary role of preventive and social
measures to solve health problems on a social
level.
The government health sector is not commercial
and the PHC doctors arc supposed the emphasize pre
ventive medicine. But this sector has not changed the
basic pattern outlined above. The doctor working in a
PHC is inclined and trained to do mainly curative work
and generally reflects the typical attitude of the upper
class, urban, elite professional. Preventive measures
when undertaken are therefore reduced to pure techno
logical and administrative measures without any social
content.
nife stand for
t
c
c
* the primary importance of preventive measures,
planned and carried out with active participation
of the community and
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MEDICO FRIEND CIRCLE
* for democratic decentralization of responsibilities
wherever possible.
Medical practice in its existing form reflects and
reinforces some of the negative, unhealthy cultural
values and attitudes in our society, eg., glorification of
money and power, division of labourers into manual
and intellectual workers, domination of men over
women, urban over rural, foreign over Indian. ..
mfc work's towards
* a kind of medical practice built upon human
values, concern for human needs, equality demo
cratic functioning.
In the present medical system, non-allopathic thera
pies given a step-motherly treatment. Allopathic doctors
call non-allopaths quacks without knowing anything
about their systems of medical care. Equally unscientific
are the claims of success made by some non-allopaths
and by some drug companies. Prejudices, ignorance,
self-interest have prevailed over open-minded scientificity in this important area of medical care.
mfc believes that
* research on these therapies be encouraged by allo
ting more funds and other resources and
* that these therapies be encouraged to take their
proper place in the modern system of medical
care.
mfc thus tries to foster among medicos a current
upholding human values and aims at restructuring the
medical profession to enable it to realize the potential
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created by modern scientific medicine.
mfc offers a forum for dialogue/debate, sharing of
experiences and experiments with the aim of realizing
the goal outlined above; and for taking up issues or
common concern for action.
Activities
mfc members are spread all over India and try to
propagate the perspective of mfc through their work.
Some members are engaged full-time in organizing
health projects in rural areas.
Bulletin
mfc is as of today, mainly a throught-current and
the monthly Medico Friend Circle Bulletin now in its
ninth year of publication, is the medium through which
members communicate their ideas and experiences to
each other. The bulletin publishes articles broadly
reflecting the mfc perspective on health problems.
Running the mfc bulletin is our chief common activity.
Anthology
Publication of the Anthology of selected articles
published in the bulletin has been a milestone in the
development of mfc. The first anthology—In Search of
Diagnosis—was very well received and was rapidly sold
out. KSSP translated it in Malayalam (two editions).
The second anthology—Health Care which way to go—
is almost sold out. Reprints of the first and second
anthologies are ready.
Annual Meet
Once a year mfc members gather at an All India
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MEDICO FRIEND CIRCLE
Annual Meet to explore a relevant topic through dis
cussion or to understand the functioning of a particular
health care project in terms of a chosen topic. Since
:974, annual meets have been held at Ujjain (relevance
of the present health services), Sevagram (present health
problems), Hoshangabad (Indian nutritional problem),
Calicut (community health approach, role of doctor in
society), Varanasi (unemployment among doctors),
Jamkhed (community health worker), RUSHA Project
(community paediatrics), Tara (misuse of drugs by
doctors), Anand (prejudice against women in medical
care), CINI, Calcutta (alternative medical education).
The Annual Meet provides an opportunity for farflung medico friends from different parts of the country
to meet each other for an intensive dialogue and to
chalk out a common action programme.
Study and action-projects by local groups, regional
camps to understand a local health problem and its
broader dimensions, health educational campaigns arc
other activities through which mfc has grown and con
solidated. The camp on lathyrism in Rewa District in
1978, the educational campaign against Oestrogen—
■Progesterone forte, about diarrhoea and misuse of
drugs are examples, mfc is also an active members of
the All India Drug Action Network.
Organization
The medico friend circle is not a rigid organization.
It is loosely knit and composed of friends from various
backgrounds, usually medical to start with, often diffe
ring in their ways of thinking and in their modes of
action. But the understanding that the present health
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services and medical education system is lopsided in the
interest of the privileged few and must change to serve
the interest of the poor people of India, is common
conviction.
mfc is registered under The Societies Registration
Act 1860; No. MAH/902/Pune/81 and under The
Bombay Public Trust Act, 1950; Reg No. F-I996 (Pune).
Membership
Anybody who broadly agrees with the perspective
and the rules and regulations of mfc is welcome to
become a member. Non-doctors are encouraged to join.
The membership fee is given below. It is understood
that members capable of contributing more than the
minimum will do so. Conversely the convenor can
waive or reduce the membership fees in deserving cases.
For membership forms and rules and regulations, please
write to the convenor.
Menibetship fees
Rs. 750.00 p.m.—
Rs. 25.00 per year
Those earning more than Rs. 750.00 p.m.—
Rs. 50.00 per year
Those earning less than
Membership fee includes subscription to the mfc
bulletin.
Bulletin subscription
Within India—Rs. 15.00 per year
(add Rs. 3.00 for payments by
cheque)
Life subscription—Rs. 250.00
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MEDICO FRIEND CIRCLE
Foreign countries
—sea mail—US $4.00 for all countries
—air mail: Asia—US $6.00
Europe, Africa & Australia
—US $9.00
North & South America—
US $11.00
All payments my be made
DHRUV MANKAD
in the name of medico
Convenor, mfc
friend circle and sent to:
Office
1877 Joshi Galli
Nipani 591237
Belgaun, Karnataka
Publications
The following are obtainable from the above address
on payment:
1. Subject-wise index of first 100 issues of bulletin.
2. Anthologies ofbulletin articles.
I—In search of Diagnosis
II—Health Care Which Way to Go
III—Under the Lens—Health & Medicine
(From Jan 1985).
3. Back issues of some of the bulletins (ask for sepa
rate list).
4. Editorial guidelines for contribution to buletin.
5. Background papers of some annual meets (ask
for separate list).
Bulletin Back Issues
Xerox copies of mfc bulletin back issues are avail
able with the Centre for Education and Documentation
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(CED), 3 Suleman Chambers, 4 Battery Street
Bombay 400039.
In order to cover costs and at the same time provide
subsidies to deserving groups as graded rate structure
has been worked out and is available on request.
For mfc members rate is—
i. set of 100 issues—Rs. 240
ii. specific issues—Rs. 4 each
iii.' specific article—0.60 p. per page
mfc Durg Campaign
For further details write to Anant Phadke,
mfc Rational Drug Policy Cell.
50 LIC quarters, University Road, Pune 411006.
326
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