COMMUNITY HEALTH / WORKER TRAINER / EDUCATION
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RF_COM_H_33_SUDHA
JLcrn H -33-1
DR MOHAN KUMAR B. THAMBAD
Background Paper - IV
Community Health Trainers Dialogue
October 1991
OVERCOMING
NEBULOUS
MEDICAL
THINKING
EDUCATION
AND
IN
ACTION
ON
INDIA
»
Debabar
Banerji*
June 24, 1991
*
Professor, Centre of Social Medicine
Community Health,
School of Social Sciences, Jawaharlal Nehru University,
New Delhi - 110 067.
Overcoming Nebulous Thinking And Action On Medical Education
India
Foundation of Practice of Medicine
Admittedly, human beings anywhere in the world have almost the
same anatomical configurations, physiological activities and
pharmacological responses.
Disease causative agents cause similar
pathological changes in them and they have responses to therapeutic
interventions.
However, it is important to note, that these
elements of medical sciences are used under different conditions
in different communities.
In any case, they form only a small
component of the practice of Western medicine.
They are merely
the bricks of edifices that are built under different conditions.
In terms of other components of practice of Western medicine, there
are many fundamental differences’ between Western industrialized
countries (i.e. the North) and the Third World (i.e. the South).
The North and the South are indeed poles apart in the practice of
Western medicine.
Performance of a delicate heart operation by a
pediatric surgeon in a sophisticated hospital in an affluent
country and treatment of a severe case of diarrhoea in a child by
oral rehydration by the mother in a remote hamlet in the Himalaya’s
underline extreme variations in the practice of Western medicine.
The difference in these two models of practice of Western medicine
is in the terms ofs
sciences;
(a) relevance of different elements of medical
(b) formation of technologies that embody those elements
of medical sciences; and,
(c) organisation and management of the
health services for the '‘'delivery” of the chosen technology.
Interplay of the complex factors associated with the prevailing
ecological setting, epidemiological situations and cultural,
social, political and economic conditions have brought about these
major differences in the two models.
Health service development in a country like India should,
therefore, be studied in terms of the cultural response to the
complex process, referred to above. This response generates?
(a) cultural perception of health hazards and their cultural
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meaning;
(b) health behaviour; and (c) various forms of health
technologies, practitioners and institutions, through cultural
innovation, cultural diffusion and/or through purposive
intervention from outside agencies. Thus, this complex process
forms the foundation or the base on which the health service
system of a country is built. The complex conditions forming the
base determine the shape of the health service system or the
superstructure and its subsequent growth and development, The
base thus places a constraint on the architecture of the edifice
that can be built on it.
The task before socially sensitive community health physicians in
India is to become architects who have the competence to understand
the basal (i.e.z concerning the base or the 'infrastructure’)
conditions, both at a given time and in a time dimension, and use
such understanding to build a superstructure which can maximise
the alleviation of suffering due to health hazards, again both at
a given time and in a time dimensiono
It may be noted that
production of architects is itself a function of the dynamic
interactions within the base.
When there is a strong, democratic
movement within a socio-political system, it is conducive to the
formation of more competent socially sensitive community health
physicians and in larger numbers.
Sometimes, as a result of the struggle of the masses, the basal
conditions may be favourable to building a stronger edifice for a
people-oriented health service system; the reverse may be the case
on other occasions.
It may be emphasised that favourable basal
conditions do not automatically lead to the formation of a
stronger superstructure, A society would need a balanced team of
architects, engineers, masons and other workers to take full
advantage of the favourable basal conditions. The onus for
attaining this balance is on the political leaders.
Efforts Towards Social OrierdLatw
One of the significant aspects of development of medical education
in India is that even before attainment of independence, both the
colonial rulers as well as the leaders of the National Movement
were conscious of the need for adopting a different approach in
the context of the entirely different conditions prevailing in
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3.
India. The concern of the leaders of the National Movement were
expressed in the report of the National Health Sub-committee of
the National Planning Committee (1948) of the India National
Congress (Sokhey Committee)o The Shore Committee (GOI 1946),
which was constituted subsequently, was much more forthright on
■f^His subject. It had very carefully discussed the central question
of abolition of the licenciate programme. One of the major
arguements of the majority of the members for abolition of that
programme was that they visualised fundamental changes in medical
education to create what they had termed as a .“Social Physician”,
The Shore Committee had observed (GOI 1946 s 18) that the
physician of to-morrow must be;
a scientist and social worker, ready to cooperate
in teamwork, in close touch with the people he
disinterestedly serves. a friend and leader he
directs all his efforts towards the prevention of
disease and becomes a therapist where prevention
has broken down, the social physician protecting
the people and the guiding them to a healthier
and happier life.....
A health organisation enriched by the spirit of
such a medical profession will naturally work
towards the promotion of the closest cooperation
of the people.
It will recognise that an informed
public opinion is the only foundation on which the
superstructure of national health can safely be
built.
The inter-linkage of the National Movement and. thinking on
re-orientation
eciuccL-cxoii jis
-» a very significant
orientation ot
of meciicai
medical^education
phenomenon. Indeed, this has given quite a distinctive
perspective to the approach to medical education in India.
As early as in the mid-fifties, India had taken the bold step to
bring about fundamental changes in the approach to medical
education, with the upgraded departments of preventive and social
medicine, expected to play the pivotal role. Subsequently, a
number of commissions have sat and a number of national
conferences have been held to stimulate this process.
. .4
4.
Taking note of past experience, the Group of Medical Education ano.
Support Manpower (Shrivastav Committee) (GOI 1975), which examined
medical education in the context of the reorganised health
services, submitted in April 1975 a programme for immediate action.
Against a background of the need (a) to relate the problem of
health to poverty;
(b) to provide training in health services to
community representatives;
(c) to strengtnen primary health
centres; and (d) to develop a-referral service complex, the Group
made many far-reaching recommendations concerning the basic content,
g-^xueture and process of medical education. issentiall
. • ie gro ..p
was for the creation, by an Act of Parliament, of a Medical and
Health Education Commission (patterned on the University Grants
Commission) charged with the responsibility oz determining and
implementing a radical programme of reform in medical and health
education, and with functioning as an apex coordinating agency in
close and effective collaboration with the statutory national
councils of health professions<,
The Shrivastav Committee emphasised the need for m-depth
discussions and taking of concrete steps for "immediate”, vigorous
and sustained implementation" in- tackling important issues. .These
includedj determining of objective of undergraduate medical
education; giving it a positive orientation." reorganising pre
medical education, revising the undergraduate curriculum, including
training of teachers; production of teaching and learning
materials; adopting suitable teaching and evaluation methods and
creating necessary physical -facilities; reducing the duration of
the course while ensuring improved standards; reorganising the
internship programme, postgraduate teaching and research and
continuing education; and, research and evaluation of health
manpower nereis»
The report of the Group was favourably received by the Government
of India which called yet another nationwide conference of heads
of medical colleges to work out details for implementing atleast
some of the recommendations. The TCSSR-ICMR report, Headth for
All". An Alternative Strateg---, further reinforced the Group's
recommendations (ICSSR-ICMR, 1901). The working Group of the
Planning Commission set up to work out a detailed strategy for
attaining Health For All by A.D. 2000, reiterated the need for
5.
radical transformation (GOT 1981a)o
These efforts are reflected in the Sixth Five Year Plan (GOI 1981b)
which states that the ’’emphasis would be on bringing about
qualitative, improvement in medical education and training" which
should include, at the undergrafv~te level, six months of
compulsory internship and modifications in curriculum,training of
medical undergraduates in certain fields relevant to the problems
of rural health care, community orientation, etc., and encouraging
private doctors to settle in rural areas through various
incentives".
Flowing from the ideas in the Sixth Plan, the
Government of India (1983) had asserted that post-graduate
education would be rationalised to effect a balance between the
national requirements of specialisations and opportunities for
medical graduates for advanced study. Continuing education and
inservice training would be promoted. Medical research would be
directed towards several problem areas like bio-medical and public
health problems, particularly communicable diseases, the economic
aspects of health administration and management, etc.
Among the
task-oriented research programmesfor achieving the above
objectives, would be "close and continuous studies in the area of
information support, manpower development, appropriate technology,
management and community involvement to ensure the reach of
benefits of primary health care programmes to the rural
population"
(GOI 1983 2 58).
The report of the consultative group of the National Education
Policy in Health Sciences (1989) is the latest document in the
series. Even though it had the benefit of the hindsight of the
earlier reports, it contrasts very sharply even in the process of
analysis of issues, in drawing inferences and in making
recommendations. It marks a ne’j low in the quality or study of
medical education in India.
Health Services, Health Manpow.-^q Development arid Medic al Bducati on
One of the most significant requirements for strengthening medical
education in any country is to consider it as a part of the overall
approach to policies and programmes for Health Manpower Development
(HMD)
(WHO 1985).
It is not possible to consider undergraduate
medical education in isolation. It has to be seen in the
background of post-graduate medical education, including education
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6a
‘
and training of physicians and other personnel for community health
work, in terms of nursing education, education for public health
engineers, social scientists, health educators, communication
specialists, and so forth. In turn, HMD can not be visualised
without having a clear understanding of the overall health service
system.
Again, a health service system has to be developed on the
basis of data derived from carerully conducted health systems
research. Therefore, research for HMD can only be conducted in
the context of Health Service Research for Manpov’er Development
(HSMD)
(Fulop and Roemer 1982).
It is not always possible to work under ideal conditions«
If one
has to consider medical education without having enough information
concerning health manpower development and/or the health service
system, it is essential to have atleast a.broad understanding of
the structure of the health service system and the approaches to
develop other components of the required health manpowero
Even with a very broad understanding of the conditions, it becomes
quite clear that defining the content of medical education is a
If the contents are
crucial issue in medical education in Indiae
not defined adequately, all the other activities in the field of
medical education lose a great deal of their relevance. This is
because in a country like India it is totally unacceptable to
interpolate the contents that have been developed in the context
of the affluent Western countries. The onus for bringing about
social orientation of the practice of clinical medicine and public
health in India rests squarely on scholars of this country.
It is
in this area that medical education in India had suffered most.
Even when very well researched ideas have been developed uo give a
different content to medical education in India, that has not been
followed by the authorities concerned.
This active resistance of
the authorities to bring about a social orientation of the content
of medical education in India is rooted in the power relations
emanating from the social structure and is by far the most
critical problem facing this field. The Shrivastava Committee
had raised the question of content or curriculum. However, it has
not realised adequately how critical this issues is in itself and
in giving shape to the other elements of medical education, which
are discussed below.
The consequence of the active reluctance to change the content is
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7«,
that the teachers by an large have alienated themselves from the
actual requirements for the making of Social Physicians visualised
by the Shore Committee. Over and abovez there are very serious
problems of having infrastructural facilities for providing
medical education. An extreme, example of almost a mockery of
medical education is to be found, in the establishment of the so
called capitation fee medical colleges in the country.
That
despite their very poor infrestructure, politicians have not taken
steps to curb the mushrooming of this type of medical colleges is
a reflection of the socio-cultural and political conditions
prevailing in the country.
Weaknesses in the infrastructure is
reflected in providing the so called rural exposure to the
students.
Unfortunately, by rural exposure it is usually meant to
take students to rural areas where teachers of the medical colleges
teach them about rural health. What has been the basis of the
teacher's teaching about rural health? What has been the
competence of the teachers to do that? What efforts have been
made to develop the content of rural health teaching? Such
crucial questions are seldom asked. Because of these limitations
it is not surprising that the much acclaimed Rural Orientation of
Medical Education (ROME) has failed so consipicuously.
The same
applies to the experience of involvement of social scientists in
medical education.
The problems in medical education that are being seen today ought
not to have been so serious hac' the institutions which had been
specifically developed for strengthening medical education had
satisfactorily performed the functions assigned to them. One
example is that of the All India Institute of Medical Sciences
(AIIMS) in New Delhi. One of the key mandates of the AIIMS has
been to provide leadership in medical education to the country as
a whole, Development of the discipline of preventive and social
medicine was an integral part of that mandate, AIIMS has fallen
far short of that mandate. Similarly, there has been the Indian
Association for Advancement of Medical Education, They have made
some brave efforts. However, these efforts were seldom followed
up in the form of specific action programmes, The idea of
having separate medical univers.4.ties is being tried out in states
like Andhra Pradesh and Tamilnadu. These Universities have not yet
come out with any new directions for action. As pointed out
earlier, the Consultative Group of National Education Policy in
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p
Health Sciences is the latest in this seriese An analysis of the
process of thinking which formed the bases of the re c omme nd at i on s
and actions of these institutions will reveal the reasons why th ey
could make so little contributions.
Crisis in the Medical Profession
One very unfortunate outcome of the present state of medical
education in India has been the -nature of socialisation of the
students who go through the process of education. It is indeed
difficult to imagine that the graduates who come out of medical
colleges, and who join various services or undertake private
practice, indeed belonged to the cream of the society at the time
when they had entered medical colleges. It is a severe indictment
of the system of medical education in India that it "converts"
some of the brightest students of the country into such dull and
unimaginative groups of the physicians, after they complete their
education. As if that is not enough): they receive a very raw deal
if they happen to join the health services in the union and state
governments, -when compared to, say, those belonging to the xAS.
The product that are seen, say, 10 years after their graduation
most often bears almost no resemblance to the brignt young boys
and girls who had been chosen for entrance into medical colleges,
This sums up the real crisis in medical education and the medical
profession (Banerji 1989)., This needs to be attended to urgently.
-'<?ed the sit^-4'”’
’
The Shrivastva Committee has
following words (GOI 1975: 38-39):
It is widely recognised that the present
•i n the
system of undergraduate medical education
is far from satisfactory.
Despite the
recommendations made by numerous '
Committees and Conferences, improvements
in the quality and relevance of medical
education have been tardy.
Although
the setting up of Department of
Preventive and Social Medicine in the
medical colleges over 15 years ago was
a step in the right direction, this by
itself has not met with significant
success as it lacked' scholarly foundations
and the field practice areas have not
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been adequately prepared.
The stranglehold of the
inherited system of medical education, the exclusive
orientation towards the teaching hospital (five
years and three months out
the five years and six
months of the total period of medical education
being spent within the - J--f-.ing of the teaching
hospital), the irrelevance of the training to the
health needs of the community, the increasing trend
towards specialisation and acqu.isition of post
graduate degrees, the lack of incentives and
adequate recognition for work within rural
communities and the attractions of the export market
for medical manpower are some of the factors which
can be identified as being responsible for the
present day aloofness of medicine from the basic
health needs of our people".
Reporting four years later, the ICSSR-ICMR Study Group (ICSSR-ICMR,
1981; 156-59) did not find the situation any betters
"In spite of all expansion, doctors are still largely
urban-based; and their distribution between different
States is uneven.
Standards have improved in some
institutions and some, sectors, but the average has
declined considerably because of the proliferation'
of sub-standard institutions. The medical education
system and the health, c
delivery system have each
gone their separate waysc
There is little
congruence between the role of the physician and the
needs of society, little equilibrium between
medical education-snd health care', Medicine is
still regarded essentially as an enterprise of
science and technology; the physician is the
repository of all knowledge and dispensations;
specialisation is the hallmark of. progress; and the
training ground is the teaching hospital. Recent
efforts to change this unhappy situation, to
produce the ‘right’ kind of doctor and to give
a community orientation to medical education, have
yet to make any meaningful impact"o
Conclusion,
The field of medical education reflects the paradox that exists in
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many other fields of socio-economic development in the country.
Gunnar Myrdal had long back labelled this paradox as a "soft state'1
-high on rhetoric and low in implementation. It may, however, be
noted that the very fact that the leadership had to take to
rhetoric shows that there are pressures from the people which
impel them at least to talk about social issues;■there are so many
countries which do not even have the rhetoric.
The critical need to bring about social orientation was being
talked hbout by the political leadership well before India
attained independence. Active steps were taken to bring about the
needed changes about four decades back. However, these efforts did
not bear fruits. On the contrary, the political leadership and the
leaders of the medical profession have not been successful in
preventing the steep decline in almost every aspect of medical
education. The profession has failed even to diagnose the malady.
The result is a plethora of prescriptions mainly focussing on
isolated symptoms. There is little scientific efforts at a
holistic conceptualisation of medical education as a complex
interdisciplinary system, which, in turn, is a subsystem of the
wider health manpower development. Again, health manpower
development must be based on a scientific approach to health
service development to meet the health needs of the people of the
country.
Seen against this background, the approach adopted by
some key studies of medical education is nothing short of quackery.
For instance, the Shrivastava Committee and the ICSSR-ICMR Working
Group had advocated the setting up of a Medical Education
Commission on the lines of the University Grants Commission (UGC)
as a keystone of their recommendations.
If they have studied the
role of the UGC in relation to strengthening higher education in
India, they would have been at least a little less euphoric about
their recommendations.
The analysis and 'the recommendations of
the U.S. Bajaj Consultative Group provide an even more disturbing
example of poor quality of thinking among top level medical
educators of the country. This shows how deep is the malady that
is afflicting medical education in India to-day and hovz urgent it
is to have a critical mass of scholars who are capable of
developing a more holistic and a more scientific approach to this
very important problem.
11.
References
1.
Banerji, D (1989)? Crisis in the Medical Profession in India,
Economic and Political Weeklyt Volo 24, No. 20, pp. 1091-1092.
2.
Fulop, T and Roemer, N.I, (1982)S Ip t e r n a t _ig n a 1 De ve 1 opme nt
°. Polic •.-, Oeneva, World Health Organization
TwhO Offset Publication l.bc 61), ppo 157-161.
3
Government of India, Health Survey and Development Committee
(1946) ? Report (Shore Committee), Delhi, Manager of
Publications, Vol.IV.
4.
Government of India, Group on Medical Education and Support
Manpower (Shrivastav Committee) (1975) Health____
Services and
Medical Education? A Programme for Immediate Action, Report/
New Delhi, Ministry of Health and Family Planning.
5.
Government of India, Working Group on Health for All bj? 2000
A.D. (1981a)s Report, New Delhi, Ministry of Health and
Family Welfare.
6.
Government of India, (1981b)? Sixth Five Year Plan, 1980-85/
New Delhi, Planning Commission.
Government of India, (1983); Annual Report 1982-83, New Delhi
Ministry of Health and Family Welfare.
Government of India (1989)? National Education Policy in
He a1th Sc ience s, (Chairman 2 J„ S.Baj aj’lDelfhi”,
Ministry of Health and Family Welfare.
7.
8.
9.
10.
11.
Indian Council of Social Science Research and Indian Council
of Medical Research (1981) ? Heplth for All? An Alternative
Strategy - Report of a_ Study Group Set up_ Jointly by ICSSR
and ICMR, Pune, Indian Institute of Education.
National Planning Committee,
Sub-Committee on National
Health (1948) s
(Sokhey Committee Report), Ed by
K.T. Shah. Bombay, Vora.
World Health Organization (1985) • Report of a E^cpert
Committee on Health Manpower Requirements for the Achievement
of Health for All Joy the year 2 000 through Primary Health
Care, Geneva, World Health Organisation#
(WHO Technical Report Scries No. 717).
x-x x-x -X-X-X'
%
_ S3-2-
Community Health Trainers Dialogue
Background Paper
II
tiye^Concerns
KEY COMPONENTS HHICH SHOULD FORM PART OF AN EDUCATIONAL POLICY FOR
HEALTH SCIENCES IN INDIA
An opinion poll on the Key Components that the 'dialogue'
participants feel should form part of an Educational Policy for
.lciences in India was carried out as a sub section of the
participant form.
These are collated under six sub sections ;
1«
2.
3.
4.
5.
6.
^'ocus
Broad components
Content / skills
Methodology
Process
Issues
The collation will give participants a feel for the collective
concerns of the group participating in the dialogueo
The list is exhaustive, <covering a wide range of ideas and issues
arising out of the diverse
(
_i
-a experience
and perspectives of the
group but the overall thrust
towards
--- -.j a more community oriented,
socially relevant, responsive, pro-people oriented educational
policy is evident.
The listing is in a contextual order using original wordings as
far
as
.
.
-possible., Since who said it is not as important as what
is said names have not been indicatedthough participants will
be able to identify their contributions.
N'ote ’
w
resP°nses were received before the new Educational
Policy was circulated to all participants o They not only
emphasise many points covered in the Bajaj report but raise
many other crucial issues which need to be discussed further
at the workshop.
o
t KEY components which should FORM PART OF AN EDUCATIONAL POLICY FOR
HEALTH SCIENCES IN INDIA
FOCUS
1
Unambiguous focus on the needs of the majority (therefore
appropriate focus on diseases of the poor and their causes)
2.
Should concentrate on diseases which effect the poor
3.
Should pay greater attention to existing knowledge in
communities in order that people can become self reliant
in many health problems
4.
Should shift from tackling only biological causes and to look
at a medical problem wholistically and tackle the root cause
5
Should shift from study of diseases only to related subjects
as well,
like ecology, environment, natural science, socio
economic structures of a society etc..
6O
Community Health with full involvement of local community
to be stressed
J
i
BROAD COMPONENTS
7.
Comprehensive health manpower development with educational
strategies
8O
Policy should cover training of all health personnel and their
continuing education
9.
Policy should build from actual Indian experience both from the
government and the NGO sectors
10. Coherent vision of links between education of medical, paramedical
and other health professionals
11o Relevance to local needs
120 Training
in Indian, systems of Medicine and of folk health
practitioners should receive equal importance
13. Social orientation of doctor
14. Stress on process of education not only content
15. Close interaction between training centres and health services
16. Linkages between health care delivery and education in health
sciences
17. Awareness of traditional / peoples initiatives for health /
indigenous health remedies / herbal medicine
18. Integration of these initiatives into all health plans
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19. Alternative systems of health care to be _giyen equal importance
20. Integration and inter relatedness of Community Health and Indian
systems of medicine
21. Continuing Education should be a component of policy
22. Policy should recognise the role of research into the various
aspects of education of health personnel
23. Involvement of local health practitioners and traditional birth
attendants (dais)
24. Compulsory placement in rural areas before securing degrees.
CONTENT / SKILLS
25. Greater emphasis on Medical Sociology
26. Developing skills in health economics
27. Adapting management to Health Care delivery
28. Defining role of behaviour modification
29
Socio economic analysis of the country
30. Analysis of the health situation of country
31. Communication and skill development
32. For health personnel to recognise and accept the need for a
multi disciplinary approach
33. To understand and be able to tap government programmes
34. To focus on functional literacy of women
35. To understand and accept that eradication of serveral medical
problems are with.other departments of the government
36. Concern for socio-economic cultural realities and skills to
translate this concern into practice
37. Promulgation of Rational Drug Therapy
38. Planning and Management from the grassroots onwards
39. Competence in comprehesive health care, imbued with human values
40. Holistic approach to growth and development
41. Deeper study of tropical diseases and local remedies
42. Community health trainers - should be given more inputs in s
legal aid; afforestation and nutrition; cooperatives; practical
nutrition; preparation of lowcost teaching aids; indigenous
medicines; safe remedies' for basic treatment.
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3.
METHODOLOGY
43. Training environment
44. Methodology of Training and Continuous learning
45. Some specialization from the very beginning (focus)
46. Involvement of all departments of health science institutions
in Community health programme
47. Integration and coordination of health sciences to various
other subjects
48. Health to be considered an integral part of social science
49. Training with a ’Health team approach’ rather than as individual
50. Training to be 'skill' oriented predominantly
51. Orientation towards 'enabling process' rather than provision of
services only
52. Promote Total Health Care and forego divisions e. g., promotive /
preventive / curative / rehabilitative etc.
53. Prime importance to be given to community based health care
54. Learning should be more population based and community oriented
55. Small group - self - and community - institution and problem
based learning
56. Greater emphasis on social, ethical and managerial components
57. Problem solving approach
58. Social medicine should be stressed during the clinical postings
also.
PROCESS
59. Selection of medical / health professionals (community sponsor
ship, gender, rural bias, age etc.)
60. Broad based and liberal pre medical education (psychology, logic,
philosophy, sociology etc.)
61. Pre medical guided rural experience
62. Role of the trainee
63. Reorientation of Trainers
64. Compulsory rural service before postgraduation
65. Modification of medical curricula to include practice in community
medicine
66. Teacher development / reorientation in social analysis and
problem solving techniques
67. Closer interaction between NGO trainers and government training
centres
68. PHC’s coming under ROME programme should be technically under
the control of medical college
69. Examination system should be reviewed
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4.x
ISSUES
70. Lower level such as RMP etc., needed, area planning with regard
to the number of specialists etc., only, These need to be
trained
71. Create healthy environment for children
72. More needs to be a focus on all members of the health team
73. VJe should examine alternatives in training
74. How do we get well trained people to work and be happy
75. Reducing number of drugs to basic ones and eliminating reduplication under different brand names - hence rationalising drug
use and availability.
76. Primary Health Care delivery of area drained by medical collego
should be shouldered by the institution
77. Privatization of medical / health science teaching institutions
should be restrained
78. Decentralization of teaching institutes
79. Decentralised planning in health policy.
This collation is derived from the response of the following 24
participants (received as of 31st July 1991)
Dara Amar, Rajaratnam Abel, Desmond D’Abreo, Margaret D'Abreo,
Pramesh Bhatnagar, Vijay Sherry Chand, C.M. Francis, Hari John,
Ulhas Jajoo, Prem Chandran John, Abraham Joseph, Dhruv Mankad,
Daleep Mukarji, Jose Melettukochiyil, Sujatha de Magry, Ravi
Narayan, Thelma Narayan, Shirdi Prasad Tekur, Sebastian Poomattom,
Amla Rama Rao, F. Stephen, Satish Samuel, Valli Seshan and
John Vattamattorn.
^oiiective_ Concerns
h
KEy CONCERNS / 153UB5 WHICH ARE IMp0RMgp f0
' -3'6 3
IN ORDER TO
■BP ™e‘ cwrmniMW ce commons
INDIA.
An opinion poll, on the kpy concerns that the
dialogue participants
feel would help
enhance the contribution of
^Community Health
Trainers in India,
was carried out as a subsection of the
Participant form.
These are collated under eight
subsections
- The Background
- Contextualising Community Health
- Exploring related issues
- Medical Education Policy
- Collating / Analysing Community Health Training experience
~ Building Collectivity among trainers
- Issues arising out of
community Health Training experience
- Additional issues.
This collation will give participants a feel for the collective
concerns of the
group participating in the dialogue.
The list is exhaustive, covering a wide
range of ideas and issues
arising out of the diverse experience and
perspectives of the
group but the overall thrust towards
a more community oriented,
socially relevant, responsive.
’ro-people oriented educational
policy is evident.
The list is in a contextual order
Uoing original wordings as far
as possible. Since who said it
is not as important as what is
said, names have not been indicated
though participants will be
able to identify their contributions.
KEY CONCERNS / ISSUES WHICH ARE IMPORTANT
TO REVIEW IN ORDER TO
ENHANCE THE CONTRIBUTION OF COI14UNITY HEALTH
I'RAINERS IN INDIA.
THE BACKGROUND
01. Increasing poverty of the masses
02. Declining health situation of
women and children
03. Growing communalism and religious fundamentalism
. Ever-growing commercialization of health care system
05. The overall need for social justice
06.
DaSrring ancient health patterns (practices) in rural
areas (e.g. ragi to polished rice)
cnees;
°7-
On
-aiQ1„es espedaliy Injections/
08. Neglect of rural arcareas by Government Health Departments /
Doctors / Hospitals
09. Drugs coming within the
scope of ’Industries’
The overall thrust in health c a re
10. To
not, if not look for tAe .altSSw
P°OreSt or
11. To explore ways of discovering cnh-i,ran,
information from the people
ltura-ly relevant health
12. T°W^kAthem (PeoPle> look st health
problems in a more
wnolistic way
13• T°
iayS °f Usin9 alternatives to empower people
especially the women and put health back
ck into their hands
CONTEXTUALISING / CI.ARIFYTNG
COM MUNITY HEAT .TH
14. Understanding of social
.
realities
in India and a deeper
analysis of the situation
1.5. Exploring Community health components
- curative. preventive
and promotive in
.n the local context
16. Community level workers / volunteers / their
potential as
primary health care provider
17. Community health in
the context of people's organisations
and changing health practices
18.
L|SorI
Xrnity health ln the context of wider societal
-actors that operate in India.
. .2
2.
EXPLORING RftLATED ISSUES
19. Changing life styles for positive health
20. What is scientific and relevant health care?
21.
22.
23.
24.
Integration of community health aspects of clinical medicine
Economics of Health
Integration of Indian Systems of Medicine with Modern medicine
Understanding of the econcr: ics of health / mechanics for
appropriation of public finance and communication / organisation
of the society
25. Lack of team work among different categories of health workers
and ways of overcoming it
26. Avoidance of identity crisis between SPM /^PSM / public health /
community medicine / community health etc.
27. Using greater levels of behavioural sciences / psychology /
communication to bring about long lasting changes in health
practice among people
28. Identifying levels of demystification of medicine
29. Issue of non medical versus medical administration
30. Role of pharmaceutical MNCs in drawing up syllabus for
medicine
MEDICAL EDUCATION POLICY
31. Understanding the existing situation
- the class from where students come
- the location of educational facilities
- the appropriateness of curriculum and textbooks
- the elitist and commercial nature of the products
of medical schools
32. Reviewing the existing Medical / Health Education Policy
from a social / economic / political context
33. Health Manpower Development - Policy
exploring existing policy and the lacunae
34 Understanding Medical brain drain
35. Evaluation System should be reviewed
36. Internship should be made more effective
37. Health Management should be stressed to a large extent
38. Training in Social Sciences to be strengthened
. .3
'i
3e
* COLLATING / ANALYSING COMMUNITY HEALTH TRAINING EXPERIENCE
39. Review of ■training
’
* '
and finding out the impact of the training
40. Quality of training
41. Methodology of training in community health
42. Use of innovative methods
43. Identification of appropriate skills
44. Follow up of health workers 10/15/20 years after their
training - what role are they playing / have they played
in health work / what areas need strengthening /"'what
methodologies are suitable, for continuing education
45. New approaches to learning
46. Problem solving methods and approaches
47. Work experience in projects
48. Collection of experiences to modify text books / teaching
materials in mainstream medical education
BUILDING COLLECTIVITY AMONG CO.I-24UNITY HEAL TH TRAINERS
49. Networking to share experiences and enhancing collectivity
50. Peer group evaluation to increase accountability and improve
standards
51. Sharing experiences, avoiding",.duplication and wastage of
resources
52. Sharing resources
53. Dialogue and sharing of experience between community health trainers
54. Develop a directory of what is available, where and for whom
55. Need to consider training at different levels
56. Regular exchange of ideas among community health trainers
of different parts of the country
ISSUES ARISING OF COMMUNITY HEALTH TRAINERS EXPERIENCE
57. Community Health trainers to be clear on what being a
catalyst means
58. Reinforcement of identity - community health trainees as
'social educators’ first of all (attitudes, motivation,
involvement)
59. To know and accept that health care is only one factor
responsible, for Health?
60. To have real experience at field levels by living with a
low income family in the village and based on this experience
to adapt their learning to give effective health education
. .4
4.
61.
62.
63.
64.
65.
Population based education should be given higher priority
Need to consider training of trainers
Is there a need / role for registration / standardization?
*
Standardization of training needs with scope for flexibility
Communication / interactive abilities of trainers to be enhanced
66. Trainers should have field contact on an ongoing basis
67. Trainers should have awareness about politics in health
68. The Art of communication should be stressed for both trainers /
trainees
ADDITIONAL ISSUES
69. The possibility of incorporating certain aspects of an
alternative into the mainstream paramedical training
70. Accreditation to enhance security / recognition of t-rainees
from a long term point of view
71. Provision of legal status to the trained
72. Provision for continuing education and capability to work
upward from any level of trainee knowledge
73. Transferring NGO experience to Government
74. Sharing of experiences / methodology with government /
professional groups in a spirit of dialogue
75. Interaction of community health trainers and ’the system’
be it professional or government
76. Mechanics of intervention at policy level (political action)
77. Community health trainer’s deep commitment to participatory
approach should influence policy of health care and medical
education.
This collation is derived from the response of the following 24
participants (received as of 31st July 1991).
Dara Amar, Rajaratnam Abel, Desmond D'Abreo, Margaret D’Abreo,
Pramesh Bhatnagar, Vijay Sherry Chand, C.M. Francis, Ulhas Jajoo,
Hari John, Prem Chandran John, Abraham Joseph, Daleep Mukarji,
Jose Melettukochyil, Sujatha. da Magry, Dhruv Mankad, Ravi Narayan,
Thelma Narayan, Shirdi Prasad 1 -kur, Sebastian Poomattom, Amla
Rama Rao, F. Stephen, Satish Samuel, Valli Seshan and John
Vattamattorn.
v * 'k
* * -A- k
k
k...
)i- 33 Lj
IDE'TIr TmTION OF LEADERS
Ifv HEALTH EDUCATION
/
Here identification and involvement of leaders in health education
programmes is not enough,
Dore important problem is to sustain their
interest; in the an. nj pa-ij responsibilities* Herein lies the skills
of a health educate- j.r. creating a situation to sustorn interests of
tic- leaders*
DRo K E.
SINHA
/
From tj.-e immemorial leadership has played a vital role
in bringing about changes in the society0
It is the human nature that
people want to work together for solving community problems vital for
the growth of the indivic'jal in particular aid of the society in general*
Indeed? the entire process of socialization is based u on the human
interaction and acculturatioru This process involves leaders in ini
tiating desired charv e for human growth*
for bringing about a change from undesirable to desirable
health practices through educational process? change-agents are required*
These change-agents are primarily concerned with the identification and
understanding of health- needs of a specific community*
They rank the#:
in order ot priority, find out available resources and develop a plan cf
action to meet the health needs*
In this process, the entire community
is involved and helped to help itself*
Ih the present day changing pattern of living?, it is of
significance to understand the multi-dimensional aspects of health and
disease? i.e* preventive, promotive, curative
It
curative and
and rehabilitative*
rehabilitativeo
has been found that most of the diseases can be prevented
And through
the process of health education? change in the knowledge, attitude and
health behaviour of the people car. be brought about*
Changing pattern of leadershi
However* behavioural c- •'i.nge requires unc erst.i idingxof the
changing pattern of leadership and the
..3 role of leaders as
nirge-agents*
It is well-known th; ■ there are variot . t^pes of le . •
t r communityo
In most of t ic cc. -s? leadership shifts frc,.
'■ L.i’- ion to
situation and the leadu.'&n ip quality o: traits are nt ■ .■ ■ ■ . lits
In
o
other words, leader- hip is not a persoi ality trait ai ■ ih can be
acquired*
Every situ-'., .on has potential leaders cr J 7 i ; leadership
quality can be developed*
I’or example? a person who h;:
been v.-isectomized
can Drove a good leader provided he is motivated to na; rate his successful
experiences to his friends, relations and the aommunit
This involves
the elements of education and training ito develop
"
his leadership qualities
an^1_iny°1V®
as, a change-agent tn motivate the peopl
in bringing about
a change in their knowledge, attitude and health behavi; T
r*o
However?' in
the villages of India, leadership pattern is still bast
upon kinship
and caste-structure*
This fact cannot be ignored*
But such leadership
is restricted to a particular segment of society*
Such leaders G«n be
f^voi-wnd in health education activities with clear understanding that
their area of influence is limited*
IIn our changing society, it is
necessary to understand who can do what, so that all the human resources
can be mobilized meaningfully to bring about desired change in health
behaviour of the people*
■i
r
-s 2 s-
Pre-requisites
.It is essential to identify leaders in the community before
they; are involved as change-agent s <,
Here, it is worth mentioning that as
e^irly as in 1949, L.Do Kelsey and CoC„ Herne in their book, "Co-operative
Extension Work” have pointed out that the pre-requisite for identification
of leaders is to know the following s
”1.
Uhat job is to bu done?
2.
What characteristics and skills this job requires?
3.
Where the person possessing the needed qualitifation
4.
What group will support or follow the person?
5.
Of the qualities he has ..'
’
can be found?
it
(a) Which of them may be improved by training
(b) Which may not be changed materially
6.
Of the qualities he lacks -
(a) Which may be developed
(b) Which may not be developed®
7o
The basis on which he can be induced to work n
In 1970,9 Dro
Dro So
SORo
RO Mehta in his book, ’’Emerging Patter* of
Rural Leadership”, has written that in the villages ’’there are pdssibly
six distinctive areas of social life”and it is necessary,'to identify
leadership in each of these areas separately”.
Six distinct areas are as follows
(a)
Persons most influential inperforming caste activities like caste
ceremonies, arranging marriages, or settling caste disputes»
(b)
Persons capable and active in organizing religious ceremonies like
’’Katha” an
(c)
’’Akhandpath”®
Persons capable of looking after the interest of village cooperative
societies®
(d) Persons worthy of acting as representatives in village Panchayats®
(e)
Persons capable and active in organizing and celebrating fairs,
festivals and sports.
(f) Persons capable of looking after the interest of village schools®
>
•
-s 3
It is not enough to know the above mentioned criteria
It is also important to know the nature and magnitude ef the health
problem, and targets for education as well as service:";-
Ip some cases, targets for service as well as education
'—y be the samef; but in others, they may bo different.
For instance,
may
in an immunization programme against smallpox, the service targets may
be children whereas
ducational targets may be either the . 'the'- or mho
father or both.
Socio-cultural .factors also play predominant role rn
decision-making process ot selection of leaders.
In certain situations 9
health rituals based on misconccotions and deep-rooted value system
and the role of priests cannot be ignored.
But at the 3ume time the
fact that has to be kept in view is that ’’whereever traditionalism has
given way for experimentation, social change has comet
Thus there are
certain situations which require more than one type of loaders. The
function of a health educator therefore is to understan;. such a situation
and decide the specific type of leaders required to bring out a change
in health practices.
For example, in a family planning motivation
programme for orthodox section of a community, it is worthwhile involving
religious leaders, satisfied acceptors of family planning and symbolic
leaders.
r
There is no denying the fact that symbolic and institutional
But, they can be more
leaders like "Sarpanchs” are very important.
importanto
effective as change-agents provided they are also functional , i.e., possess—
Such leaders are accepted
ing know-how in modern methods of agriculture,
Therefore,
situations must
as change-agents for diffusion of innovationo
taking
into
consideration
experiences
of work in a.
be carefully examined,
finding
out
negative
and
positive
forces
at work,
particular situation,
before
actually
identifying
loaders
for
their
stive
involvement
et Co,
in health programmes.
Net hods
.Based or th. iield experiences of orQani?_.ng health
education programmes in urban, semi-yrbnn and rural areas throucn the
involvement of local leaders and community participation , s 'me- r f tne
methods adopted for identification of leaders arc as io. i o.us <■
T The discusion metho d - I he discussion n-?t nod has been
pot ential
found to be an effective and simple method of ident ify.
Through formal and informal discussions or ai , topic during
leaders.
group meetings on various occasions, potential leaders
lear'- rs ; n b identified
who can initiate discussion and take the members of th aveup in the
direction in which they should move.
But it is essential to differen
tiate between a mere talker and a real knowledgeable i totor.-.
This
method also provides opportunities for potential xeauc. . to arose
interest in them and bring out their talent. This met
H is very useful
for long-term programmes.
2* The workshop method - In this method, a large group is
divided into sub-groups and leadership emerges out in each sub-group.
Through this method, a health educator can locate, over a per io d of t ime s
who can take the responsibility in undertaking the desired jobo In such
situations, the role of health educator is that of a consultant, observer^
discussion leader, etc.
-s 4 o-
Group observer — This is anthropological way of locating
leaderso
In this method, the health educator works in a commuhity for
quite sometime and makes his observation regularly*
On the basis of his
observations on various situations he prepares the list of potential
leaders. Here, it is important for the health educator to create a
siutation - where the community members do not get the impression that
they are being observed* This approach is action-oriented and the
selection of leaders is based upon the actions taken by the potential
leaders of the community«
Socio-metric method - This method is a little more
technical than the other methods. This method is generally used by
professional health educators, extension educators and trained social
workers* The pre-requisite for this method is well thought out set of
questions to be asked to the members of the different sections of a
community. The questions for example may be ’’Whom de you consult
when you fall ill?”, ’’Whom do you consult for the marriage of your
daughter", "Whom do you consult for purchasing particular variety of
seeds?" etc.
In this way, names of influential persons are listed from
different strata of a community and it is generally found th&t there
are only five to seven common persons whose help is sought to find the
solutions of various problems of different members of the community.
These potential leaders are known as "initiators” or "spark plugs" for
other members of the community.
5* The election method - Nany times leaders are
identified through formal or informal electiog method,
Ip this method,
the health educator involves the entire community or section of a
community in giving their opinion regarding their representatives to
work as change agent.
Go Seniority and past experiences - Sometimes, leaders are
identified on the basis of their involvement in health and welfare progra
mmes for the community. Experiences of working with certain persons
have proved useful in preventive and promotive aspects of health* Such
leaders are generally enthusiastic and energetic and in most of the cases
are innovators*
The above mentioned methods of selection oi? identification
of leaders are merely suggestive^ However, selection ci leaders depends
considerably upon thb situation and purpose for which they are selected
as change—agentso
Here identification and involvement of leaders in health
education programmes is not enough*
More important problem is to sus
tain their interests in the assigned responsibilities* Herein lies the
skills of a health educator in creating a situation to sustain interests
of the leaders.
1
pept. of Preventive ft
Social Medicine
St. John’s Medical CoHeglg
-a
BANGALC'RS-560G34.
<Lo r*n H - 3 S - S”
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AUDIOVISUAL
1.
AIDS IN HEALTH EDUCATION
What is an Audic- Visual Aid ?
An instrument or a device to assist the instructor in transmitting
facts. skills knowledge and understanding to a learner*
Audio Visuai aids are the materials and devices used in learning
situations to supplement the written or spoken word in the transmission
of knowledge, attitudes and increase the retentive power.
II.
Value
1)
2)
3)
4)
5)
6)
12)
8)
9)
of Audio-Visual aids?
Help to give correct concepts or impressions.
Stimulate interest
Promote better understanding
Supplement other sources of learning.
Add to variety to teaching methods.
Flake economy of timeo
Promote intellectual curiosity.
Tend to reduce verbalism or the. repetition of words.
Contribute to longer retention of 1
learning.
10) Can give new concepts of things
of ordinary experience.
III
outside
of the range
Types of Audio-Visual aidss
Audio Visual aids are broadly classified as two brand
division
a) Project?
1) films
2) Film strip
L.
I
3) Film Slide
4) Epideoscope
5) Overhead projector
.6) Television.
r
1
cont... .2.
A
4-
2 -
B) Non—pro i ect ed ’aidss
1) Black board
2) Charts, Granhs, Maps
3) Posters
4) Flash Cards
5) Flip charts
6) Flannel graphs
7) Pupoets
8) Models and specimens
9) Radio
10) Tape recorder
11) Folder
12)
Leaflet
13) Booklet
Filmss-
A motion picture is a series of still pictures, taken
in rapid succession, developed and finally projected combined with sound.
Advantages^
1) Provide real life experiences
2) Attract and hold audience attention
3) Combine sight and sound thus acting on two senses
at one time
4) High emotional response of the viewer
5) The audience are very close to the
objects, places
and situations that they could not ordinarily see.
in their daily live£.
/
Disadvantages^
1) No scope for discussion in the middle
2) One way process
3 ■
I
3) very costly
4) Needs Transport
5)
U
v
If films are not produced locally, it has a limited
value
!
3
Film Strips
A filmstrip is related sequence of transperent still
of 35 mm. film.
pictures or immages on a strip
Advantages s
1)
Lessexpensive
2) Flore useful
3) Can be- operated by the speaker-^asy to handle
4) Can be produced to
meet the local situation
5) Can be operated both by electricity as well as petromax.
I
Disadvantages s
1) When too long it will not be interesting.
2) Rough handling
Film-Slide;
A slide is an
may reault in damage.
individually mounted.transparent picture or
immage projected by passing a strong light through it.
Common sizes- 2” x 2”
or 3i i? X si" or 31/3 x 4i.
Advantages s-
1) Attract the attention of LT’io audiance, and arouse
interest in them.
2) Assist for lesson development.
3) Helps fur review of instruction.
4) Could be prepare locally without much financial resources.
Disadvantages £-
1) Liable to be damaged in the absence
of care,
2) Inproper use may cause disinterest in the audiance-#
Over head Proiectors
1
which could
A mechnical device used for teaching purposes
project the material as and when written.
%nt. .. 4
j
4 -
Advantages”
1) The material
is comparitively easy to prepare.
2) A variety of materials could be handled#
3) The instructor can face- the audience#
4) The instructor can point to or write on the material
while it is being projected#
Disadvantages"
instructor
It may become difficult”to use effectively if the
has not prepared the lesson plan#
Epideoscooes
■ A projected aid in which the printed material could
be made use of for projection.
Advantages *
1) Easy to handle
2) Less work to the
instructor.
3) Dual advantages i# 6o $ we ceuld use both slides and
printed matter.
Dis a d va n t a g is s
In the absence
of electricity it cannot be used#
I
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V.
Relevant Health Education:
Education by Appropriate Analogy
One cannot expect positive results from an educa
tion or political action program which fails to respect
the particular view of the world held by the people...
it is not our role to speak to the people about our
view of the world, nor to attempt to impose that view
on them, but rather to dialogue with the people about
their view and ours. We must realize that their
view of the world manifested variously in their action
reflects their situation in the world. Educational
and political action which is not critically aware of
this situation runs the risk either of the banking or
preaching in the desert.
Pedagogy of the Oppressed^
Paolo Friere
In the above quote by Paolo Friere, reference is feade to the
banking mode of education, a mode of education prevalent through
out the developing world. What is implied by the term banking
is that information is deposited into a villager’s mind verbatim,
as if the mind were empty. This mode of education presupposes
that once information is deposited it will incur interest over
time.
The poverty of this type of education is seen in village
India today in thedividend it is yielding in the form of inertia
and the compartmentalization of new ideas.
What is required is a form of education which engenders
synthesis and fosters the organization of new and existing infor
mation as opposed to the compartmentalization of information into
separate spheres of reality . The process of education which is
advocated evolves out of dialogue and the posing of appropriate
questions which reveal and challenge assumptions. Such education
necessitates preliminary investigation of the cognitive universe,
the phenomenological context in which the villager lives.
One of the purposes of a community diagnosis of health
study is the identification of indigenous concepts which may be
used in the framing of relevant educational strategies. These
strategies, rather than being based on ideas outside the villagers
comprehension, are based on what is already known or questioned.
In this sense, the mode of education recommended is an extension
of classical modes of education which communicated knowledge con
ceptually through analogies and metaphors poetically orchestrated
around immediate experience.
The reasoning behind this mode of education can be
illustrated with reference to everyday speech. Theeeveryday
speech of villagers is composed of numerous analogies, metaphors,
and proverbs. To understand such speech one has to comprehend
more than simply the words spoken. What is necessary is an
understanding of the relationship between what is spoken about
and what is being referred to. Commonly, an idea which is
easily understood on one plane is used to describe an idea or
istuation on another plane. By explaining something in this manner,
one is able to convey knowledge within one's cognitive framework,
permitting a minimum number of words to be used to convey a
maximum amount of understanding; understanding facilitated by
reference to what is already known thus making memory easy.
During the project, core staff experimented with analogical
reasoning as means of explaining new health ideas. First, attention
was focused on domains of knowledge and experience with which
the villager was familiar andwhich were commonly exploited in
local proverbs, analogies, etc. Then, such domains of knowledge
were considered in relation to priority issues in health education.
It is the opinion of the research team that it is possible to
explain any common biomedical concept vix a vis indigenous concepts
by maximising analogical reasoning. The examples given below may
illustrate the strategy used.
.9
V
-2-
1.
FIELD: BODY
1<1 Nutrition:
For your rice crop, you need cow manure, green leaf, and
ash. If you have less manure, your crop will have no heigh, if less
gree leaf is put. the crop will be less, if less ash is put the
husks will appear but inside there will not be grains. The body
is like that. Fish and grain are like manure, green leaf like
vegetables, minerals (iron, calcium) like ash. If you want a good
crop, you must make correct balance.
1,2 Family Planning - spacing
If you plant too many paddy seedlings very close to each
other, what will happen? Do they not interfere with each others
growth, do you not get a poor crop? Having children close together
is like that - should a mother give breast milk to one child
while pregnant with another? (Culturally women(South India) think
they should not continue breast feeding, but do because of a lack
of availibility of milk, funds to purchase milk or benevolence
particularly towards a male child.)
2.
WOMANS CYCLE: SEASONALf MOON CYCLE
2.1
benefit?
cycle.
Relative fertility in woman’s monthly cycle:
If a crop is planted in the wrong season is there any
A woman’s cycle is like a seasonal cycle, like the moon
Menses is like amavase/amavas/ (no moon, an inauspicious
time of overheat when no new work is begun)-- as the moon becomes
more full toward hunime (full moon- auspicious time which is cool
and linked to fertility) the benefit (labha) of acts begun is m
more, Hunime in a woman is the period 10-15 days after her
menses, if child is desired the seed should be planted in that
season. If a child is not wanted the seed should be thrown
at another time.
3.
COOKING: DIGESTION
3*1 Dehydration
If you are cooking some food and there is not enough
water in the pot, what happens? The food becomes dry and burns,
the pot burns as well and if not removed from the fire it may
become spoiled. Digestion is like cooking. If water is less in
the body, the body becomes dry and begins to burn, fever comes as
well as weakness. If water is not put in the stomach pot, the
heat spoils the blood and a lack of water may cause a person to die.
3.2 Dehyderation and Diarrhoea
Diarrhoea is like a hole in the stomach pot—water keeps
coining out and if more is not placed in the pot, the blood bums.
Wather must be placed in the pot until the hold can be repaired.
Repair requires medicine but even more immediately important
than repairing the hold is not spoilling what is in the pot
for that is life blood.
3.3 Dehyderation and Fever
Fever is like a pot boiling without a cover, The
liquid evaporates and the food (blood) in the pot burns, To
reduce this problem, medicine may be given which acts as a cover
for the pot(aspirin) but sometimes the problem is that the fire
under the pot is too hot. In such cases, medicine must be given
to reduce the fire/fuel (food) and the body must be kept cool.
But most important in any kind of fever is that the water in the
body be enough to prevent the blood in the stomach pot from
burning.
....3.
-33.4 Fontanel sinking in baby
When boiling rice, if the water becomes less what happens?
Doesn’t the rice in the center of the pot sink down? And then i f
water is added doesn’t the depression come back to normal level?
the liquid
in the body
So it is with a baby. If
:
- is less the fontanel/
When
enough
liquid
is
given
the
depressed area
netti depresses,
comes to the normal level.
3.5 Preparing Electrolyte solution
In the cooking pot, water is needed. For the stomach pot,
when water is urgently needed, boiled water which contains sweet,
salt, and sour is best. Salt is needed for the blood, Kara
(piquant) should be reduced as this increases heat. To help
digestion some sweet and sour are needed. Therfore, for every glass
of water, a pinch of salt, a small amoutn of sour (lemon, local
fruits) and sweet (2 sppons of jaggery, sugar, honey), are needed.
Digestion is the center and the most important precess in indi
genous ideology: connected to most illnesses)
4.
House? Body
Insects: Germs
4.1 Many types of insects may enter a house. If one is
inexperience and has much work these insects may be idisregarded
expecially if the person thinks they are harmless. Then one day
the person may feel some irritation, like the trouble given by
bedbugs, and wonder what is the causes. By that time, many
insects may be in the house and it will be difficult to get rid
of them xv’ithout disrupting the activities of the house. At
other times, a person may not know what causes such insects to
come in great numbers like oil being left on the floor attracting
cockroaches. It is the duty of family andfriends to help inexperi
enced people learn such things, just as it is the duty of adults
to instruct children which plants are foods and medicine and which
are poisons.
,
The body is like a house, Krimi enter because the doors
are left open(weakness), because something attracts them, or
because the body permits them to enter thinking they are harmless
guests or beggars. In the case of insects entering a house,
knowledge comes after seeing and experiencing them. In the case
of illness entering the body, however, Krimi (use a similar local
term) which cause illness are not visible. It is not enought to
tell a man that “some Krimi11 cause illness,” so he should not
allow them in bis body. The body, however, can be taught a
lesson. This the purpose of a vaccination. A vaccination con
tains harmful Krimi made weak by poison. When these Krimi enter
the body, they make trouble—but only a little trouble, not like
the trouble which many would cause if they came to the body in
number. They body learns how to both recognize these trouble
some Krimi and kill them. Side effects, such as fever and chilis
are not bad; they are good signs that the body is learning to ree
congnize and fight Krimi through experience. Yes, the side
effects, kxiew as cause troubld but just as in children, sometimes
an important lesson must hurt just a little. In the future,
if these Krimi come they can be killed more easily and if a
body has learned to recognize them by experience, it will not let
them enter in number or willsweep them clear, the way a woman
sweeps a house clear when she sees ants coming in number. Like
sweeping, this requires a short gap in normal activity, in this
cas it may cause small problems like a one day fever or diarrhoea.
But better this thana big illness later, A vaccination then
is a way of the body gaining Krimi anubhawa (experience)—the
more anubhava for such Krimi diseases one has, the less chance of
getting an illness. That is why children with less body experience
get
-4a Krimi diseases more, and why once a child gets Krimi
disease like chickenpox or whooping cough, his chances of getting
these diseases again is less than other children. Only some
krimi can be swept out of the body house, however, others are
so common that the body can not prevent them from entering
the house as this would be a full time job and man has other
works. In such cases, man must learn what attracts such Krimi, w
what these Krimi do not like (e.g. smoke for mosquitoes), andhow
to keep this doors closed (good hygienic diet).
1. Krimi is one term used by villagers to describe invisible
worms.
*The diseases which should be used here at?e those which
etiology surveys have indicated are associated with external
worm/germ type agents. Ayurvedic pandits tell us, for examples,
that undigested food or impure blood attracts certain Krimi. It
is necessary to make these conditions less and to teach the body
who are its friends and who are its enemies.
5.1
Harvest: Deliver
Fertilizer: Feeding of Woman during Pregnancy
Near the time of the harvest/ if the crop looks weak 1/ is
that the time to think of adding manure to the field 2 So it
is with pregnancy. A diffic It delivery is often caused by
weakness and lack of blood in the mother as well as the baby.
At the time of delivery, it is not possible to increase blood,
(unlessbbcod is given by transfusion- -for villagers who are
aware of what a transfusion is). For this reason, it is necessary
for a pregnant mother to eat blood/stren^th producing foods.
Dhatu (a local term which refers to accumulated strength and is
associated with diet) requires time to be produced and for
this reason blcod/strength producing foods must be consumed
throughtout pregnancy.
1
Weakness is emphasized here, not crop size. It is common
place throughout India for women to link large babies with
difficult delivery (as well as problems during pregnancy)
Rather than confront this strong attitude directly,r it is .better
appropriate
health education strategy and
to use a culturally
<
_
' ’ Big is best is an
emphasize ’more blood and more strength.
ethnocentric approach and in any case, the
C size of a baby is
not directly correlated with strength as villagers speak of
babies whomlook big but are only full of water, indicating
an undersirable state.
2
A local proverb expresses a similar idea: Hwhen a man is
thttsty, is that the time to start digging a well?H
♦
The Doctrine of Multiple Causality
Relatively few illnesses in rural South India are associated
with only one possible etiological factor. Most illnesses are
thought capable of being caused by any one of several factors acting
alone or in concert with others. Moreover# once ill# a villager is
considered vulnerable to additional etiological factors which may
prolong or compound illness making it more complex to manage or cure
This is one reason why patients sometimes consult different types
of practitioners simultaneously so as to remove/ manage multiple
etiologicalfactors or reduce their after effects. Another factor
which complicates illness classification and lay medical decision
making is the fact that similar symptiom sets may be interpreted
differently (as types of one illness or different illnesses ) due
to the onset or progression of symptoms as well as suspected
etiological factors. For this reason# data presented on the etio
logy of illnesses in this report# although based on considerable
survey and case observation research should be considered data on
dominant notions of etiology not fixed ideas.
The latter point is important when planning appropriate
health education strategies. It is stressed that ideas about etio
logy are flexible. We found that new ideas can readily be introduced
tkak in the context of dialogue when explained in terms of existing
etiological concepts or perceived states of the body (based on indi
genous notions of physiology) associated with the illness in question
As can be seen by the list of etiological factors which follows
indigenous concepts can be found for most biomedical concepts.
Scope exists to define particular illness episodes in terms of alter
native etiological notions (if a prevalent idea is counter-productive
to health behaviou) as long as the factor attributed is not anti
thetical (in qualitative affect)to the type of symptoms manifested.
For examples# most itchy skin rashes among children are ambigiously labelled Kaj ji: 1 a condition strongly associated with
over heat in the body and treated by a restricted dies (less Ushna
no nanjufoods) and the application of cooling leaves. A differen
tiation of Kaj ji into different types caused by a) worms of external
origin eating the skin (scabies, impetigo) and b) overheat (kwashi
orkor related sking;esopms /artimlarly on the limbs# phrynoderma#
vitamin A deficiency) was conveyed to villagers without much diffi
culty. This overt differentiation was invluable to us in communi
cating health education information. We were better able to explain
why
1
2
This term is used in both South and North Kanara Districts.
See notes on etiology which follow and a forthcoming report on
dietary restrictions during illness.
Scabies treatment required the placing of a poisonous medicinal
lotion on the skin for 48 hours and the necessity for boiling one’s
clothing (to kill minuscule worms and to get rid of worm eggs;
worm eggs being a concept known to villagers from their experience
with picking lice). It also helped us to convey dietary advice in
cases of malnutrition. As opposed to discounting local ideology#
we planned a nutrition strategy to confront existing ideology, we
about kaj ji caused by states of malnutrition. When a state of mal
nutrition. Wtaui x xtete fitf manifested in skin lesions with pruritus,
■22211112 foods were suggested# such as green gram and ragi# seasme oil
(essential fatty a cids)# and vine spinach (vegetable) protein and
vitamin A ) which were culturally acceptable. Accepting that one
form of Kajji was caused by overheat (and designing a nutrition strategy
accordingly) while differentiating Kajji into different types increased
the compliance rate of those under taking scabies therapy in our makesshift first aid station and more iryortatnly, the credibility of our
education message.
-F
-2Another point to be appreciated is that what appears to be a
symptoms of illness may be interpreted as a sign of some broader
problem (dosha, upadra) effecting the one who is afflicted or his
family unit 2. Alternative notions of the possible etiology which
are dwelled upon may be related to attempts at linking causality
to particular’social domains (social relationships ) where vulnera
bility or instability exists; or they ay be attempts to projected
resposibility away from normal interaction spheres (onto wandering
spirits, inauspicious celestial effects, etc. ) as a means of reduc
ing guilt, etc.3 In other words, suspected etiological factors may
'be functional expressions of anxiety connected to competition,
jealousjr or guilt, (in respect to fulfilling obligations, role ex
ex
pectations, or one's duty)
To sum up;
Rather than underminging health education efforts, the doctrine
1.
of multiple causality accomodates new ideas and facilitates inno
vative health education.
1
Sesame oil is considered cooling in South Kanara but heating in
parts of Tamil Nad. This is an example of why region-specific plan
ning based on a knowledge of indigenous ideology is import©
2 This is especially the case if the one afflicted is the weakest
or most vulnerable family member, i.e. a young child or pregnant
woman.
3
For example, evil eye as well as toxic breastmilk may be asso
ciated with a case of infant diarrhoea. Obviously notions of evil
eye focus.
2. Indigenous concepts of etiology complement biomedical concepts
of etiology (if not logically than analogically).
3. New ideas introduced appropriately in terms of concepts which
the pKKXEixak
villager can relates to/ facilitate
both understanding and greater scope for their application of
these ideas.
4. An entrance into the villager's conceptual universe, as well
as personal medical history# •can be gained by discussing both the
classification of symptoms asi partic lar illness categories and
the suspected causes of an illness experience.
3
(cont.) attention away from the mother and feelings of guilt*
Notes on common notions of etiology and
associated symptoms in South Kanara District^ Karnataka
1.
Less food/ Kadim.e tinas/
Specifically# this refers to eating an insufficient quantity
of the staple food one is accustomed to eating (in this case,
rice). It is important to keep in ±ind that the villagers sense
of body cycle normality derives from the maintenance of a routine
digestive cycle and body signs associated with this staple specific
cycle ’faces consistency and regularity, urine color, timings
of hunger, etc.)
2.
Improper dies: /apathya/
a*
b.
taking meals erratically (among castes maintaining
routine commensality patterns)
eating foods having properties counter-indicated in par
ticular seasons, aowt
to particular age-groups.
3.
-3-
in transition periods, and during illness episodes.
commonly, in children, giving chillies and hot curries
before the age of 2.
connrionly, in adults, eating excessively spicy foods /kara/
c.
d.
3.
Bad blood
/netter hal/
a.
bad blood is thought to be caused by overheat /ushna,
garam/toxidity /nanju/, loss of slepp. inappropriate eating
habits, exposure to extreme weather conditions, hard work,
past illnesses and powerful medicines ^consumed presently
or in the past).
b.
Sluggishness and weakness are associated with bad blood
interfering with the flow of substance in the body. This
is sometimes associated with vata as well (see below).
c. Bed blood in the head and stomach is thought to be pushed
out by vomitting while bad blood in the intestines and
legs causes sores /pudi/
d.
Wounds which become infected are associated with bad
blood(an internal factor) more often than lack of external
cleanliness
e.
During amenorrhoea and pregnancy (a condition described
as nanjiin character) impure blood which is normally
Research in other regions of Karnataka and a knowledge of
ethnomedical literature in India, suggests that most of these
factors have widespread relevance to rural areas.
f.
expelled frpqR the body is thought to be retained and
mixed with good blood (causing bad bleed.)
Some illnesses are ascribed to bad blood being passed on
from mother to fetus or breastfeeding child.
4.
Climatic changes /have mana/
Bluctuations in temperature are thought to throw the body off
balance. For villagers, the healthiest time of the year is
when the temperature is most constant. Climate changes are
suspect especially at times of seasonal change. These times
are associated with bad winds and the movement of spirits
(discribed as qali or sonku)
5.
Heat in the body
a.
/ushna,qaram /
A certain amount of controlled heat is required for the
maintenance of bodily processes especially the digestive
process. Controlled heat is associated with strength
(trana, shakti) while an exees of heat may cause and be
associated with the following symptoms.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
burning sensation in stomach.
burning sensation in eyes.,feet, and hand (anaemia,
calcium deficiency)
burning sensation during urination
Indigestion
diarrhoea/ constipation/(especially dry stools)
blood in feces
redness of the skin/ rashes/ boils
dry cough
body pain, particularly back ache
cracking of soles and palms
-4-
11.
12^r
13.
balding/hairles ness
dissolving of bones: bones becoming brittle
dhatu loss, mental upset and confusion
b.
A state of overheat (ushna) can be passed on from mother to
child, through the breastmilk causing the baby to experience
indigestion, diarrhoes, boils, or fever.
c.
Overheat is the after (end) effect of many other etiological
factors (e.g. food climate, evil eye, encounters with a spirit,
mental worry). Therefore it is important to ascertain if the
term is being used as a general statement or in conjunction with
notions revealed by further inquiry. The most common general
references to overheat is to refer to the eaxtlng foods, the feel
ing of hunger, or sleeplessness.
6.
Excessive Coolness (tampu, tandi)
In terms of prevalent health (and for that matter, ritual)
ideology, cool /tampu# is needed to controlheat in the body.
Generally, in reference to health, tampu is associated with
with weight gain and slower digestion. Too much tampu is
thought to manifest the the following symptoms:
1. excess phlegm
2. cold, runny nose, sore throat
3. wet cough
4. indigestion and constipation (fewer bowel movements as
opposed to dry feces)
5. complaints that the blood has become thick and doesn’t flow
properly causing fatigue.
6. headache.
3.
b. Excess cool is thought to be transferred through breatmilk
causing baby to experience indigestion, cold and accumulation
of hlegm.
7.
Toxic substances /nanj1/
a. Nanji can result from:
1. the retention of bad blood not emitted by routine body cycles
(amenorrhoea and pregnancy seen as the disruption of the
menstrual cycle).
2.
3.
4.
substances consumed by the body which it cannot digest such
as the unctuous juice of brinjal or drumstick (foods classi
fied as nanju.
the consumption of too many sweet foods, oils, or impure
foods.
child receiving impure breastmilk from its mother.
b* Nanii is associated with infection, pus, boils and itchiness.
Nanji in the blood is thought to prolong the cure of most ill
nesses: particularly wounds, skin diseases and intestinal complaints,
for this resion, foods classified as nanju are not eaten during
illness episodes.
Ca Nanji
visha (poison).
____ (toxic) should not be confused with ____
. > It ia
generally believed that naniu foods are the best tasting foods
tasting foods and their consumptions isj common.
8.
An excess of one of the three body humors (tridosha):
a.
The principle of body humoreis the basis °f ayurveda. the classical
-5-
system of Indian medicine. It may first be emphasised that few
villagers (as well ad few vaidya , fural herbal practitioners .)
know much about the principles of ayurveda. However, ayurvedic
terminology and the use of ayurvedic regimens are very much part
of folk medical cultures in India. While tridosha, as a principles
of body physiology, is not known. the effects of humoral aggra
vation (the symptoms manifesting) are known andhumoral terminology is
used in colloqial languages to describe the*course’of such symptoms
Most commonly these ’causes' are associated with the eating of foods
clssifed locally as having a quality (guna) which produces these symp
toms when consumed in excess or at inappropriate times. 1 As might
be imagined, interaction between laymen and learned ayurvedic
practitioners 2 has caused a number of ayurvedic terms to to flow
into the local vernacular where they are given local meanings,
and usuage.
b.
Symptoms associated with tridosha terminology:
1.
Pitta
a. nausea
b. tasting of bitterness in mouth
c.
d.
e.
f.
g*
h.
2.
dizziness
loss of mental equilibrium, mental upset, taking
nonsense
yellow urine
heartburn
yellowing of body / jaundice
associated with overheat in the body
Kapha
* “
‘ ‘
‘ , It may be noted that young children
a. aphlegm
laden
cough.
are thought to have a propensity toward kapha disorders
and have more kapha in the body. For this reason, res
piratory illnesses are often not treated in the early
stages. This does not mean, however, that mothers do
not try and check the excess of kapha, for a number of
curative and preventive home remedies are utilized.
b. mucus exuding from the nose, eyes, mouth, or anus
(foamy stools)
c. foaming at the mouth particularly after febrile fits
among infants is linked to an excess of kapha as well
as sgirit attack.
1.
The
classification of fpods
with reference to the tridosha is
------------------o
more complex than this tone should consider the ayurvedic
concepts of triquna , Viriya, and vipaka but for our purposes
this passing reference is sufficient).
2.
I will refer to these practitioners as pandits to differentiate
them from vaidya practitioners who dispenses herbal medicine but
do not follow a system of diagnosis and therapy.
3.
Vata:
Vata is the wind (movement, motor function) principle in the
body. An excess of vata is thought to cause body pain and when
vata is blocked it is thought to cause stiffness in joints.
Vata conditions are sometimes linked to less blood. Vata is
associated with the effect of sanni planet (Saturn) and excretions
from the body which are blackish in color.
• ••6
-6-
Vayu;
4»
Vayu is associated with wind in the form of gaseousness within
the body causing:
a. indigestion, flatulence
b. feeling of fihihlness and being stuffed up
c. feeling of breathlessness
d. fatigue, laziness
CONTAGION FACTORS / antu. pagarana /
gali
a. This term literally means wind, it is used to describe a
spirit wind (sometimes called sonku), a malevolent wind,
carrying illness from one village to another, and the wind
ensuing from an ill for menstruating person when he/she
passes.
9.
be
It may be noted that some illnesses associated with gali
such as chickenpox or measles are thought to manifest
from the stomach first not the external surface of the
body. Pox fall / burundu/ on the body surface from the
interior.
c
Gali is thought to cause sudden dramatic symptoms usually
associated with overheat or cause impurity to theb^ood
resulting in boils, pox coming to surface of the skin
etc. Specific reference to sonku is more ip Ati month
and'is associated with sudden fever or pain.
10.
breath / svasa / of a person who is ill.
11.
crossing / kadapu/
An idea exists that crossing (steppin over, passing through
a transition point) associates one with the malevolent qualities of the material / force crossed, Common agents cited
are body excrements of the ill (faces, urine, saliva, scabs),
shadows or blood of menstruating women, food touched by the
ill etc.
12.
Contact with impurity /mailge, basta, made/
a.
direct contact with impurities such as saliva /dalle/ or
tlje consumption of impure substances is commonly associated
with ifection and the appearance of boils.
b.
contact with the pus of one who has a skin disease or
diseases in which lesions manifest.
contact with the breath of a diseased person in life and
the spirit of a diseased person after death /khale/.
c.
a;:
13.
touching the body of a diseased person or his personal
effects (clothes, blankets, etc.)
Minuscule worms, germs / krimi^ puri / keidi /
Many illnesses are attributed to be caused by worms of internal
of external origin. Folk notions of physiology give functional
role of worms / five da puri/ in the digestive process. Some
illnesses are spoken of as caused by having more or less of these
worms, more active or sleeping worms which for example may cause
loss of appetite or improper motion. These worms are particular y
' * * *j is listless,
suspect when a small child has a loss of appetite,
grindsThis
teeth, or has a bulgvomits, is irritable, has diarrhoea,
'
ing stomach, many other diseases, particularly fungal diseases and
infected wounds are also attributed to worms. The notions of
-l-
minuscule (invisible) external worms /Krimi pudi/ which enter a
body causing illness are similar to biomedical concepts of germ,
virus, and are a part of the folk health culture.1 It may be neted
however, that the etiological factors are associated with precipitat
ing reasons for these external agents being attrated to particular
persons or being able to enter domains (body) domain, house domain,
village domain) normally protected (closed to intrusion, disruption)
ritually or by substances enhancing one’s positive health. This
reasoning often focuses attention on states of vulnerability (due to
climatic changes, lack of spirit protection, transition in one’s
life, states of impurity etc. ) Here we find the basis for a strong
indigenous concept of preventive and promotive (positive) health.
14.
Hereditary factors:
This is a complex concept which may refer to:
a. illness being passed on through the bloodline of a
lineage (matrilineal, patrilineal reference)
b. an illness which comes as a course or recompense to an
individual or family due to non-fulfillment of obligations.
sin. papa, karma etc.
c.
an illness which another family member experienced in the
past associated with either spirit attact by the deceased
or a sign from the deceased of its presence.
1.
The concept of external etiological factors (minuscule worms-.
Krimi, insects - Rita is found within ayurvedic dogma.
15.
Spirits:
Each type of spirits is associated with a social domain or
state pf
wildness/uncontrol. Suspicion of a particular
type of spirit focuses attention on imbalance or vulnerability
in that domain. References to vague stars / spirits of the wild
(of the forest, transition points, etc.) focuses attention and
responsibility for illness away from social domains / relation
slhips other wise suspect. Examples from South ^arnara are:
ships
a.
Rule — ancestor spirit. Knowledge about the lineage
of Rule effecting the afflicted throw light on friction/
jealousy in that kin group or between the kin group of
the afflicted and that which the Rule represents.
b.
butfe -spirit of a social domain jaga/be it the family
domain Kutumba village, kingdom, forest etc. A buta
is a manifestation of power which can be either malevolent
of benevolent depending on his this personified power is
controlled. Suspicion about specific buta usually is
associated with instability in domains tcommonly, non
fulfillment of obligations towards the members of that
domain (alive and dead) with Reference to wild or controll
able buta are often associated with responsibility projectingaway from the person experiencing problems.
c.
naga - a snake deity associated with fertility as well as
skin diseases such as leprosy and herpes zoster, eye
complaints, menstrual problems, breast pain in a lactating
woman and sterility. In this case, folklore has influenced
the association certain illnesses with naga.
d.
pj-de - spirit of a deceased child thought to be attracted
to other children out of love or envy. The touch of pide
is associated with a wide range of childrens illnesses.
The pide may be a deceased family member or a roaming
spirit.
....8.
-8-
Marl - (Bhagavti, Amma) Goddesses associated with pox
diseases either inflicted out of love or anger. Goddess
linked illnesses are often not spoken about as speaking of the
goddess and the illness is thought to bring the god ess
into presence thus spreading the disease.
Note:
illnesses caused by spirit trouble are freferred to NOT
as a roqa (disease) but as dosha or upadra disturbances/
trouble.
16*
Stars:
The illeffect of celestial bodies is commonly referred to
as qraha chara . The lay public does not know much about astrology.
Saturn, Sanni is often associated with vata complaints, no moon
with over-heat in the body and full moon with coolness and an
increase in kapha. Coughting and fits are thought to increase
during the periocT of no moon and full moon as well as as
sankranti (another transitional point) andpatients report this
to practitioners to aid dianosls.
17.
Fate: multiple notions exist of qualified (transformable)
and unqualified fate.
a>
hanne baraha - predetermined fate (writing no fore head), non- negotiable. ( at birth, one's destiny is
written)
b.
adrishta - bad luck
c.
Karma - inherited or self made sins or obligations
which necessitate and bring recompense.
ayasu - life expectation, associated with the concept
of rebirth.
d.
e.
18.
papa - accumulated sins.
Evil eye
evil eye is associated with visible
e - dristhi/
dr
signs of overheat
ove:
in the body (sudden appearance of rashes,
fever, unconsciousness) especially in children and pregnant
Dristhi is also
women (e.e. those most vulnerable). ______
related to guilt projection by mother when child falls ill.
19.
Witchcraft * associated with competition, jealousv, suppressed
anger within andncross linerage and caste lines /mata/
20.
Dhatu loss - dhatu is a body substances associated with
positive health and vitality, ^atu is responsible for the
control, the control of desire, concentration, virility and the
ability to gain weight. Commonly, dhatu is feared to be lost
due to masturbation or sexual excess where if leaves the body as
semen. Specific foods produce and reduce dhatu. A reducatlon
dhatu makes one vulnerable to illness.
Pregnancy desires* unfulfilled desires during preganancy
21.
are thought to affect fetus development and are associated with
limbs and sense organs, defects, car discharges etc.
Review of etiological factors by brpad category (internal),
external, moral
Internal:
1.
Food/dlet:
4- less of staple food
b. inappropriate food - season - age
. ♦
-9c«
d.
e.
Impure food, toxic (nanju) food eaten in excess
food which aggravates tridosha
gaseous (vays) foods interfering with movement and
body cycles
2. Excess of uncontrolled heat in the body or excess cold:
(see additional notes on the hot / cold idiom)
a.
b.
c.
3.
loss of feeling of balance in body/mind
lack of control over one's supply of vital qualitative
energy
Interference of physiological processes resulting in
blockage of basic life systems -- digestion, defe
cation movement of blood and energy/trana,shakti/
menstruation etc.
Blood becoming:
a.
b.
c.
less
impure
thick/thin
As a result of:
1.
2.
3.
4.
5.
6.
4.
less or inappropriate food, poor digestion
overheat in the body
over work
exposure to extreme climatic conditions
spirits
hereditary factor (related to moral factors
sin, etc.)
ancesors.
Aggravation of the tridoshas
Tridosha viewed as substances causing illness when in
excess: more than a view of humors playing a necessary
rold in the physiological process.
a. Vata
b. pitta
c. Kapha
5.
Dhatu loss:
1. overheat
2. improper diet
3. sexual excess, deviancet masturbation
6.
Aggravation or suppression of intestinal worm activity in
the gut, as well as reduction of optimum number of worms
necessary ifjor digestion or an increase of worms past the opti
mum.
7.
Impurity (body or blood) due to natural processes (menstrua
tion the blocking of natural processes (amenorrhoea, consti
pation, or the entrance into a state of body (delivery) or
status (birth, death) transition. Associated with states of
vulnerability, or states where other etiological factors are
attracted.
10
-10-
8.
Non fulfillment
pregnancy desires.
External Factors:
1.
2.
bad
Cop£act with those who are ill(touch, crossing them or
oody excretions)
3.
contact with impurity
minsscule worms or insects
5.
6.
7.
negative qualities of seasons, seasonal changes
8.
witchcraft
9.
effect q£x cerestial bodies— stars, planets. etc.
spirit contact; curse, trouble
evil eye
Moral Factors:
r
1.
notions of fate (ayasu, karma/ hane baraha)
2.
spirit trouble- failure to upkeep obligations/responsibility in domains of prescribed social interation (family
lineage caste, village.)
*
*****
*******
*
•f
Oo
h
M 37- J °
CHld-C I
INSTRUCTIONS
FOR
COMMUNITY HEALTH WORKERS
CHAPTER 10
First Ajd in Emergencies
As you live within the community itself
the first person to be contacted by the people in ? you will ususally be
your village if any
accident occurs.
It is, therefore, important that you should know how
to give first aid in an emergency.
In all emergencies after giving first aid you should send the
patient immediately to the Primary Health Centro.
Give
hive r
emergency
“
first aid for the following conditions
refer
9
cases
the
Primary
Hpn1thC
hlS^ toVi
e/r
rima7 Health
Henlth Centre as necessary and inform the
Health Worker(Flale/Female)
10.1
10.1.1
Drowning
,
Drowning occurs when the p
person has inhaled water into the lunq and
the lungs become full of water instead of air.
If a person who has drowned is brought
t o you, proceed as follows?
(i) Turn the patient face down with
and the arms .stretched out.
be placed downwards.
If
the head turned to on e side
a slope exists, the head must
(ii) 2dCV°Ur hanc' ar"Ufld tho patient's abdomen and raise the
dy to encourage the water to run' out of the lungs.
(in) Clear the mouth of weeds or any othermaterial obstructing
air entry, and of false teeth, if any
(iv)
Loosen the clothing around the neck and waist
kiv) Loosen
(v)'Apply artificial
— respiration using the method shown in
slide TA-1e
p
Do^not
stop until the breathing has been
re-edtablisheda for
• •- at ?least a quarter of an hour.
(vi) After
recovery do not let the patient sit; u
up. Transfer
him/her lying
’
p
on a stretcher to the nearest
—~ -» P rimary
Health Centre
--- j as soon as possible.
10.1.2
wire.
Llect_ric shock
An electric shock is caused by a [
person touching a live electric
The signs of electric
shock are as follows?
1. The patient is unconscious
2. The patient■is
-a in contact with a source of electricity
promptly i/oTrV130 3 PBrSOn Whl llas an Metric shock
you must act
promptly m order to save
save his
his life.
Procsed as FolIous.
life.
1. Wherever possible shut off the current
2. Free the person from the source of s '
electricity by using a
-h or pull him away
piece of wood, paper or rubber to push
3‘
inimodintely
Mouth-to-mouth respiration should be
continued for
for as long as the pulse is felt.
ns shown in
a long time, and certainly
After the patient has r
presenceof any burns and refer torecovered,, examine the skin for the
.) the Subcentre for further treatment.
2/-
• 11
!
o
o
Q
Z
o
o
Educate the community on how to avoid electric shock by
on the following points?
talk-ing
’
1. Ensure that al] electric points are safe and that there are
no exposed live wires.
2. Prevent children from playing with electric switches and sockets
3. Prevent children from climbing up electric poles
10 1. 1 Heat stroke
Heat stroke results from
f
exposure to excessive heat and sun and may
occur during the hot summer ------months,
It is more likely to occur in those
who have been drinking alcohol and those who are weak.
The early signs and symptoms of heat stroke are as follows!
1.
2.
3.
4.
5.
6.
High temperature(up to 42°C)
Headache
Dizziness
Nausea and vomiting
Cramps in the limbs
Dry, flushed, hot skin
The patient may become uncensciousn later on.
When this happens he
usually dies.
When you see a patient with heat stroke proceed as follows?
1. Put him in the shade in the coolest and most airy place
2. Lin dp es 6 him completely
3. Pour cold water over him or apply cold cloths
4. Give him cold water to drink if he is conscious
Educate the communit y on how to avoid heat stroke by talking on the
following topics?
1. Avoid exposure to direct sunlight
2. Drink plenty of cold water with lime juice and salt if possible,
during, the hot season
’
3 . Cover the head and back of the neck with
a turban or towel
when exposed to the sun for long periods
4. Avoid drinking alcohol
10.1.4 Snake bite
Snake bite results in punctured wounds lcaused by the fangs of a
The wounds by themselves are minor ones
j, but in India there |are a
number of poisonous snakes and hence, unless you see the snake and know
that it is non—poisonous, you should always treat the bite as poisonouso
snake.
Signa and Symptoms
1
The patient may tell you that he
has been bitten by a snake
T reatment (s ee
slide FA—3)
1. Tie a piece of cloth tightly
above the bite to prevent the
blood .from returning to the
heart.
2. The two wounds produced by the
snake’s fangs are visible
2. With a clean razor blade, make
four to six cuts 1 cm deep over
the area of the bite
3. The patient may show signs of
poisoning(bleeding or paralysis)
3. Squeeze the part hard so that ■
blood flows out of the cuts.
4. The patient may show signs of
shock
4. Apply potassium permanganate
crystals in the cuts
J
s 3 ?
Signs and Symptoms
Treatment (see
slide FAw.3)
5. Apply a piece of clean
gauze
or cloth on the cuts
6. Rush the patient tp the nearest
Primary Health Centre and
inform
______ Healt h Worker (Male/Female)
the
10.1.5 5^J?^ojx^tinn
at f/13 f?®rS°2 S^LnQ 5y a ^c°rpion, usually a child.
atphe site of the sting and shows signs of shock. ' A complains of severe pain
prisonous and if the chile' i- onoii
shock,
h scorpion sting is
serious results.
d physlcally
the sting
J may produce
---------- - ----
Treatment^ _____
1. The patient will tell you that he has
1» Apply a cold compress to the
been stung by a scorpion
site of the sting
2. The wound is red and there
may be bleeding?. Treat for shock
3. Signs of shock are present
particularly 3. Give APC tablets
in small children
4. Refer to the hospital or the
PHC
pHC? if signs are severe
10.1.6 Insect stings
Bee,
t-------
■
■
wasp and bornet stings occur frequently in rural areas,
if the nests of these insects
especially
---------j are disturbed.
I
Signs and symptoms
T reatment
1. There is a history of being stung by
an insect
2. The site of the sting locks
red, swollen
and is painful
1. Apply a. cold compress to the
site
2. Give APC tablets
3. If the pain and swelling are
severe, or if there are signs
of shock, inform the Health
Worker(Male/Female)
1C © 1•7 Dog
bite
In India where jrabies
'
is prevalent, if
if a
a person is bitten by a stray dog
the injury should he taken
-i seriously.
7
Wounds from dog bite
are infected because dirt
and germs are introduced into
the wound from the teeth
of
the dog.
---------- ---------- ^X-Ons and sj/mptoms________ ~
1. There is a history of dog bite
2.
here may be one or more irregular
wounds
—_ ______ Treatment___
1. Clean the wound with soap and
wat er
2. Swab the wound with antiseptic
lot ion
3. Apply mercurochrome to the wound
4. Always inform the Health tdorker
(.riale/F emale)
10•1.8 Accidents
An accident is an event which happens unexpectedly,
injury depends on various factors.
The accidents which you
1. Wounds
3. Features(Broken bones)
”
The extent of the
are most likely to come across are as follows?
2. Sprains and dislocations
4. Burns and scalds
..004A
•V!
? .4 2
Sometimes there maybe a history given that the patient has received
an injury-.to the .head or some ether part of the.body but there is no visible
injury.
However, in these cases the patient may be unconscious, may show
.signs of shock yr may complain of pain.
In all such cases you must transfer
■f.
;
:
rimary
e''llth"-Ce^re Mediately and inform the Health
As a Community Health
assistance is as follows?
Worker you are a first aider and'the aim of your
(i) To prevent immediate
danger of death
(ii) To prevent the patient’s
condition from getting worse
In o]
rder to achieve those aims, \you must remember the following rules
and follow themi every time you are dealing with an accidents
(i) Stop any bleeding
Give artificial i00
. respiration
Guard’against shock
-------- : jr treat’ for shock
Do- not i
remove clothing unnecessarily
, '
Reassure
_j the patient and relive pain
(vi) -Arrahg
Centre or hospita!
t0 thQ nearBst Pj?imary Health
(ii)
(iii)
Civ)
(v)
1• Wounds
wound is- a to r or break in the skin following an accident. The
deeper the wound the more likcly.it is to bleed and.to get infected as it
cannot be
Y°U mUSt st'°P tha bleeding and, as far as
possible, prevent infection from occurring.
A wound ~may be.caused by the skin being;
(i) BrazedUee slide FA-4); this is usually a superficial wound
eg
(ii) Cut
..
by
knife or other'sharp cutting, in st rument
(see
. slide A—5)« this is usually accompanied'by profuse bleeding
. ..and tho deeper structures may also, be cut.
(ill) lorn,
e.g., by barbed wire(see
slide Fa—6)j or by a blunt
instrument? the.odgos of the
wound are irregular and there
is bruising
(iv) Punctured, e
,g., by a knife, nail or bullet; This wound is
small but deep so that important organs may be damaged.
T reatment
(i) Hake the patient sit
or lie down
(ii) Handle
.3 the injured part gently
(iii) Wash
the wound with clean water and soap.
Always clean away
from the wound
kiv;' Remove
-...-vj a.
as much dirt or foreign
matter as possible
(v) Wash the
-..j wound with antiseptic lotion
(vi) Stc'
“
op any bleeding by using’direct
pressure or by applying a
tourniquet
(vii) Apply |
msrcurochrome and dust the wound with sulphonamide powder
(viii) If the
wound is gaping, apply strips
FA-?)
the ddgestogether(.see slide
>f adhesive plaster to bring
y
(ix) Apply
a clean dressing and bandage (see slide FA—8)
(x) If rz
necessary treat for shock
(x^) Givp A PC tablets
G tablets
(xii) Support the arm in
a sling when necessary
You must always refer the
patient to the PHC in the following
(i)'If the l
wound is large and needs stitching
(ii) If there
o is severe bleeding
n
cases?
S 5 s
(iii) If there is shock
or the patient is uncoscious
(iv) If there is a
foreign body embedded in the wound
(v) In all deep
wouncs of the chest and abdomen
2*
These occur when a Joint is twisted by tripping, or falling,
or by -a sudden wrench. In.1 a sprain the joint is not displaced , while
in a dislocation it is (see slide .FA-g)
Signs and s ympt□ms
T rcatmcnt
!■ I— n. ,», —i ».
m ""
(i) Severe pain in the Joint at thj time
of injury
f
If there is a sprains
(i) Rest and support the injured
(ii) Swellingl of the joint
(iii) Bruising around the joint
joint in the most comfortable
posit ion
(ii) Apply a cold compress and
bandage the Joint firmly
(iii) Inform the Health Worker
(Malo/Female)
(iv) Reduced rmovement of the joinig
(v) Deformity/ of the joint (only in
dislocation)
(vi) Signs of shock may be present
v t^t'herc is a dislocations
(i)
Rust and support the injured
joint in the most comfortable
position
4
(ii) Treat for shoik if present
if present
(iii) Transfer the patient to
the Primary HGaith Centre
(iv) Inform the Health Worker
(Flale/Female)
3* Lractures.
A fracture is a broken bone,
It may be cracked , broken into two
pieces or splintered.
f urthcrmoro. fractures may bes
(i) ClosedJ there is no wound leading down to the
no wound leading down to the
no bone protruding through the skin(see Slide
J hrXn H0rG 13 a
nund aching
from the
skin
a^
wound
reaching from
the skin
rsoi uuhc, .op the
broken
rAB^r
ken bone
bone may
indksee Slide FA.-n)
bone and'there is
bone
FA-lo)
right down to the
through the
You must remember the following rules when dealing
with a fractures
(i) All fractures should be given first aid treatment
an d sent to
the Primary □a 1th Centre or hospital
Interfere as little as possible with j ~
uhni- •;
U
T -u 1
'
------ ---------- a Tracture and do only
what is phen
11 rt------i.to prepare the
..
*
absolutely
necessary
patient
for the■>
journey to the Primary Health Centre
or hospital
(iii) Immobilize the fractured part
(ii)
4. Bums and scalds
Burns are rcaused by dry heat such as fire,
□xpl ision of pressure
stoves, petrol burns,j Ihot metals and electrocutioh.
Corrosive chemicals
such as strong acids from batteries of
cars can also cause burns.
Scalds produce the same
<
type of injury as burns and
are caused by wet
heat such as boiling water, steam,
j hot oil or ghee and tar.
The truat-iu^t
is intr’C”r
in-1 - cni<3 wiji
■ _.?rv
•jh-4-'- -
skin
S 6 2
Signs and symptoms
Treatment "
(i) History of a fall or a hit
(ii) Pain at the sit o or near the
site of fracture
(iii) Tenderness at or near the
(i) Place the patient in. a comfortable
position with the injured part
well supported
(ii) Do not remove clothing
(iii)
site of fracture
(iu)
Immobilize the injured part by
using a splint and bandages
Always immobilize the Joint
above and below the frature size
Inabilit y to move the fractued (iu) Treat for shock, but do not give
limb
any drink as the patient may
have co have an anaesthetic for
setting the fracture on arrival
at the Primary Health Centre.
(v) Deformity of the limb
(v)
Refer to the nearest Primary
Health Centre
(vi) Spelling at the sit Li of fracturs(vi)
Female)
(vii) Fracture may be felt
(viii) Movement at a place where
there should be no movement
(ix) Broken end of bone seen
protruding under the
Inform the Health Worker(Male/
kin
IF the fracture is an open one in
addition to the six steps mentioned
carry out the followings
(vii) Cut away and remove the clothing
over the wound and cover it with
a clean dry dressing
(viii) Stop any bleeding by applying a
pad and bandage.
If the bleeding
is severe and comes out in spurts,
apply a tourniquet.
4.
Burns and scalds
Burns are caused by dry heat such as fire
9 explosion of pressure stoves.
petrol burns, hot
I
metals and electrocution. Corrosive chemicals such as
strong acids from batteries
---------- of cars can also cause burns.
Scalds produce the same type
'
of injury as burns and are caused
wet heat such as boiling water 9 steam, hot oil or ghee and tar.
by
The treatment of burns fand scalds will depend on whether the skin is
intact or only partially destroyed
, 1 or whether it is completely destroyed.
Signs and symptoms
Skin intact or only partially destroyed
(i) The skin may be red or blistered
(see slide FA-12)
(ii) Signs of shock
(iii) Severe pain
T reatment
(i) Wash with soap and water
(ii) Apply sulphonamide ointment
(iii) Dress with gauze or clean
cloth
(iv) Nake the patient drink
plenty of fluids
o o a o 7/
? 7 g
Signs and symptoms
Treatment
Skin completely destroyed
(i) The burnt area looks raw
(ii) Signs of severe shock
(iii) Severe pain
(i) Cover with a clean sheet or
other piece of cloth
(ii) Flake the patient drink plenty
of fluids
(iii) Rush to the Primary Health
Centre
In cases where the skin is
— intact
------- — or only partially destroyed, in fo rm
the Health Worker so 1that he/she can take over the treatment of the
case or
advise you what to do.
10o2
Carry out procedures in dealing with accidents
!• Splints
splint*, is a rigid appliance, usually made tf wood or metal, which is
tied to a fractured limb to sunport it and^prevent movement from taking place
at the site of fracture. Splints can be improvised by using any article
which is rigid en ugh and of sufficient length for the purpose f>r which it
is required.. Rolled newspapers, magazines, a branch of a tree, etc., can be
used for splinting in an ’emergency.
The body itself can be used for splinting p’---------purposes e.g. a fractured
arm can be straoped to the side of the chest to immobilize
-J it, or a fractured
leg can be tied to the other leg.
Using a splint ? If a splint is not used m
roperly, it may cause damage.
Therefore, remember the following points when using] a splint (see slide FA-13)
(i) Flake sure that the fractured
area is properly supported while
placing it on the splint
(ii) Flake.sure
that the splint is well padded with cloth. This is
particularly important when splints are impr ivised from pieces
of wood which are uneven
(iii) Make sure that the splint is sufficiently long to immobilize the
joint above and the joint below the fracture
(iv) Hake sure that the bandages used to secure the splint have the
knot tied on the splint and not on the flesh
2.
Bandaging
The Triangular Bandage
The triangular bandage is usually
used as followss
(i) In first aid (for retaining
a dressing, as a tourniguet
i
, to tie on
a splint, to hold the lower limbs- together or as a pad)
(ii) As a
a sling,
sling. when the upper limb is
injury or an infection.
to be rested because of an
The bandage can be used in four sizes(see slide FA—14)
You must always eensure
“
that the knot used in trying a bandage is
secure and that there is no danger of its slipping,
The knot which is
used is the TReef Knot! because the more it is tightened,
9 the more secure
it becomes.
Also it can easily be undone if you want to undo the knot
without damaging the band '.ge(sec slide FA-15).
o o s 8/
s 8
2
Some uses of the triangular bandage
(i)
(i) The
The large
large arm sling (see slide FA-16)
Note that the knot is at the side of the neck and not at the back.
(ii) The hand bandage(see ;slide FA-1?)
(iii) Th^ foot bandage (see ;slide FA-10)
(iv) The elbow bandage(seei slide FA-19)
(v) The shoulder bandage(;.see slide FA - 20)
(vi) The hip bandage(see lslide FA-21)
(vii) Bandage for back of chest(see slide FA-22)
(viii) Bandage for front of chest(see slide FA-23)
(ix) Head bandage(see slide FA-24)
The Roller Bandage
The roller bandage is used to keep dressings in place
general rules when using a roller bandages
Remember these
(i) Roll the bandage tightly before you start using it.
(ii) When you start bandaging, make two or three turns on top of each
(iii)
other to'fix the end of the bandage firmly
*
When bandaging a limb always start from below ^ind work your way
upwards
(iv) Flake sure that the bandage is not too tight by checking that there
is no numbness
Some uses of the roller bandage
(i) Bandaging the forearm(see slide FA-25)
(ii) Bandaging the hand(sec slide FA-26)
3. Treatment,,of shock
Shock usually occurs following a severe injury,bloodihg, pain or
omotiondl upset.
Shock may occurs
(i) Immediately after injury
(ii) Within half an hour to severeal hours after injury when it is
caused by loss of bjood oxternallyor internally
Signs of shock
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
tix)
(x)
Pallor of face and lips
Beads of sweat on the forehead
Clamminess of the skin
Cold hands and feet
Shallow breathing
Rapid and feeble puls □
Vomiting
Restlessness
Vacant expression
Unconsciousness (at a later stage)
The treatment of shock takes priority over any other treatment
except bleeding.
Proceed as followss
(i)
Lay the. patient down on a stretcher, or a charpoy.
If neither
is available lay him down on the ground on a sheet or blanket
(see slide FA—2?)
I.
? 9 :
(ii) Raise the foot of the stitcher or charpoy about 22 cm off the
ground
•
■ warm
--------- h a(iii)' Keep the patient
hirti ...44with
a blanket
warm *-by• covering
(iv) Avoid any unnecessary handling
(v) Stop any bleeding
(vij If the patient is conscious give him hot t ea
aiigar
with plenty
.
.
(vii) Splint fractures and cover wounds before sending the patient to
the Primary health Centre
the nearest
Primary Health Centre or hospital
(viii) Transfer the patient to t._
----- 4. kontnol^cLf _bLMedina
Bleeding or loss of blood accompanies
a fracture or damage to organs occurs•
an accident in whioh a wound,
If there is oozing or a steady flow of blood, it can usually be controlled
by direct pressure on the wound(see slide FA
FA-28)o
— 28) <>
a tourniquet
If, however, bleeding is severe and is coming out in spurts,
A narrowfold triangular bandage 2 . .a
will be needed tn control bleeding,
broad
belt
or any other piece of material of
handkerchief, a necktie, a t_
improvised
tourniquet*
sufficient length can be used as an
Method
applying the.Tourniquet(see slide FA-29)
The method described here refers to the use of an improvised tourniquet*
Proceed as followss
a width of 5 cm*
(i) Fold the triangular bandage or handkerchief to
the
middle
of
the upper
(ii) Apply it on clothing at the level of
or lower limb
(iii) Tie the free ends of the bandage in a half-knot on the outer side
of the limb
(iv) Place a pencil, piece of wood, spoon, etc*,
on the half-knot
(v) Complete the knot to hold the pencil in position
(vi) Twist the Pencil gradually so as to tighten the bandage until
the bleeding stops
(vii) Use a second bandage tied around the limb to keep the pencil in
the tightened-up position
(viii) Leave the tourniquet in place, but loosen it gently every
15 minutes
(ix) If the bleeding has stopped 9 leave the tourniquet in place but do
not tighten it up again
(x) If the bleeding starts again, tight en the tourniquet and repeat
steps vi, vii and viii
(xi) Go with the patient.to thej ^rimary Health Contra, if possible
so that
you can control the bleeding
(xii) Attach a label, or any
any piece
piece of
of paper,
paper to the patient’ s shiit showing
the time when the tourniquet was applied.
Note? A tourniquet is a very useful appliance to use in the presence
of open fractures of
a limb.
Control of bleeding from the nose
Nose bleeds are fairly common and are due to rupture of small vessels
in the walls of the nostrils*(see slide FA—30) for the method of controlling
bleeding from the nose.
If the bleeding does not stop refer the patient to the
Primary Health
Centre.
ocedC/-
s 10 :
Control of bleeding from ttie
palm of the hand
If the bleeding is not severe try
slide FA-31.
and control
it as shown in
Refer the patient to the Primary Health Centre in cases of moderate
severe bleeding.
or
10.3 ^Keep a record of first aid giveh to each patient
Enter in y^ur Medical Care Register particulars of first aid given
to any person (
«
♦&
/////////////
«
I
<2-0^ H " 3^3-•I 9—
chapter-JI
CHUUC 1
INSTRUCTIONS
FOR
.COMMUNITY HEALTH WORKER
Treatment of Minor Ailments
When people in your area are ill, they will usually first come to you
for treatment as you are living in the area.
It is, therefore, important
that you should know how so treat minor ailments.
#
.
You should be' careful to refer cases in good time according to
the instructions given.
Whenever you are in doubt about the treatment 9
consult the Health Worker(Male/Female) or refer the patient to the
Subcentre or Primary Health
Centre.
In the case of infants and young
children, advise the parents to
take the child to the Subcentre or PHC
if the condition gets worse or if there is no improvement
within 12 hours.
Give simple treatment for the foil-owing
'
*
signs and symptoms and refer
cases beyond his/her competence to the Subcentre or Primary Health
Centre.
fever
Fever can occur with many diseases and it is, therefore, important
to look for other signs and symptoms accompanying the fever.
In young children high fever can often result in convulsion and
hence it is necessary to control the fever as early as possible.
Ldh en
you
see a person with fever, proceed as follows?
1. Enquire how
the fever started and how it progressed.
2. Ask about other accompanying signs and symptoms such as headache,
nausea, vomiting, diarrhoea, cough,
cough or running nose
3. Look for a skin rash
4e Enquire whether the patient has had sny shivering
5. Ask if there is pain in any specific part of the body
6. If the patient is a child , note whdther there is rapid and
difficult breathing
7. Take the temperature
If there is fever with rigor and sweating or without any accompanying
symptoms always consider it as a case of malaria and take thick and thim
blood smears and give chloroquine tablets.
In additions
i
Ask £he patient to remain in bed
Give A PC tablets
Tell the patient to drink plenty of fluids
Advise the application of cloths wrung out of cold water to the
forehead and limbs or sponging the body with cold water
5. See the patient on the next day to find out whether any other
signs or symptoms have developed
6. Refer to the Subcentre if?
1.
2.
3.
4.
(i)
(ii)
(iii)
(iv)
The fever does -not come down within 24 hours
The fever goes up
Other signs or symptoms develop
The fever is accompanied by stiff neck, vomiting,
convulsions or
unconsciousness
Headache
Headache can also occur with many diseases and it is, therefore,
important
for you to look for other signs and symptoms
when a patient
has a headache.
When a
patient complains of headache, proceed as
follows?
s 2 ?
(i) Ask the patient
whether he has other symptoms, e.g. sore
throat, earache, toothache or dizziness
(ii) Look for fever, rash, stiff neck(see Slide NA 1) discharging
ears, running nose, sore eyes or vomiting.
headache as follows^
Treat the
(i) Give APC tablets
(j i.) Rub the forehead with methyl salicylate oi^ment and apply a 3
tight band around the forehead
(iii) Treat other symptoms accompanying the headache such as sore
eyes, earache, toothache, cough or cold
Always refer
the patient to the Subcentres
If the headache is accompanied by stiff neck, dizziness,
vomiting or swelling of the feet
2« If the patient is a pregnant woman
3. If the headache persists beyond 24 hours
1.
Backache and pain in th.e^..ApinfeS-
Backache may be caused by strain or injury,, or it may be the
symptom of some disease.
If a [person complains of backache proceed
as follows?
1. Ask how long the pgin has been present
2. Ask whether the patient has had any injury
3. Ask whether there are other symptoms such as fever, pain in the
joints or pain in the
lower limbs
the spine
4. Aee whether there is any deformity of
Treat the backache as followss
1. Rest the joint as much as possible
2. Give APC tablets
3. Rub the back with methyl salicylate ointment or warm oil and
cover with a cloth
Refer the patient
to the Subcentre.s
1. If the backache is accompanied by deformity or pain the lower limb
2. If the baekache persists for more than three days
3. If the backache gets worse
Pain in the joints may be due to injury, infection or ageing. The
joints which are most likely to be involved are shoulder, elbow, wrist,
spinal, hip, knee and ankle (see slide flA
NA 2)
If a
person has pain
in the joints 9 proceed as follows®
1. Ask which joints are painful and for how long the pain
has been present
2. Note whether the joint i£> raa ^^bt, swollen or tender and
. ’a
*«•
whether there is fever.
Treat the joint
pain as follows?
1. Give APC tablets
2. Ruh the joint with methyl salicylate ointment or warm oil
3. Apply heat to the joint by means of?
(i) A hot water bottle or
(ii) Hot sand or
(iii) Soaking in hot water and salt
3/-
2 3 2
4. Cover with a warm cloth or bandage
This treatment must be repeated three or four times during the day.
Refer the patient to the Subcentre?
1. If the patient is a
child with pain in several joints accompanied
by fever
2. If the joint is
hot, swollen and tender
3. If there is no improvement after 2 days
of treatment
Cough and cold
Cough is a common condition which is usually associated with
diseaces of the throat or lungs.
Whenever you see a patient with a cough, proceed as follows?
1. Ask for how long the person has been
coughing
2. Ask whether the cough is dry or whether it is accompanied by
sputum, or whether there is a whooping tough
3. Ask whother the patient has fever, a sore throat ,
pain in the
chest, difficulty in breathing, vomiting, or blood-satined
sputum
4. Ask whether the person has lost any weight recently
Treat the cough as follows?
1. Give APC tablets
2. Give cough mixture
3. If the cough is accompanied by sore throat, ask the patient
to gargle frequently with a solution of hot water and potassium
permanganate or salt
4. Apply menthol and eucalyptus oil ointment to the throat, chest'
and back and cover with a warm cloth
5. Ip the child has whooping cough, ensure that the child is?
(i) Kept in bed
(ii) Kept away from other children
(iii) Given frequent, small, s:emi-solid or liquid feeds
Refer the patient to the Subcentre?
(i) If the »ough is of more than 15 days .duration
(ii) If the cough is accomanied by sputum, spitting blood, or
loss of weight
(iii) If the patient has pain in the chest, difficulty in breathing
or vomiting.
A common cold occurs more frequently in the rainy season or winter
months and is more often seen among those who are weak and ill nourished.
The symptoms of a common cold are?
(i)
{ii)
(iii)
(iv)
Running nose or a blacked nose
Watering eyes
Headache and body ache
Fever
The patient may also have a sore throat
and ear discharge.
If a patient has a cold proceed as follows?
1. Givo APC tablets
s 4 ?
2. Give steam inhalations with menthol and eucalyptus oil ointment
3. Apply menthol and eucalyptus oil ointment in the nostrils and
on the throat, chest and back
4. Give the patient plenty of fluids to drink especially fruit
juice if possible
5. See that the patient, especially if it is a young child, gets
sufficient nourishment
6. Tell the patient to
rest as much as possible
Refer the patient to the Subcentre?
/
(i) If there is severe headache, toothache, or earache accompanied
by profuse nasal discharge, fever and rigors
to eat
(ii) If a baby or child With a cold refuses
(iii) If a child has difficulty in breathing
fl
Diarrhoea
In diarrhoea-the patient has frequent loose stools.
Diarrhoea
may be caused by taking food or water which is contaminated by disease
germs or worm eggs, or by- using dirty hands for eating.
When you see a
patient with diarrhoea, proceed as follows?
1. Agk how long the patient has had diarrhoea 9 how many
stools
are passed and the type of stool passed
2. Ask whether the patient has any fever, vomiting 9 or pain in the
abdomen, or whether he has passed any worms
3. Look for signs of dehydration, viz., sunken eyes, dry mouth,
wrinkled skin(see slide NA 3)
Treat the patient as follows?
1. Give bismuth kaolin mixt-ure with water
2. Give plenty of fluids to drink
3. Give a soft diet without spices, e,.g. banana, buttermilk,,
arrowroot conjee, or rice gruel
4. If there is severe diarrhoea or signs of <dehydi?at ion, give
rehydration .mixture.
If rehydration powder is not available,
make a solution as follows?
(i) Add a pinch of salt and a handful of. sugarG.see slide NA 4)
to a little over 1 litre(l bottle or about 6 teacups) of
clean water
(ii) Boil the mixture for 10 minutes
(iii) If available add the juice of half .a sour lime to the solution
and mix well
(iv) Keep the container covered and cool the mixture until it can
be given without the risk of burning the mouth
Give
intervals.
the patient small quantities of
this mixture at frequent
Refer the patient to the Subcentre?
(i)
(ii)
(iii)
(iv)
(v)
(vi)
If
there are
signs of dehydration-.
If the stool looks like rice water
If the stool contains blood and mucus
If worms are being passed
If the diarrhoea is accompanied by fever and vomiting
If there is no improvement within 24 hours
Vomiting
In adults, vomiting may result from eating food which is infected
or which does not agree with the person, or it may be the result of
overeating or excessive drinking.
5/-
: 5 :
In children and infants, vomiting is common and may be caused by
giving the child food which is fatty, spicy or insxiffici-ently cooked,
by improper feeding techniques,
or by infection caused by taking
contaminated food or water<»
liNen you see a patient who is vomiting 9
proceed as follows?
1. Ask how long and how frequently the patient has been vomiting and
what is the nature of the vomit, e.g. blood, bile, undigested
food or water
2. Ask if there are any other symptoms such as pain in the abdomen,
diarrhoea, constipation or fever.
If the patient is a woman,
ask whether her menstruation has stopped
3. Look for a rash, yellow skin and eyes, signs of dehydration,
or signs of malnutrition.
Treat the patient as fellows:
In adults?
1. Give magnesium hydroxide tablets
2. Give a milk diet
In children:
1• Give skimmed milk and boiled water
2. If there is severe vomiting or signs of dehydration give
rehydration mixture
Always refer the patient
Ll
to the P rimary n ealth ..Cent re:
(i)
(ii)
(iii)
(iv)
If the vomit contains blood
If the patient is dehydrated
If the patient is
unable to retain anything
If the vomiting is severe and is accompanied by rice water
stools
(v) If there is no
improvement within 24 hours
Pain in the abdomen
Pain in the abdomen may be caused by a disorder or disease of any
of the organs in the abdomen such as the stomach,
intestines,
intestines, liver
liver,
spleen, kidneys, bladder and, in women, the uterus,
Depending on the
organ involved the pain is
in a different part of the abdomen and is
/accompanied by various, other s ymptoms •
If
you see a patient
with pain in the
abdomen, proceed as follows:
Ask how long the patient has had pa'in
2. Ask where the pain is felt
3. Ask whether the pain is present all the time or whether it
comes and goes
4. Ask whether the pain is related to:
(i) Taking food
(ii) Passing urine
(iii) Menstruation(in women)
5* Ask whether the patient has had any injury or blow □n the
abdomen
6, Ask whether there are other symptoms
vomiting, diarrhoea or constipation
7. Check whether the patient has yellow
such as fever, nausea,
eyes a»d skin
• 6/-
u
2 6 s
8. Ask whether the urine is dark brown in, colour or whether it
.
. is blood stained
9. Ask whether any worms have boon passed
T re at
in the stool or vomit
the patient as follows-
T r cat m ent
Abdominal pain associated with
(i) Advise
1. No other symptoms
( .
milk and soft diet with
no spices or raw vegetables
(ii) Give magnesium hydroxide tablets
(iii) Give APC tablets
(iv) Give 2 teaspoons of ginger juice
or 1 teaspoon of garlic juice
2. Diarrhoea
(i) Give /■’ PC tablets
(ii) TBeat for diarrhoea
3. Constipation
(i) Treat for constipation
4. Nausea and/or vomiting
(i) Treat for von.iting
5. Passing worms
(i) Refer to Subcentre for treatment
6. Jaundice
(i) Give plenty of sugarcane juice to drink
(ii) Refer to Primary Health Centre
(iii) Inform Health Worker(Maie/Female)
7• Fever and vomiting
(i) Refer to Primary Health Centre
(ii) Transfer patient lying down
(iii) Inform Health Worker(Male/Female)
8. Passing urine
(i) Give plenty of fluids to drink
(ii) Give A PC tablets
(iii) Refer to Subcentre for treatment
(i) Call the Health Worker (Female) or
9.Pregnancy
trained
10o Vaginal bleeding
Signs of shock
dai
(i) Give A PC tablets
(ii) Refer to Health Worker(Female)
(i) Treat for shock
...
•■(ii) Refer to the Primary Health Celitjre.
(iii) Inforr. the Health forker(Male/Feiaie)
Constipation-
A person is constipated when he is not going to the latrine regularly
to open his bowels and has much discomfort and straining while passing a stool.
A common *cause of constipation is carelessness about going to
the latrine when the need to pass
a stool is felt.
When a patient has constipation
proaeed
as follows?
1. Ask how long the patient has been constipated
2. Ask whether there are any other symptoms such as vomiting,
abdominal pain, or fever
Treat the patient as follows?
1. Give magnesium hydroxide tablets
2. Advise the patient to drink plenty of water
...7/-
s 7 :
3* Advise the patient
vegetables
to cat plenty of fresh fruit and green leavy
Refer the patient
immediately to the Primary Health Centre and
inform the Health Worker Male/Female?
(i)
If the patient has vomiting and severe abdominal pain
accompanying constipation,
Do not give any treatment.
: Toothache
Toothache is a common complaint, especially in those persons who
do not take care of their teeth*
When a person is suffering from toothache proceed as follows?
1. Ask for how long the tooth has been painful
2. Enquire if there is any fever
3. Look at the tooth to see if there is any decay of the tooth
or swelling and redr-^s of the gums
Treat the patient as follows?
5.
1. Give APC tablets
2. Advise the patient to wash out the mouth frequently with
lukewarm water containing a few crystals of potassium
permanganate or salt
3. If cloves are available in the patient Ts home ask the patient
to chew one with the affected tooth
4. Send the patient to the Primary Health Ccntrefor further
treatment and inform the Health Worker
Earache
Pain in the ear is usually caused by infection in the ear or
in the throat.
It can also be due to the presence of wax or of a
foreign body in the car*
When a patient complains of earache,
proceed as follows?
1. Ask how long the patient has had earache
2. Enquire whether any-foreign body such as an insect or a solid
object has entered or has been pushed into the ear and
examine the ear for the presence of a foreign body
3.See if there is any discharge from the ear
4.Enquire if there is any sore throat
5*Ask if the patient has any dizziness or disturbances of hearing
6.Take the temperature
Treat the patient as follows?
1. Apply sulphacetamide ear drops in the affected ear (see
slide NA—5)
If there is any discharge from the ear, clean
the ear gently with cotton wool on a mat ch—st ick (st ick
swab) before apolying the ear drops
(
2. Give APC tablets
...8/-
i
one
O
O °
Refer the patient?
(i) If tho patient has fever
(ii) If there is no relief after 24
To the SybcentreS
hours of treatment
To the Primary Health Centres
(i)
If there is a foreign body in
the ear
(inform the Health Worker (Mala/Female)
(ii)
If the patient has dizziness
or disturbe.nces of hearing
SOrc eyes
'■
irritation
Sore eyes arc caused by infection of tho eyes or eyelids
or injury by foreign bodies such as udust or thorns, or by chemicals such
as pesticides.
Sore eyes arc
also found in children who have measles.
When a patient has sore eyes, the eyes look red 9 there is watering,
and pain in the eyes.
and tho patient
complains of a burning sensation
Epidemics of sore eyes spread very rapidly and you are likely to
see a large number of cases at one time in your area.
If a patient has sore eyes9 procoed as follows.
1.
2.
3.
4®
how long the patient has had sore eyes
Find out
the
patient has had any injury or foreign body in the eye
Ask if
Take the temperature
,
Note whether the patient has any skin rash
Treat tho patient
as follows^
' , Always
1. Clean the eyes with boiled water and cotton wool.
swab from the side of the nose out wards (see sslide
.---- HA b)
Place
2. Apply sulphacetamide eye drops three times a day.
the drops inside the lower eyelid(see slide HA ?)
3O Cover the eye with an eye pad and bandageC.see slide HA b)
4. Give APC tablets
5. Keep the patient away from bright light
Referral after treatments
(i) Transfer^ the patient immediately
to the Primary ^calth
Centre if there is an eye injury or a foreign body
in the eye
(ii) Refer the patient to the Subcentre if there is no
improvement ■ aft er treatment for 24 hours
(iii) Inform the Health Worker(Hale/Female)
Worker(Hale/Fcmale) if a child with
sore eyes has measles
Boils, Abscesses and Ulcers
1. Boils and Abscesses
A boil is a red, painful swelling of the skin which is very
commonly seen’ and which is caused by infection.
If it is neglected,
develops into an abscess which contains pus and has to be Qpened. up.
it
The condition occurs more frequently in children who are not kept
clean or arc badly nourished.
s 9 s
Signs and symptoms
(i)
Swelling
Swelling
(ii) Redness
(iii ) Tenderness
(iv) Pain
(v) Fever and headache may be present
Treatment
(i) Apply pieces of cloth
wrung out of hot water
in which neem leaves
have been boil-:^.
(ii) Keep the Hub at
(iii) Give APC tablets
Refer the patient to the Subcentre?
(i)
If there are red streaks and tenderness extending beyond the boil-
\ii) If an abscess forms
(iii)
------ If there is no relief after 2 days of treatment
2. Ujeers
Ulcers or sores of the skin occur as a result of injury,
infection,
a poor diet, and in patients suffering from certain communieablo diseases such
as leprosy/ or sexually transmitted diseases.
An ulcer has th^ following characteristics?
(i) The skin is broken
(ii) The <area looks raw and red
(iii) There- is
-3 a discharge which may be watery or may be foul-smelling
and consists of pus
(iv) The area is painful
(v) There may be fever and headache
When you
see a patient with an ulcer , proceed as follows?
(i) Ask how long the patient
has had the ulcer
(ii) Note if there
are any signs of malnutrition
(iii) Ask if the f
patient has any other symptoms, e.g., fever, headache
or rash or tires easily
(iv) Take the temperature
Treat the patient as follows?
(1) Clean ths ulcer with cotton wool and boiled water to which a few
/..X ^r°Ps of antiseptic lotion are added.
Clean away from the ulcer
kxi)
pply pieces of cloth wrung out of hot water to which antiseptic
lotion has been added
(iii) Applyr mercurochrome
mercurochrome
(iv) Apply sulphanilamide ointment o:
"
t ^|ust with sulphonamide powder
(v) Apply a clean dressing and keep in place with
,
------ 1 a bandage or
adhesive plaster
Refer the patient to the Subcentre
(i)
(ii)
(iii)
(iv)
(v)
If there is fever
If the patient has had the l!
ulcer for more than one week
If the patient hag several ulcers
---- j or tends to get tired easily
If the ulcer is
-j on the genital organs with
.. 7 j or without discharge
If there is no improvement after 2 days of treatment
Scabies and.Ringworm
1• Scabies
This is an infection of the skin in l* 1 * 7
which there is a rash or tiny cracks
appear in the finger webs, the front of the
-..3 wrists and elbows, the armpits,
the wastline, the thighs and the external genitals,
-- ->
Itching is severe,
especially at night.
I
s 10 s
Scabies is coiP'.ioii among people who do not bathe regularly and is
frequently seen in communities with poor personal hygiene.
If you see
a patient with scabies, you are likely to find that other members in
the fa nily also have scabies.
If
you see a patient
uiith scabies treat as follows?
(i) Bathe with soap and water using a brush to open all the cracks
(ii) While the skin is slightly wet, apply benzyl benzoate emulsion
(ill)
(iv)
(v)
(vi)
(vii)
(viil)
over the whcle body except the
Allow ^he body to oartly dry
Rpply a second layer of bemzyl
Leave the emulsion on the body
Bathe thoroughly with soap and
Put on clear, clothes
Repeeit ths treatment for three
head and neck
benzoate on the whole body
for 24 hours
water
days
Note? All clotring and bedding
should be washed well and if
possiole boiled.
Refer the patient to the Subcentre if
there is no improvement after treatment.
2. RtnswasE.
Ringworm is an infection of the skin which appears as flat, ring-shaped
areas with a red bcrdci- and a lightly coloured scally centre,
It can
occur on anypart o’ the body'including the scalp.
Ringworm is
accompanied by itching.
Treat a pat ion's with ringworm as follows
s
(i^ Bathe with soap and water
(ii) Break the scally centre with a brush
(iii) Apply Whitfield ointment
(iv) Wear clean clothes
Refer the natimt uo the Subcentre if there is no improvement after
treatment.
Keep a record of the treatmentgi^en ito ea :i;‘ patients
.
j
- -
r
You should...maintain a Medical Care Register in whirb the following
information should be recorded?
(l) Date (2) Name (3) Age ((4), House No
(5) Symptorrs/Signs
(6) Treatment given (?) Advice given (s) Referral(t
--------- .jo whom referred)
Note? See Appendix Is Cuide for the Use and Administration of
Drugs for the dosages for different age groups and Appendix Ils
Contents of kit for Community Health Worker.
: 11 :
APHDWK I
Guide for the Use and Administration- of Drugs
A. Drugs for internal use
Dosage and administration
S.No.
Drug
Uses
Remakes
0-1 year
15 &
above
1.
IRC tablets
(i) Common cold
(ii) Sore throat
(iii) Fever
(iv) Headache
(v) Backache
(vi) Joint pains
(vii) Toothache
(viii) Earache
(ix) Fhin in
abdomen
2.
W?Suine
(i) ralaria
(presumptive
treatment)
i tablet
with honey
1 tablet
2 tablets 3 tablets
uith honey
Ccugh
mixture
(i) Cough
(ii) S ore throat
■2 teaspoon
3 times a.
day
1 teaspoon 2 teaspoons 3 teaspoons 4 teaspoons
3 times5
3 times
3 times a
3 times
a day
a day
day
a day
<
(150 mg per
tablet)
K
1-4 years 5-9 years 10-14 years
3*
y tablet
•J- tablet 1 raolet
dissolved in
dissolved 3 times
honey or
in honey a day
or water
water after
feeds 3 times 3 times
a day
a day
1 to 1^tablets
3 times
a day
2 tablets
3 times
a day
Tablets
should not
be taken
' on an empty
stoma, ch
4 tablets
To be given
in a single
dose after
taking thick
and thin
blood films.
Tablets should
not be taken
on an empty
stomach.
P-t.o.
It 12 :
AFPEWIX I contd.
Dosage and adniinistration
S.No.
Uses
Drug
5-9 years
10-14 years
teaspoon
1 teaspoon 1 to ly
3 to 4 times 3 to 4 timesteasnoons
a day '
a day
3 to 4
times a
day
2 teaspoons
3 to 4 times
a day
2 teaspoons
3 to 4 times
a day
(i) Mix powder
in a little
water in a
cup and
drink imme
diately
without
allowing
powder to
settle.
(ii) Add more
water to
cup and
drink
mixture
?■ to 3
tablets
3 to 4
tablets
To be taken
at bed time
with water
or milk
0-1 year
4-
Kaolin
powder
(i) Diarrhoea
5.
Magnesium
hydroxide
tablets
(i) Constipcition
(ii) Vo.mitting &
Nausea
(iii) Indigestion
6.
?._hydration
Reh;
powder
pow.
(chorosol)
.Remarks
15 &
above
1-4 years
1 tablet
+ tahle-t
with honey with honey
1 to 2
tablets
2 tablets
Single dose to
be taken
after food
(i) Dohyira-Di--Jsolve powder in 1 litre of water and give small quantities
tion
to the patient tliroughcut the day. In children, give 1 teaspoonful
every 10 to 15 minutes.’
Notel'You must be very careful in treating infants below one year of age. Instruct the mother to take the infant
immediately to the Subcentre if the infant1 s condition’ get worse or if there is no improvement within 12 hours.
..az
-APPENDIX I contd.
1 13 ::
B . Drugs for external use
S.No.
Drug
Uses
7. Antiseptic lotion (i) For cleaning wounds
and ulcers
0.
Benzyl benzoate
emulsion
Method of administration
of lotion to about
a cup of boiled water.
Add | teaspoon
"
'
’
,
Sw-A^.vound
or ulcer from
ELace cotton swabs in lotion,
vjithin outwards.
(i) Scabies
(ii) Lice
9.‘
bnthol and
eucalyptus
oil ointment
(i) Colds
(ii) Coughs
Apply ointment in nostrils • Rub ointment on throaty chest
and back and cover.with a warm cloth
S team inhalation:
x
Boil water in a small vessel. Ad'3 1 teaspoon of ointment
to the hot waler and inhale the steam keeping the head
under a towel. In the case of a small child the mother should
keep the child on her lap with a twol covering the child .and
the steam inhalation. She should take care to prevent the
child from burning or scalding itself.
10.
Mor cur oc1' r one
2%
(i) Cuts and scratches
(ii) Dog bite
Wash wound with clean water and antiseptic lotion. Apply
dressing
mer euro chrome with a cotton swa.b. Apply a clean
<
and bandage*
11 .
1 icthyl
salicylate
ointment
(i) Headache
(ii) Backache
(iii) Pain in joints
(iv) Sprains
Rub ointment gently on painful area* Cover with a piece of
warm cloth or apply a firm bandagd. Repeat treatment, as nece
ssary to relieve pain.
12.
Methylated
spirit
(i) To clean skin before talcing blood
for making thick & thin blood
films
Take some spirit on a cotton swab. Press the left ring
finger of the patient tightly so that blood. collects at
the°tip. Swab the tip of the finger and prick the clean
finger with the Hagedorn needle.
(ii) To sterilize
Hagedorn noodle
Always keep the Hagedorn needle used for pricking the
finger in a bottle containing methyls-ted spirit.
!
J 14
APPENDIX I contd.
S.Uo.
Drug
13.
Potassium
Tbrmanganate
Uses
(i) In snake bite
(ii) Sore throat
(iii) Toothache
(iv) To clean wounds
and ulcers
14.
15.
16.
Sulphac ct amid o
eye and ear
drops(10%)
Sulphanilaiiiid e
ointment
Sulpho, onamid e
dusting powder
(i) Sore eyes.
Incise site of the bite, squeeze out poison and apply
crystals to the wound
Add crystals to cold water until the water is coloured
light purple
Use tliis solution as a gargle, : cuthwash, or for cleaning
wounds and ulcers.
Hie solution must be prepared fresh and used immediately.
After cleaning affected eye with boiled water and cotton
wool, instil 2 drops inside lower eyelid(4 times a day for 2
days J.
(ii) Earache and ear discharge
After cleaning affected carwith cotton wool on a match stick,
instil 2 drops inside oar(3 times a day for 2 days).
(i) In infected wounds
and ulcers
Clean wound with antiseptic lotion. PDry with clear cotton
swab a d apply ointment on wound or ulcer,
--- . Apply clean
dressing and bandage.
(ii) In burns and
scalds
Clean wound with soap and water. 1^
Apply ointnent on burn or
scaled and cover wzi.th clean dressing
(2.) In fresh, clean wounds
Clean wound or ulcer with antiseptic lotion. P_
Dry with a
cotton swab• Dust powder in the wound or ulcer, Cover
with dressing and bandage•
(ii) In small ulcers
1.7.
I'fethod of adrainistration
Whitefeld ointuient (i) Ringworm
Bathe with soap and water and dry the s' in well. Apply
ointment on affected area (4 times a day for 1 week).
15 :
APPENDIX II
Contents of Kit for .Community Healthjforker
1. Slide (5) in slide box
£• Clpth for cleaning slides
3. Hagede.rn .neejalle
4« Pencil
5. Clinical, oral thermometer
6. Graduated medicine glass
7. Scissors
8. Razor blade
9» Cotton wool
10. Gauze
11. Roller bandcige
12. Triangular’bandage
13. Adhesive plaster
14* Soap dish and soap
1$. Towels(2)
16. Suitable containers for drugs(l7)
17. Forms for reporting of blood smears
18. Franked envelops addressed to the Primary Health Centre
19• Exorcise book(200 pages)
20. Diary
21. Health Education Materials (flip chart on faaiily welfare)
22. manual for Community Health Worker
23• Kit-hag
Medicines to be carried by Community Health Worker
For internal use
1 • Aspirin, Phcnacotin and Caffeine (APC? tablets
2. Chloroquine tablets
3. Cough mixture
4* Kaolin powder
5. I'fegncsium hydroxide tablets
6. Rohydration powder (choresol)
For external use
7 • Antiseptic lotion
C. Benzyl benzoate Mplsion
9* - jonthol and eucalyptus oil ointment
10. 'hrcurocliromo ? per cent
11. 1 .ethyl salicylate ointrent
12. I'fethylatod spirit
13 • Potassium permanganate crystals
14. Sulphacotamide eye and oar drops 10 per cent
15- Sulphanilamide skin ointment
16. Sulphonamide dusting powder
17• Whitefield ointment •
Additional material to bo kept with selected members of the community
1 • Bleaching powder in pots
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h. -
VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14, COMMUNITY CENTRE, S.D.A.,
NEW DELHI 110 016
PHONES : 668071. 668072
GRAM : "VOLHEALTh" New Delhi-110 016
C-53
THE VILLAGE HEALTH WORKER
LACKEY OR LIBERATOR ?
DAVID WERNER
Throughout Latin America, the programmed use of health auxiliaries has,
in recent years, become an important part of the new international push of
“community oriented” health care. But in Latin America village health
workers are far from new. Various religious groups and non-government
agencies have been training promotores de salud or health promoters for
decades. And to a large (but diminishing) extent, villagers still rely, as they
always have, on their local curanderos, herb doctors, bone setters, traditional
midwives and spiritual healers. More recently, the medico practicante or
empirical doctor has assumed in the villages the same role of self-made
practitioner and prescriber of drugs that the neighbourhood pharmacist has
assumed in larger towns and cities.
Until recently, however, the respective Health Departments of Latin
America have either ignored or tried to stamp out this motley work force of
non-professional healers. Yet the Health Departments have had trouble
coming up with viable alternatives. Their Western-style, city-bred and citytrained M Ds. not only proved uneconomical in terms of cost effectiveness;
they flatly refused to serve in the rural area.
The first official attempt ata solution was, of course, to produce more
doctors. In Mexico the National University began to recruit 5000 new medical
students per year (and still does so). The result was a surplus of poorly
trained doctors who stayed in the cities.
/
The next attempt was through compulsory social service. Graduating
medical students were required (unless they bought their way off) to spend
a year in a rural health center before receiving their licenses. The young
doctors were unprepared either by training or disposition to cope with the
health needs in the rural area. With discouraging frequency they became
resentful, irresponsible or blatantly corrupt.
Next came the era of the mobile clinics. They, too, failed miserably.
They created dependency and expectation without providing continuity of
service. The net result was to undermine the people's capacity for self care.
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It was becoming increasingly clear that provision of health care in the
rural area could never be accomplished by professionals alone. But the
medical establishment was—and still is—reluctant to crack its legal monopoly.
At long last, and with considerable financial cajoling from foreign and
international health and development agencies, the various health depart
ments have begun to train and utilize auxiliaries. Today, in countries where
they have been given half a chance, auxiliaries play an important role in the
health care of rural and periurban communities. And if given a whole chance,
their impact could be far greater. But, to a large extent, politics and the
medical establishment still stand in the way.
My own experience in rural health care has mostly been in a remote
mountainous sector of Western Mexico, where, for the past 12 years I have
been involved in training local village health workers, and in helping foster a
primary health care network, run by the villagers themselves. As the villagers
have taken over full responsibility for the management and planning of their
programme, I have been phasing out my own participation to the point where
I am now only an intermittent advisor. This has given me time to look more
closely at what is happening in rural health care in other parts of Latin
America.
Last year a group of my co-workers and I visited nearly 40 rural health
projects, both government and non-government, in nine Latin American
countries (Mexico, Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica,
Venezuela, Columbia and Ecuador). Our objective has been to encourage a
dialogue among the various groups, as well as to try to draw together many
respective approaches, methods, insightsand problems into a sort of field
guide for health planners and educators, so we can all learn from each other's
experience. We specifically chose to visit projects or programmes which
were making significant use of local, modestly trained health workers or
which were reportedly trying to involve people more effectively in their own
health care.
We were inspired by some of the things we saw, and profoundly disturbed
by others. While in some of the projects we visited, people were in fact
regarded as a resource to control disease, in others we had the sickening
impression that disease was being used as a resource to control people. We
began to look at different programmes, and functions, in terms of where
they lay along a continum between two poles : community supportive and
community oppressive.
Community supportive programmes or functions are those which
favourably influence the long-range welfare of the community, that help it
stand on its own feet, that genuinely encourage responsibility, initiative,
decision making and felf-reliance at the community level, that build upon
human dignity.
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Community oppressive programmes or functions are those which, while
invariably giving lip service to the above aspects of community input, are
fundamentally authoritarian, paternalistic or are structured and carried out in
such a way that they effectively encourage greater dependency, servility and
unquestioning acceptance of outside regulations and decisions; those which
in the long run are crippling to the dynamics of the community.
It is disturbing to note that, with certain exceptions, the programmes
which we found to be more community supportive were small non-government efforts, usually operating on a shoestring and with a more or less
subrosa status.
As for the large regional or national programmes—for all their inter
national funding, top-ranking foreign consultants and glossy bilingual bro
chures portraying community participation—we found that when it came down
to the nitty-gritty of what was going on in the field, there was usually a
minimum of effective community involvement and a maximum of dependency
creating handouts, paternalism and superimposed, initiative destroying norms.
I don't have time to elaborate here, but anyone who is interested in a
more detailed account of community supportive and oppressive health pro
gramming may send for a copy of a paper I presented in England last year
entitled Health Care and Human Dignity.* (C-52)
In our visits to the many rural health programmes in Latin America, we
found that primary health workers come in a confusing array of types and
titles. Generally speaking, however, they fall into two major groups :
auxiliary nurses
or health technicians
health promoters
or village health workers
— at least primary education plus
1-2 years training
—average of 3rd grade education
plus 1-6 months training
—usually from outside the community
—usually from the community and
selected by it
—usually employed full time
—often a part time health worker
supported in part by farm labor
or with help from the community
—salary usually paid by the programme
(not by the community)
—may be someone who has already
been a traditional healer.
# Health Care and Human Dignity by David Werner, 1976. Available through the Hesperian
Foundation, P.O. Box 1692, Palo Alto, California 94302, USA.
cover copy and postage. Also available from VHAl (C-52).
Please send $2.00 U.S. to
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fn addition to the health workers just described, many Latin American
countries have programmes to provide minimal training and supervision of
traditional midwives. Unfortunately, Health Departments tend to refer to
these programmes as “Control de Parteras Empiricas"—Control of Empirical
Midwives—a terminology which too often reflects an attitude. Thus to Mos
quito Control and Leprosy Control has been added Midwife Control. (Small
wonder so many midwives are reticent to participate !) Once again, we found
the most promising work with village midwives took place in small non
government programmes. In one such programme* the midwives had formed
their own club and organized trips to hospital maternity wards to increase
their knowledge.
What skills can the village health worker perform ? How well does
he perform them ? What are the limiting factors that determine what he
can do ? These were some of our key questions when we visited different
rural health programmes.
We found that the skills which village health workers actually performed
varied enormously from programme to programme. In some, local health
workers with minimal formal education were able to perform with remarkable
competence a wide variety of skills embracing both curative and preventive
medicine as well as agricultural extension, village cooperatives and other
aspects of community education and mobilization. In other programmes—
often those sponsored by Health Departments—village workers were permitted
to do discouragingly little. Safeguarding the medical profession’s monopoly
on curative medicine by using the standard argument that prevention is more
important than cure (which it may be to us but clearly is not to a mother
when her child is sick) instructors often taught these health workers fewer
medical skills than many villagers had already mastered for themselves. This
sometimes so reduced people’s respect for their health worker that he (or
usually she) became less effective, even in preventive measures.
In the majority of cases, we found that external factors, far more than
intrinsic factors, proved to be the determinants of what the primary health
worker could do. We concluded that the great variation in range and type
of skills performed by village health workers in different programmes has
less to do with the personal potentials, local conditions or available funding
than it has to do with the preconceived attitudes and biases of health
programme planners, consultants and instructors.
In spite of the often
repeated eulogies about “primary, decision making by the communities
themselves”, seldom do the villagers have much, if any, say in what their
health worker is taught and told to do.
* In Pinalejo, Honduras.
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The limitations and potentials of the village health worker—what he is
permitted to do and, conversely, what he could do if permitted—can best be
understood if we look at his role in its social and political context. In Latin
America, as in many other parts of the world, poor nutrition, poor hygiene,
low literacy and high fertility help account for the high morbidity and mortality
of the impoverished masses. But as we all know, the underlying cause—or
more exactly, the primary disease—is Inequity : inequity of wealth, of land, of
educational opportunity, of political representation and of basic human rights.
Such inequities undermine the capacity of the peasantry for self care. As a
result, the political/economic powers-that-be assume an increasingly pater
nalistic stand, under which the rural poor become the politically voiceless
recipients of both aid and exploitation. (See Figure 1) In spite of national,
foreign and international gestures at aid and development, in Latin America
the rich continue to grow richer and the poor poorer. As anyone who has
broken bread with villagers or slum dwellers knows only too well : health of
Fig. 1
Too often ald and exploitation go hand in hand.
''WE FEEL IT OUA
MORAL DUTY TO HELF
THE POOR STAND ON
THEIR OWN FEET *
AW
/
°i
hi
ZJ J
COULD IT BE A
VICIOUS CIRCLE?
Increased aid
(with strings .
. attached)
Increased dependency
of poor on rich, of rural
conriunlty on central govt,
and of central govt, on
foreign and multilateral
agencies.
I
Stronger central power
(national, foreign,
multinational)
Weaker people
tl
Increased debt
(poor owe rich)
V.
THE
AID
CYCLE
\ \
I T
Humiliation, decreased
dignity, increased
irresponsibility, sense
of futility, misdirected
anger.i
Increased
exploitation
Increased outside
manipulation and control
2^MMun,ty health ceu
326, V Main,
I Block
^oramangala
Bang«/or«-560034
(
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the people is far more influenced by politics and power groups, by distribution
of land and wealth, than it is by treatment or prevention of disease.
Political factors unquestionably comprise one of the major obstacles to
a community supportive programme. This can be as true for village politics
as for national politics. However, the politico-economic structure of the
country must necessarily influence the extent to which its rural health pro
gramme is community supportive or not.
Let us consider the implications in the training and function of a primary
health worker:
If the village health worker is taught a respectable range of skills, if he
is encouraged to think, to take initiative and to keep learning on his own, if
his judgment is respected, if his limits are determined by what he knows and
can do, if his supervision is supportive and educational, chances are he will
work with energy and dedication, will make a major contribution to his
community and will win his people’s confidence and love. His example will
serve as a role model to his neighbours, that they too can learn new skills
and assume new responsibilities, that self-improvement is possible. Thus
the village health worker becomes an internal agent-of-change, not only for
health care, but for the awakening of his people to their human potential ...
and ultimately to their human rights.
However, in countries where social and land reforms are sorely needed,
where oppression of the poor and gross disparity of wealth is taken for
granted, and where the medical and political establishments jealously covet
their power, it is possible that the health worker I have just described knows
and does and thinks too much. Such men are dangerous ! They are the
germ of social change.
So we find, in certain programmes, a different breed of village health
worker is being molded., one who is taught a pathetically limited range of
skills, who is trained not to think, but to follow a list of very specific instru
ctions or “norms”, who has a neat uniform, a handsome diploma and who
works in a standardized cement block health post, whose supervision is
restrictive and whose limitations are rigidly predefined. Such a health worker
has a limited impact on the health and even less on the growth of the
community. He—or more usually she—spends much of her time filling
out forms.
In a conference I attended in Washington last December, on Appropriate
Technology in Health in Developing Countries, it was suggested that
"Technology can only be considered appropriate if it helps lead to a change in
the distribution of wealth and power”. If our goal is truly to get at the root
of human ills, must we not also recognize that, likewise, health projects and
health workers are appropriate only if they help bring about a healthier
distribution of wealth and power ?
7
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)
We say prevention is more important than cure.
willing to go ? Consider diarrhoea :
But how far are we
Each year millions of peasant children die of diarrhoea. We tend to
agree that most of these deaths could be prevented. Yet diarrhoea remains
the number one killer of infants in Latin America and much of the developing
Fig. 2
WE SAY PREVENTION IS MORE IMPORTANT THAN CURE—
BUT WERE SHOULD PREVENTION BEGIN ?
EFFECT
Needless Suffering and Dehumanization
M
Disproportionately high morbidity and mortality
(especially infants, mothers and young men)
t
t
Infections, such as diarrhoeas and pneumonia, violence, etc.
Poor nutrition, poor hygiene; low literacy, high fertility.
Low initiative, misdirected anger
I
t
Inequity of:
Wealth
Land
Health Care
Education
Representation
Human Rights
■> Q
THE
AID
CYCLE
t
Existing Power Structure
—financial power groups
—political power groups
—medical establishment
—legal profession
—religious power groups
1 '
Private
Governmental
Fore'fln
<______
Multinational
i
GREED
(short sighted self-interest)
CAUSE
PREVENTIVE
MEASURES :
Social reform
(or revolution)
Humanization
(Evolution)
(
world.
8
)
Does this mean our so-called “preventive" measures are merely
palliative? At what point in the chain of causes which makes death from
diarrhoea a global problem (see Figure 2) are we coming to grips with the
real underlying cause.
Do we do it ...
... by preventing some deaths through treatment of diarrhoea ?
... by trying to interrupt the infectious cycle through construction of
latrines and water systems ?
... by reducing high risk from diarrhoea through better nutrition ?
... or by curbing land tenure inequities through land reform ?
Land reform comes closest to the real problem.
But the peasantry is
oppressed by far more inequities than those of land tenure. Both causing
and perpetuating these crushing inequities looms the existing power stru
cture : local, national, foreign and multinational.
It includes political,
commercial and religious power groups as well as the level profession and
the medical establishment. In short it includes ... oursleves.
As the ultimate link in the causal chain which leads from the hungry child
with diarrhoea to the legalized inequities of those in power, we come face to
face with the tragic flaw in our otherwise human nature, namely greed.
Where, then, should prevention begin ? Beyond doubt, anything we can
do to minimize the inequities perpetuated by the existing power structure will
do far more to reduce high infant mortality than all our conventional preven
tive measures put together. We should, perhaps, carry on with our latrine
building rituals, nutrition centers and agricultural extension projects. But
let’s stop calling it prevention. We are still only treating symptoms. And
unless we are very careful, we may even by making the underlying problem
worse ... through increasing dependency on outside aid, technology and
control.
But this need not be the case. If the building of latrines brings people
together and helps them look ahead, if a nutrition center is built and run by
the community and fosters self-reliance, and //agricultural extension, rather
than imposing outside technology encourages internal growth of the people
toward more effective understanding and use of tneir land, their potentials
and their rights ... then, and only then, do latrines, nutrition centres and
so-called extension work begin to deal with the real causes of preventable
sickness and death.
This is where the village health worker comes in. It doesn’t matter much
if he spends more time treating diarrhoea than building latrines. Both are
merely palliative in view of the larger problem. What matters is that he get
his people working together.
(
9
)
Yes, the most important role of the village health worker is preventive.
But preventive in the fullest sense, in the sense that he helps put an end to
oppressive inequities, in the sensethat he helps his people, as individuals
and as a community, liberate themselves not only from outside exploitation
and oppression, but from their own short-sightedness, futility and greed.
The chief role of the village health worker, at his best, is that of liberator.
This does not mean he is a revolutionary (although he may be pushed into
that position). His interest is the welfare of his people. And, as Latin
America’s blood-streaked history bears witness, revolution without evolution
too often means trading one oppressive power group for another. Clearly,
any viable answer to the abuses of man by man can only come through
evolution, in all of us, toward human relations which are no longer founded
on short-sighted self-interest, but rather on tolerance, sharing and
compassion.
I know it sounds like 1 am dreaming. But the exciting thing in Latin
America is that there already exist a few programmes that are actually
working toward making these happen—where health care for and by the
people is important, but where the main role of the primary health worker is
to assist in the humanization or, to use Paulo Freire’s term, conscientization
of his people.
Before closing let me try to clear up some common misconceptions.
Many persons still tend to think of the primary health worker as a
temporary second-best substitute for the doctor ... that if it were financially
feasible the peasantry would be better off with more doctors and fewer
primary health workers.
I disagree. After twelve years working and learning from village health
workers—and dealing with doctors—I have come to realize that the role of
the village health worker is not only very distinct from that of the doctor,
but, in terms of health and well-being of a given community, is far more
important. (See Appendix)
You may notice I have shied away from calling the primary health worker
an ‘auxiliary’. Rather I think of him as the primary member of the health team.
Not only is he willing to work on the front line of health care, where the needs
are greatest, but his job is more difficult than that of the average doctor. And
his skills are more varied. Whereas the doctor can limit himself to diagnosis
and treatment of individual “cases”, the health worker’s concern is not only
for individuals—as people—but with the whole community. He must not only
answer to his people’s immediate needs, but he must also help them look
(
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)
ahead, and work together to overcome oppression and to stop sickness before
it starts. His responsibility is to share rather than hoard his knowledge, not
only because informed self-care is more health conducing than ignorance
and dependence, but because the principle of sharing is basic to the well
being of man.
Perhaps the most important difference between the village health worker
and the doctor is that the health worker’s background and training, as well
as his membership in and selection by the community, help reinforce his will
to serve rather than bleed his people. This is not to say that the village
health worker cannot become money-hungry and corrupt. After all, he is as
human as the rest of us. It is simply to say that for the village health worker
the privilege to grow fat off the illness and misfortune of his fellow man has
still not become socially acceptable.
Forgive me if I seem a little bitter, but when you live with and share the
lot of Mexican villagers for 12 years, you can’t help but feel a little uncom
fortable about the exploits of the medical profession. For example, Martin,
the chief village medic and coordinator of the villager-run health programme,
I helped to start, recently had to transport his brother to the big city for
emergency surgery. His brother had been shot in the stomach. Now Martin,
as a village health worker supported through the community, earns 1,600 pesos
($80.00) a month, which is in line with what the other villagers earn. But the
surgeon charged 20,000 pesos ($1000.00) for two hours of surgery. Martin
is stuck with the bill. That means he has to forsake his position in the
health programme and work for two months as a wet-back in the States—in
order to pay for two hours of the surgeon’s time. Now, is that fair ?
No, the village health worker, at his best, is neither choreboy nor auxiliary
nor doctor’s substitute. His commitment is not to assist the doctor, but to
help his people.
The day must come when we look at the primary health worker as the key
member of the health team, and at the doctor as the auxiliary; The doctor,
as a specialist in advanced curative technology, would be on call as needed
by the primary health worker for referrals and advice. He would attend those
2-3% of illnesses which lie beyond the capacity of an informed people and
their health worker, and he even might under supportive supervision, help
out in the training of the primary health worker in that narrow area of health
care called Medicine.
Health care will only become equitable when the skills pyramid has been
tipped on its side, so that the primary health worker takes the lead, and so
that the doctor is tap and not on top.
(
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Fig. 3
TIPPING THE HEALTH MANPOWER PYRAMID ON FTS SIDE
THE TYPICAL PYRAMID
THE PYRAMID AS IT SHOULD BE
The doctor
is on top
The people come first
MDs
NURSES
O
O
2
S
PARAMEDICS
“O
□3
2
m
O
o
COMMUNITY
HEALTH WORKERS
30
GO
m
GO
2
o
GO
The doctor is on tap
(not on top)
COMMUNITY
The community is on the bottom of the stack.
Each level is rigidly delineated.
z
c=
The community health worker assumes
the lead role in the health team.
Fig. 4
The primary health worker
lives and works at the level
of the people.
His first job is to share
his knowledge.
(illustration from the book
Where There is No Doctor
by David Werner).
COMMUNITY HEALTH
CELL
326, V Main, I Block
Koramongala
Bangalore.560034
India
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APPENDIX
Comparison of the Medical Doctor and the Primary Health Worker
(Note : The medical doctor as described here is the typical Western-style
M.D. as produced by medical schools in Latin America. Clearly,
there are exceptions. Most Latin American medical schools are
beginning to modify their curricula to place greater emphasis on
community health. However, not modifications but radical changes,
both in selection and training, are needed if doctors are ever to
become an integrated and fully positive part of a health team that
serves all the people.)
CONVENTIONAL DOCTOR
VILLAGE HEALTH WORKER
(at the best)
Class
Usually upper middle class
From the peasanty
How chosen
By medical school for :
grade point average;
economic and social
status.
By community for : interest,
compassion,
knowledge of
community, etc.
Preparation
Mainly institutional, 12-16
years general
schooling,
4-6 years medical training.
Training concentrates on
* physical and technologi
cal aspects of medicine.
* and gives low priority to
human, social and politi
cal aspects.
(This is
now changing in some
medical schools.)
Mainly experiential. Limited,
key training appropriate to
serve all the people in a given
community :
*
Dx & Rx of important disease
*
Preventive medicine
* Community health
* Teaching skills
*
Health care in terms of econo
mic and social realities, and
of needs (felt and long term)
of both individuals and the
community.
*
Humanization (conscientization) and group dynamics.
Qualification
Highly qualified to diagnose
and treat individual cases.
Especially
qualifiedI
to
manage
uncommon
and
difficult diseases.
Less qualified to deal effe
ctively with most important
diseases of most people in
a given community.
Poorly qualified to supervise
and teach VHW. Well quali
fied in clinical medicine, but
not in other more important
aspects of health care; he
tends to favour imbalance;
wrong priorities.)
Moreq ualified than doctor to
deal effectively with the impor
tant sicknesses of most of the
people.
Non-academic quali
fications are : Intimate know
ledge of the community, lan
guage, customs, attitudes to
wards sickness and healing.
Willingness to work and enrn
at the level of the community,
where the needs are greatest.
Not qualified to diagnose and
treat certain
difficult and
unusual problems; must refer.
(
13
)
Orientation
Disease/Treatment/Indivi
dual patient oriented.
Primary Job
Interest
The challenging and interes
ting cases. (Often bored by
day to day problems.)
Attitude
toward the
sick
Superior. Treats people as
patients. Turns people into
•'cases"
Underestimates
people's
capacity for self-care.
Health/Community oriented.
Seeks a balance between cura
tive and preventive. (Curative
to meet felt needs, preventive
to meet real needs.)
Helping people resolve their
biggest problems because he
is their friend and neighbour.
On their level.
as people.
Treats patients
Mutual concern and interest
because the VHW is village
selected.
Attitude of
the sick
toward M.D.
or VHW
Hold him in awe. Blind trust
(or sometimes distrust).
See him as a friend. Trust him
as a person, but feel free to
question him.
How does
Medical
Knowledge
Hoards it.
disDelivers "services",
courages self-care, keeps
patients helpless and de
pendent.
Shares it.
Encourages informed self-care,
helps the sick and family under
stand and manage problems.
Accessibility
Often inaccessible, especially to poor.
of
Preferential
treatment
haves over have-nots.
Does some charity work.
Very accessible.
Lives right in village.
Low charges for services.
Treats everyone equally and
as his equal.
Considera
tion for
economic
factors
Overcharges.
Expects disproportionately
high earnings.
Feels it is his God-given
right to live in luxury while
others hunger.
Often prescribes unnecessa
rily costly drugs.
Overprescribes.
Reasonable charges.
Takes the person's economic
position into account.
Content (or resigned) to live
at economic level of his people.
Prescribes only useful drugs.
Considers cost.
Encourages
effective home remedies.
Relative
Permanence
At most spends 1-2 years in
a rural area and then moves
to the city.
A permanent member of the
community.
Continuity
of Care
Can't follow up cases becacuse he doesn’t live in
the isolated areas.
Visits his neighbours in their
homes to make sure they get
better and learn how not to
get sick again.
(
14
)
Cost
Effectiveness
Too expensive to ever meet
medical needs of the poorunless used as an auxiliary
resource for problems not
readily managed by VHW.
Low cost of both training and
practice.
Higher effectiveness than doctor
in coping with primary pro
blems.
Resource
Require
ments
Hospital or health centre.
Depends
on
expensive,
hard-to-get equipment and
a large subservient staff to
work at full potential.
Works out of home or simple
structure.
People are the main resource.
Present
Role
On top.
Directs the health team.
Manages all kinds of medi
cal
problems,
easy or
complex.
Often overburdened with
easily treated or preventa
ble illness.
On the bottom.
Often given minimal responsi
bility, especially in medicine.
Regarded as an auxiliary (lackey)
to the physician.
Impact
on the
Community
Relatively
low
(in part
negative).
Sustains class differences,
mystification of medicine,
dependency on expensive
outside resources.
Drains resources of poor
(money).
Potentially high.
Awakening of people to cope
more effectively with
health
needs, human needs, and ulti
mately human rights.
Helps community to use resou
rces more effectively.
Appropriate
(future ?)
Role
On tap (not on top).
Functions as an auxiliary to
the VHW, helping to teach
him more medical skills and
attending referrals at the
VHW’s request. (The 23%
of cases that are beyond
the VHW’s limits.)
He is an equal member of
the health team.
Recognized as the key member
of the health team.
Assumes leadership of health
care activities in his village, but
relies on advice, support, and
referral assistance from the
doctor when he needs it.
He is the doctor’s equal (alth
ough his earnings remain in
line with those of his fellow
villagers.)
APPROACHES
TWO
0
Taking care of others
fifakc 2
14 tiroes
fPontf G15& /
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I
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leorrtlfr ccireFoi* 1
—-tti€n9$&lyCs>
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m op
THE LA.ND
OF
’Ttr
CARE_______ __
HEALTH
IV—MW
KNOWLEDGE
l
pciA
/
Thctnk
Irra: pit of
IGNORANCE
encourages independence,
encourages dependency
and loss of freedom •
gelf-reliance and, equality,
VILLAGE HEALTH WORKERS CAN HELP DOCTORS LEARN THE SECOND APPROACH
1
COMMUNITY HEMIH TEAM TRAINING PROGRAMME
PROSPECTUS
CATHOLIC HOSPITAL ASSOCIATION OF INDIA
CBCI CENTRE, GOLDAKKHANA
ASHOKA PLACE, NEW DELHI-110001
PHONE : 310694
INTRODUCTION
Philosophy and Vision
In the light of the WHO's call 'Health for All by 2000 AD'the revised
national health policy of the Government, and in line with the document by
Pontifical Council Cor Unum on "the new orientation of health services with
respect to primary health care', the teaching of the Church and of the recent
Popes, and the statement of the CBCI from time to time, as well as in the light of
this consultation, the working team of CHD of CHAI concludes that:
1.
In a country like India, so vast and varied, where 80% of its popula
tion live in the rural areas and about 90% of the country's health care
system caters to the need of the urban minority, a new orientation
and rethinking of the whole health care system is the need of the
hour.
2.
Health is the total well-being of individuals, families and communities
as a whole and not merely the absence of sickness. This demands an
environment in which the basic needs are fulfilled, social well-being is
ensured and psychological as well as spiritual needs are met. Accor
dingly a new set of parameters will have to be considered for
measuring the health of a community such as the peoples part in
decision making, absence of social evils in the community, organising
capacity of the people. The role women and youth play in matters of
health and development etc. other than the traditional ones like infant
mortality rate, life expectancy etc.
3.
The present medical system with undue emphasis on curative aspect
tends mainly to be a profit-oriented business, and it concentrates on
'selling health' to the people, and is hardly based on the real needs of
the vast majority of the people in the country. The root causes of the
illness lie deep in social evils and imbalances, to which the real
answer is a political one, understood as a process through which
people are made aware of the real needs, rights and responsibilities,
available resources in and around them, and get themselves organised
for appropriate actions. Only through this process can health become
a reality to vast majority of the Indian masses.
4.
The concept of Community Health here should be understood as a
process of enabling people to exercise collectively their responsibili
ties to maintain their health and to demand health as their right.
Thus it is beyond mere distribution of medicines, prevention of sick
ness, and income generating programmes.
In the light of the above conclusions, we identified the exploited and the
unorganised masses, particularly those in rural areas as our target group.
1
We intend to reach this groups through the existing health institutions in the
country, especially through the member institutions of CHAI and other individuals
and groups engaged in the field of people-oriented programme. In this process,
possibilities of collaboration with other voluntary organisations, which up-holds
similar philosophy and objectives will be explored to the maximum.
To initiate and promote Community Health programmes in India with the
above vision and objectives, we have designed a 15 months course for Commu
nity Health Team Training in collaboration with the Voluntary Health Association
of India. This long term programme with theoretical and field level training was
initially designed by VHAI. We hope that this programme will give our partici
pants sustained guidence and support in three ways:
1.
CHAI and other resource persons will be in contact for a period of
15 months.
2.
The Community Health and Team Training will emphazise team train
ing and give priority to training several participants from a project,
thus ensuring local support for each other.
3.
We will train personnel from programmes which are geographically
close together so that a wider regional support is provided for the
participants in terms of sharing resources and experiences.
Aims and Objectives
The overall aim of the Community Health Team Training Programme is to
help prepare teams to participate in the building up of healthy communities with
emphasise on people's involvement using appropriate and local resources and
responding to community needs.
Specific Objectives :
2
To help participants
1.
develop a broad understanding of a healthy community.
2.
increase their ability to analyse the society to evolve strategies for
bringing about a just social order.
3.
to plan, organise, implement and evaluate their own programmes.
4.
acquire relevant knowledge, skills and attitudes to achieve the above
objectives.
5.
build support systems within their team and at the zonal/diocesan/
congregational level.
Criteria for Acceptance in the Training Programme
1.
Application should be sent by the sponsoring authority to the organi
sing body of the programme: viz. Diocese, Congregation, Action
group etc.
2.
Preference will be given to persons from programmes which are
willing to sponsor two or more candidates for the full duration of the
training.
3.
There should be a written agreement between the sponsor and spon
sored candidate that the candidate will continue to work in the same
programme for a period of at least two years after the completion of
the course. In case of transfer, due to serious reasons the person
should be replaced by another, having the same basic training.
4.
It is essential that the candidate have experience in working in rural
areas.
5.
The candidate should be able to read and write English, and should be
conversant with the local language.
6.
No specific professional qualification is essential.
Course Outline
I.
Understanding of a healthy Community
//. A.
a.
concept of health, community and community health;
b.
relationship between 'health' and development;
c.
approaches to development;
d.
understanding of community involvement and relevance of community
organisation;
e.
spiritual dimensions—Biblical, pastoral and liturgical;
f.
study of relevant church and state documents.
Analysis of the systems & structures
Present social, economic, political and cultural structures affecting
health and other aspects of the community.
An introduction to the various systems, their historical development
and the values which are inherent.
Relationship between the micro-level and macro-level situation.
Analysis of the existing health care system.
3
B.
Values and attitudes required in building a healthy society
III.
To plan, organise, implement and evaluate a Community Health Programme
IV.
V.
VI.
4
a.
methods of analysing an Indian village.
b.
methods of identifying community needs and priorities and the skills
required.
c.
Identification of local resources.
d.
collection of information, analysis and interpretation.
e.
planning a community health programme.
f.
the role of the village community and team, in community health
programme.
g.
role of NFP in community health programme.
h.
promotion of home remedies in community health programme.
i.
the role of health personnel in community health programme.
j.
principles and methods of evaluation.
Government Programmes
a.
Overall view of Government policies and programmes (at all levels)
b.
Administrative structure of various services at the local and state
levels.
c.
collaboration of voluntary agencies with the Government schemes.
Introduction to communication and Training Techniques
a.
Theory and principles of communication.
b.
Methods and media of communication.
c.
Inter personal communication.
d.
Preparing low cost audio visual aids.
e.
Theory and methodology of training.
Basic Management skills
a.
Team Building
b.
Role analysis and role negotiation
c.
Management by objectives
d.
Tension management/counselling.
Methodology and course design
the medium of the course will be English.
—
the training programme is spread over a period of 15 months in this
way :
Introductory
Residential course
3 weeks
1st month
Visit by CHAI team to
each participant's programme
5 days for each programme
3rd month
General meeting
5 days
6th month
9th month
12th month
Visit by CHAI team to
each participant's programme
5 days for’each programme
14th month
Closing seminar
1 week
15th month
1.
The three week initial residential course will cover the main concepts
of Community Health and Development, analysis of the structures
within a village and some basic guidelines to initiate a comprehensive
Community Health Programme. At the end of the three weeks the
participants will set specific objectives for their work for the next
five months.
2.
Three general meetings will be held every three months for five days.
In these meetings participants will discuss the activities undertaken by
them in the interim period, receive additional inputs on a particular
topic and set objectives for the next three months.
3.
There will be a closing seminar for one week to evaluate the pro
gramme and to sum up the learnings of the course in the light of the
participants' experience.
4.
The CHAI team will visit all participants twice; once after the initial
three week course and once before the closing seminar. The first visit
is to help participants in:
a.
initial planning of their programme.
b.
involving the rest of their team in their work.
The second visit is to assess the implementation of the learning of
the course.
5
.
/
5.
The participants will be expected to :
submit short assignments related to topics discussed in the course.
submit a major paper by the end of the course based on a study of
any chosen aspect of the community. The subject of the study
will be decided in consultation with others in their own pro
gramme and approved by the CHAI resource persons.
make an assessment of their own accomplishments and their
community health programme before and after the training pro
gramme.
keep a diary on the unusual events/observations made during
their village visits.
hold regular meetings with the rest of their team and keep minu
tes of each of these meetings.
Location of the Course
For the effective implementation of the programme the course will be
conducted for participants working in a given geographical area eg. Diocese,
District, etc.
Course Expenses
The course expenses, including the boarding and lodging of the CHAI
resource team are to be met by the organising body.
Whom to contact
The Programme Director
Community Health Department—CHAI
CBCI Centre
Goldakkhana
New Delhi 110 001
6
(C. G /vn H
I «
It
COMMUNITY Hr’.L*H CELL
226, V Main, I Block
^o^mongala
Communitv Health bww
-kw Scheme: A Plan
India
for DemocratisatioD
Mark Nichtrr
The
Health Worker (CHW) schcw.
sr>: r aftn
of the Jemata
party government at the Centre, while laudable in its
... has been poorly implemented. The failure of the
scheme can be traced to some serious drawbacks in tm founding principles of the scheme itself.
This article, while broadhf supporting the spirit and philosophy inherent in the Ra Narain scheme,
proposes an alternative plan of community health service whose structure is more democratic, and whose
working will be more responsive to the felt needs of the rural p yndatiom
ON April 20. 1977, Rai Narain, at that
*ime I nion Minister tor Health and
Farni V, eHare, announced the creation
of a uev type of Community Health
Work'’! buiieine to increase health care
del:very to the rural poor. The scheme
wa; introduced with modification in
selcct-. c aistriets of those states accept
ing the programme. Reports on the suc
cess of the scheme have been contro
versial. Gases have been cited where in.di vidua] CHWs have been found to per
form their duties remarkably well,1 but
as an overall programme, the Rai Narain
Pian, while being laudable in spirit,
leaves much to be desired in Terms of
implementation. In the words of one
4 district hcaitli officer, “the scheme is
a premature baby; its survival requires
; a lot of special care, but who can give
that kmd of carer We in the Health
i Department barely have enough time to
j supervise. our own staff ... ih& idea is
/ good, no doulrt, hut a seed is only as
good as the soil into which it is put.
;■ Someone should have done some
ploughing first and someone should be
there for weeding”.
These comments are revealing when
on<- reviews evaluations of the scheme’s
iinpleanentatiop.. Take, for example, reports submitted. b‘. lb
Institute of
^Economic Growth£ on the villager’s
perception of the CHW and CHW’s
pre-couception of v, nc. tiieir role should
he; or toe
the Department
iff Lingui^ics'
the University of
Delhi? or. the communicability and
compi-ehen^hWy ot
CHW Training
Manual, ft has_cp.mmonb'.... beep,_the
case thaj_^niixig^HW2_Are_ no: veil
informed abotK..the _scheine. many
jobless opportuniS'-j are attracted to
th--.’ procrammc_ay .a .so.’.jr.C.G of imagin•c 'emHc'-Tie”;: and K'ca!
political
. uumn; un: ry,
jraug .CH Vy^seiec■m. T1'- .-•;•»itjfw ha.- h-. and .i^rgn*
.-/l.-;....
w
«uppor‘
'Oi-vrusf local iki-‘.h ■■jTf' and n. '.
'evuier; p._iniar’i.'
constitute health.
. -.■r.ix/jetM-.-.u -ivl.-... fpr_ insTruction
n
beeL 2'dveiy ■prepare:'! wiritout the
ki/jw’i dgr -Of local lan.i;ua/e_(j)articu"
s.iriy disease and-bixl . .cenuino‘ or
the villagers’ oogn.t.v- framework. Tim
has fostered the development of health
education strategies which, instead of
being cultural^ apt opriate, are a
figment of some write s imagination
and pienonceived. -notions
The poor foundarmn of the CHW
scheme — candidate selection, percep
tion of the CHW role and organisation
of instruction ■— discloses the poverty
of its implomemation. The same point
could be made about the quality of
preparatory orientation given to CHW
trainers or the disinterest of PHC
staff in administering the scheme, etc.
but this is .not the purpose- of tins
article. Our purpose is rather to
suggest a viable alternative to the
existing Raj Narain scheme; a plan
which may be explored in concept if
not in content by healrh planners and
concerned politicians. The plan re
tains. if nor accentuates, the spirit
and philosophy of the Raj Narain
scheme, but alters thf form of imple
mentation and development.
The present plan places emphasis on
preliminary
groundwork
preceding
CHW candidate selection, training
course organisation and implementa
tion. This groundwork would include
targeted community diagnosis research
and greater communitj’ awareness of
its role in -establishing and shaping a
village level primary health care re
source. Without a preliminary com
munity diagnpsi." _of
nutrition,
health and medical ideology /behaviour,
the development of cuituralh appropriatc health education. /strategies is
impossibie.
W-thout knowledge of
cbmrmirj!’ feh neen
and creder-ei
ge •- f • < * i • •. ■ on 2 o in/ c ■ ’ i n > h : n: ? y .mpp or!
wi‘; lag far behi .
?-.-pectat:ans cf
heahh planners ar •/ ccncernec pol:-:.: n_ pres?;'. ', p/.Se:ht --ty m tn.
pjogrammt-/
tralisation and dcinsritutionalisation of
the overall scheme, and greater com
munity control of the health services
provided to- m benet.t. It calls for a
CHW network which is autonomous
although complementary to the gover'nmen; medical care network.
Tpe
existence of two separate interrelated
health care neiw.ri.will ensure that
the corrm ; ■ :i> na.- an_opportunity to
articulate its views in regard to the
ryp<- of medical senices that are pre
sent!. being provided. The health
department, on the other hand, will
have an opportunity to demonstrate the
effectiveness of its programmes provi
ded th.;’ community support is realised.
Once it is initiated, community input
max play an important role in the
y'- structuring
of government health
vities: a role at first critical and
tnen constructive. Moreover, the role
^of the CHW could emerge as that of a
p-!mar\ health care resource responsi
ble to the community as opposed to
another cadre of health auxiliary or
doctors’ assistants . responsible to_ the
health bureaucracy. If
the CHW's
role retains the latter status, it is
doubtful that ongoing community sup
port w:.i! be mobilised unless such
support is the outcome of the persona!
: n,ol an oiitstandmc incumbent.
Rather than banking on one person,
the plan places emphasis on the deve
lopment of a strong base. Village
health committees_.will _-DnUi-be--^ible
fo gain widespread interest and suppo-; ”• th: comru-’/.y when vested
with speu’iic powers and_r.csp.onsib b■je- w:
v.Hi. afiec: ..the populace at
large.
Individual CHWs will only
feel tree to express community cissarisi'icti' • - anc t,?i- needs when a
CHW 'grand pan chav a
grand ruucha*?' v ?
exists. The
be
abk tr
as
CHV
the r/.
met!:
7
lanuary 5.
I
-980
ECONOMIC AND POLITICAL WEEKLY
operative which can ensure a reliable
-ind
continuous supply
simpis
medicines wirhin rhe reach of the
poor, demonstrate the power of cooperative action and maximise the
services and training of CHW and
PHC staff alike.
diagnosis
These apprentices will be-
COMMUNTTT DIAGNOSIS ReSZAHCH
Hirure .search ream leaders.
They should preferably have past tieid.Airk experience.
Interviewer instructors should be
chosen ftor future project work in the
district from
■ n a zroup of interviewers
The plan is presented from below,
selected to carry out a battery or open*
Attention will first be directed toward
ended. suveys
»•
on nutrition, health and
Local concepts of physiolyogy.
preliminary research necessary for the
medical1
ideology/behavioutr.
work cycles, economic cycles, weights
Interplanning of regional CHW program
and measures systemviewers who demonstrate ii good field
Local concepts of physiology.
mes. Following a discussion of how a
technique, interest in community dePrevalent notions of disease etiocommunity diagnosis element may be
velopment work, self initiative
and
logy and contagion.
introduced into the CHW scheme,
responsibility should be retained after
Illness terminology and classificaselection of initial impact sites -and
the survey work is completed. They
tioi> including, the signs and symp
the initiation of Village Health Com
will work
toms
with— as core staff research assis„
■ associated
.»
...
. - folk
,—; -illness caterants in training for position, as inter- ■^•■73 iL™™
mittees is considered. Next, rhe con
—'*—■". of iUnesa?.;
' , toisrannatioii, andi progression hrtot :
cept of culturally relevant CHW train viewer instructors in successive district
different categories of illness states.
ing is briefly considered as well as the
projects. They will assist in data tabu
Local preventive, and. promotive
formation of medical co-operatives as
lation- and follow up research as well
health measures.
The nutritional context; (a) foods
tangible incentives for the existence
as function as
community organisers
available, season, cost; (b) mean? of
of a village health committee. This
communicating to villagers in an impreservation;
(c) maximisation of
discussion is followed by a _____
model of
zone the nature of the CHW
available foods in different seasons;
scheme and the function and benefits
how such asscheme might be adminis(d) qualitative food classification.-and
their influence on diet during illness,
tered if it became possible for the
open to village health committees.
pregnancy' and post partum: and (e)
scheme to be disentangled from gov
The number of interviewers should
child leeding practices.
ernment medical service which suffers
Present medical behaviour in rela
be in accord with the socio-demogra
from its own organisational weakness
tion to the utilisation of home reme
phic make-up of the area selected for
dies, indigenous medicines and doc
es, supervision problems, and resource
, study as well as the capacity of core
tor’s medicines.
restraints.
staff to adequately' supervise their
Illness specific patterns of resort in
ficl I workers.
Personnel
should be
the use of coexisting pluralistic
Organisation of Community
therapy systems- and reasons for such
st
.ed on the basis of four day field
patterns (economic, social, cultural,
Diagnosis Teams
trials and an interest in community
etc), among rural and town popula
and not merely by
Initially, a study of typical village development,
tions.
Survey data on health expenditure
and town health arenas in an impart academic qualifications. Whenever pos
by the.lay population.
taiuk in each district should be con sible. male and female candidates
A spot map of all existing health
ducted by a community diagnosis re should be balanced. The age of the
manpower residing in the impact
interviewer
is
not
as
important
as
the
search team led by an experienced team
zone.
leader. One research team leader for respect that the interviewer can- elicit
Felt health and development needs
in the community.
expressed by social groups residing
each district should receive training at
in the survey area, as well as data on
a state level community' diagnosis
The state level community diagnosis
;oward the Community
training/research centre.
Candidates research/training centre should have at
Health Worker Scheme, and the con
should be social scientists with pre its disposal, if not on its staff, a nutri
struction of village health commit
tees.
vious
research eexperience. Training tionist, and epidemiologist, a pediatri
should primarily be;
practical in-field cian, an applied linguist, and a tropical ’
Ski.Ei.'noN of Impact Sites
instruction and instructors should have disease technical advisor. Formal links
already earned out a successful com should be established between the
Community Diagnosis staff members
munity diagnosis study themselves.
A centre and health related research cen should initially disseminate information
procedure lor community diagnosis tres, departments of social and preven aoout the CHW scheme towards the
should be followed but each team lea tive medicine, etc. Post-graduate candi end of their study period when survey
der should have to demonstrate an dates should be encouraged to utilise ing felt needs. After concluding initial
ability to adapt the methodology to a
the data collected by research teams and research work they should spend addi
different set of research conditions. thus take part in analysis work as part tional tiine in.. a. pre-chosen impact
Guidelines for such studies are pre of their graduate study. This will zone explaining the scheme to villagers
sently being drawn up by an explora acquaint them with the facts of rural lying within
. _ ------ i a given economic status
tory community diagnosis
research reality and bring to light new aspects ceiling.
project? As experience in community of Iwhaviour patterns. At the same time
It is. (‘ssential that voting members
diagnosis methodology'
researchers on of the VHC should fail within a fixed
increases, the advice offered by these researchers
state level community diagnosis re- data to be collected can serve to iin- economic ceiling approximating the
search centre will be responsible for prove the quality and breath of field economic capacity of the majority of
disseminating new ideas and holding research
undertaken.
Each
district people living in the area. Wealthier
workshops for team leaders.
should, moreover, have honorary medi villagers, it is reasoned, will provide
cal ad visors appointed to assist
the for their own health needs regardless
Team leaders should be assisted by
community diagnosis research team and of rhe existence of CHWr and VHC. In
one or more social scientists under later the CHW training staff and CHW
clusion of wealthier villagers will, more
going apprenticeships in community grand panchayats.
over, increase tangential . political acti.
38
I
Research into the following topics
should be undertaken by local teams.
The variables of class, caste, education
age, and locale (interior village, pro
gressive village, town) should be taken
into account when these variables are
relevant.
*
..
‘
:
I
__
• -fc
-
i
.■
i
I
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1
ECONOMIC AND POLITICAL WEEKLY
viry and influence peddling. However
veaithier villagers may be invited to at
tend the VHC and become members of
.he village medical co-oper2t’.veT parti*
eulariy if they are service minded.
Moreover, it should be the VHC*s pre
rogative to choose a person of .-ny in
come status as a CHW for the village.
On the basis of the response gene
rated, researchers should prepare a list
r those villages showing me t in
terest in the scheme.
From this list,
villages displaying the greatest degree
of social cohesion and the least number
of existing health resources should be
selected as impact villages. Community
diagnosis team members should visit
these villages and arrange for well pub
licised public meetings so that the popu
lace can air its views on how a village
health committee should be chosen and
organised. As a means of initiating discv '-»n- at these meetings, community
d.
Jsis staff should present their find
ings on this subject from the felt needs
<urvey undertaken. Villagers, at the
meeting, should be told the benefits of
entering the programme as well as the
responsibilities of the community. In
centives would include training for a
local candidate in first aid and promorive health, a small supply of basic me
dicines to be administered to the poor,
and seed money for the establishment
of a medical co-operative. Responsibil.ties of the VHC would be the forma
hen and bi-monthly meeting of a village
health committee, assistance in the
evaluation of CHW performance and
management of the local medical co•perative.
ideally, a short film could be made
..a each socio-linguistic region realisti
cally depicting the life, training, and
duties of the CHW and the organisa-i
•: the VHC and medical co-operaSuch a film would l?e a good means
gathering the rural populace. It
could be accompanied by talks with
CHWs from existing programmes.
The selection of members of a VHC
should Follow the mandate decided at
•he public meeting. At the time of
choosing the health committee, terms
of membership should be established
and a procedure should be set up for
the public review of village health comnuttee activities.
It is advisable to organise VHC and
train CHWs in stages. Initial impact
villages should not be grouped together
bur should be situated amidst two to
four uncovered villages. These other
s ullages will have an opportunity to see
rhe scheme in action and if the scheme
A successful, uncovered villages will re<’uest inclusion into phase two pro-
January 5. 19S(X
F
should undergo
gramtnes instead of having to be sold Prospective trainers
rhe idea.
Moreover, experience
has a brief training course in the organisa
proved that initial CHW
?andidates tion of lesson- plans and the medical”
are often unemployed and think, that context of the CHW programme. The
rhe post will lead to permanent employ curriculum of the training course should
ment. It will soon become clear that
flexible enough to accommodate the
recommendations of prospective trainers
such is not 'he case .end candidates in
phase two may be of a more appro loilowing their aeid orientation and
priate type. The weeding out of oppor the expressed felt needs ot villagers
tunists will thus become easier in pro elicited by community diagnosis team
members. Of particular importance
gressive stages of the scheme.
here is patterns of resort data in re
spect to preferred forms of treatment
Tilwong
For specific diseases. CHWs should re
It is strongly .suggested that trainers ceive training in appropriate allopathic
staff memshould, not be PHC stall
and alternative therapies in accord with
bers. There are many reasons for the preferences of the local population.
this. PHC staff are already over'
Where no clearly effective preferred
worked, and it is rare to find a therapy type is known, CHWs may be
feels that he can
PHC doctor who
trained in the eclectic administration of
adequately supervise his existing staff both allopathic and indigenous thera
let alone assist in the training and
pies enhancing the patient's chance of
•mpervision of another cadre of workers.
recovery.
Moreover, the popularity of the scheme
Community diagnosis team members
will initially be greater if it is disso
should play an. active part in the latter
ciated from the PHC. Initial contact
stages of the training course. They
with PHC staff will create the wrong
should assist by helping trainers antici
impression that the CHWs are junior
pate reactions to new ideas. It is im
members of the PHC staff. At all times,
perative that CHW education courses
it should be stressed that the role of
prepare prospective CHWs to confront
the CHW and PHC staff are comple
existing ideas which either clash or
mentary.
support modern health ideology. In
It would be octter if a mix of in formed educational strategies should be
terested house surgeons desiring to planned accordingly.
enter government service and a few
Training should encourage the maxi
respected rural practitioners be selected
misation
of locally available resources
as trainers. These trainers should be
given guidance and support from dis and manpower. Ideally, the CHW
trict health educators, departments of should become a liaison between local
social and preventive medicine in near sources of therapy and specialist ser
vices. CHWs should be encouraged to
by medical colleges, and members of a
district level CHW steering committee. enter into referral networks of their
House surgeons are considered to be a local health arenas and provide triage
good choice as trainers, as CHWs will service as opposed to compering with
be less intimidated by them than by existing practitioners. They should be
established doctors. These younger doc seen as a source of assistance and not
tors. it is reasoned, will be more acces as a competitive threat. In this re
gard. CHWS and project staff should
sible to CHWs who will view them as
become familiar with local practitio
a source of technical knowledge.
ners, explain their purpose and ask for
Before being able to train CHWs,
their assistance. Where deemed appro
the prospective trainers must undergo
priate by the community, local practi
an orientation course. This course
tioners can be asked to be honorary
should he broken into three sections.
First, trainers should read a copy of members or advisors to the VHC.
the report submitted by the community
diagnosis team. A few days of discus
sion and dialogue should follow organ
ised by the community diagnosis re
search team. Next, the house surgeons
should undergo a two week live-in
period with members of the community
diagnosis team. They should not prac
tice medicine during this period, but
rather enter into the cognitive universe
of the layman by attending interviews,
carrying out a few surveys, and engaging
in dialogue with
indigenous practitio
ners.
It should be made clear from the be
ginning
that CHWs are not being
trained as doctors’ assistants or exten
ders. Their work should be defined as
primarily involved with preventive and
promotive health. The early treatment
and recognition of minor ailments,
which can develop into major diseases
if neglected, should be presented as
one aspect of preventive health. How
ever training in first aid should not
overshadow training in nutrition, and
practical means of enhancing environ
mental health. Specific suggestions on
39
11
work, avau ability. (.■onMUtmify provides a peFcenrace of
the alteration of diet and improvement of their interest
'ed monev towards the purchase.
jf health habits can de made after nata and general •jjmnurnity /pinion. If ‘he
Funds, and not medicine, should he
v
’
HC
;s
not
sat;
died
.vtth
the
CHW's
collected hv conimumty diagnosis staff
supplied to medical co-operatives, in
on existing dietary and health habits performance, they may request that the
order to give each, community a chance
CHW
return
rhe
Jlucared
merhcine
has been reviewed by the CTTVV train
:o manage its own supplies. so "hat each
k'.r
and
find
.»n
.litemadve
candidate
ing itaff.
cumnHinity is not dependent on the
For
the
next
training
period.
Ail
cases
Training courses should be organised
government medicine distribution sysduring: months when essential agricul •u' dissatisfaction should be investigated
rem which
has its own
drawbacks.
.
.'c.wjnirv
u:
i-tnosis
fieldstaff
dur
tural ‘Operations are not taking place.
Moreover,
villagers
question
the
etficacy
ing phase one and Ater by the CHW
Initial training should be of
:>hort
of government medicines, due to past
grand
panchayat
to
minimise
cases
erfduration, preferably no longer than four
experiences, which may in reality haveweeks. After this, CHW novices should petty jealousies.
had more to do with dosage and sup
who
have
undergone
CHW
novices
start a first aid station in their village.
ply than quality. Li any case, grand,
the
three
month
trial
period
to
the
CHWs
should
Eor three months, the
panchayats should purchase large stocks
satisfaction
of
the
X
HC
and
their
attend weekend courses geared toward
of medicine from reputable sources. If
trainers will
becon»e members of a
specific skills as a means of upgrading
reordering periods fall outside a vil
their knowledge. CHWs should be taluk level grand panchayat of CHWs. lage’s time of need, such a village will
encouraged to suggest topics for these This panchayat will have the responsi
be in a position, to order drugs locaffy
weekend courses. First aid should be bility of suggesting and planning addi
for the duration. District steering com
initially stressed because it is doubtful tional ’short-term training courses. It
mittee
representatives
should give
should
exercise
the
right
to
call
to
the
that villagers will listen co the advice
guidance
to
CHW
grand
panchayats
or the CHWs until they prove their medical officers Attention PHC person
about the ordering of drugs, generic
nel
whose
w'ork
is
not
deemed
up
to
worth. Gradually, the emphasis of
names, and reputable sources.
CHW training should be directed to standard by village health committees.
Complaints
may
be
addressed
to
the
Medicine is to be sold to villagers at
wards nutritional and environmental
health issues. Ongoing education after ADHO when they pertain to the work cost, or if the VHC deems it appro
the third month should be available of PHC doctors and senior health staff. priate, at a slight profit margin. These
upon request from a CHW grand pan This would be the case when senior medicines may be recommended, by a
staff do not pay credence to cases re local CHW, a PHC staff member, or
chayat.
ferred by
CIIWs. A
procedure for be prescribed by private or government
The training of a second batch of
airing grievances is essential if an ef doctors. Medicine supplied by the gov
CHWs in phase two should benefit from,
fective triage system is to be establish ernment to CHWs in kit form (Rs 600
the experience of phase one. Trainers
ed between CHWs, PHC field staff, yearly) may be used for the very poor
should better be able to anticipate dif
(as defined by the village health com
. d medical personnel.
ficulties and unforeseen subject areas
Experienced CHWs who have under mittee) or as initial doses of medicine
demanding increased attention. More
gone considerable additional training to be issued by the CHW during field
over, CHWs from phase one should
and who have pnwen themselve^ in the visits and to be followed up by medi
play an instrumental part in the re
organisation of training material and in field may be asked to take part in the cines purchased by the patient.
evaluation of junior CHWs and to be
The CHAV grand panchayat should
the training of colleagues in the field.
come advisors or assistants for CHW
Members of the CHW grand panchayat
work jointly with the BDO in procur
trainers during new training courses.
ing ready supplies of local medicines,
should have the power to replace in
available organic supplements which
effective training staff.
Vir.rAGE He.xi.ih Co-Operative
Location for training courses should
can be preserved and locally produced
l>e strategic in accord with transport
The village health committee should tonics, nutrition supplement biscuits.
facilities. Whenever possible, training initially be given seed money for the etc. If there is tremendous felt need
villagers in some regions for
courses should be in rural settings, hav establishment of a medical co-operative. among
ing no oppressive connotations. For Drugs stocked will vary with the re tonics, which on the commercial mar
this reason, panchayat
halls, temples, quirements of the community, storage ket are overpriced and of a higher
and schools are more advisable than facilities, distance to formal sources of strength than is required, small-scale
PHCs or taluk board hospitals.
medical care and supplies, medical per industry grants should be awarded to
sonnel residing in the area and the level local parties to meet thb felt need.
Evaluation’ of CHWs
of training of the CHW. If the CHW These grants should be sanctioned by
is the only medical resource, medicines the CHW grand panchayat and BDO
of
first
batch
After training of the
after the local mixture has been ap
stocked
should reflect the disease speci
CHWs has lx‘en completed, novices
proved by a nutrition expert.
More
fic
training
sessions
attended
by
the
trial
should undergo a three month
over. subsidies should be awarded for
CHW
as
arranged
by
the
CHW
grand
period during which time they should
the procuring and distribution of seeds
be given weekly supervision and sup panchayat or CHW training staff. It and seedlings of those plants which are
should
be
possible
for
specific
CHWs
to
port by members of the training team
knowledge of particular diseases high in the vitamins and minerals defi
and the community diagnosis
team. gain
if
these
diseases are chronic, especi cient in the area. CHWs should have
Once a weak for at least two months,
access to a supply of food supplements
<Hie trainer should visit the village thus ally if the villagers have no recourse to For cases of severe protein and caiorie
medical
assistance
at
present.
There
demonstrating ongoing support. This
malnutrition such as exists for school
will also give the CHW a chance to fore, the medicine content of co-opera
feeding programmes.
tives
will
varv.
Provision
should
be
ask practical questions about specific
'Die medical co-operative should be
made
for
purchasing
the
initial
cases. Evaluation of CHWs should be
initiated
only after a village health com
based on observation of th<.T fieldwork supply of basic medicine. This amount mittee has been formed, a CHW has
may
i>e
increased
for
the
purchase
of
and not by written examinations.
undergone both training and an initial
The village health committee should additional drugs if trained personnel three month trial period, and a place
exist
to
adsnfni'-'ter
them
and
if
the
evaluate the ” ork of CHWs in tenns
40
I1
l
I
i-
Ig
i
S
rar the storage of medicine provided by
'he VHC has been approved by the
CHW training staff. The prices
ail
medicine should be posted in public
and records of co-operative sales should
be open for public inspection and should
be subcutted quarterly to the CHW
grand panchayat.
A charge for treat
ment by CHW (10 to 20 paise) may be
fixed by the village health committee
tor those who can. afford to pay.
CHW Grand Panchayat
I
Six months after their initial train
ing and successful evaluation, CHW
novices should become members of a
taluk level grand panchayat. This pan
chayat should meet monthly to plan
new training courses, reorder essential
medicines for medical co-operatives,
hear grievances, and discuss new health
information and plans for community
health programmes.
The panchayat
should be a -whole day affair with the
morning being reserved for a general
metting attended by CHWs only, and
the afternoon reserved for a general
meeting with the members of the block
development office and community dia
gnosis staff, the .WHO and senior PHO
staff, and other advisors.
The grand
panchayat should not come under the
control of the health department but
be an interdependent body attached to
the BIX) and supervised by the district
steering committee representatives.
It
should have at its disposal a part time
typist and accountant.
prenticeship. The team leaden should
choose one interviewer From the present
project 15 an assistant-cum-interviewer/
instructor. Interviewers having poten
tial as instructors should be retained
as core staff after the completion of rhe
initial four-month survey- conducted by
local interviewers. They should assist
senior core staff in their various acti
vities associated with the formation of
village health, conunictees and the deve
lopment of educational
strategies for
CHW training.
New research teams can be dispatch
ed to nearby districts or taluks requir
ing individual community diagnosis
studies in accord with differential so
cio-cultural conditions. The differences
between taluks should be considered by
core research staff when entering a dis
trict so they can estimate the radius of
relevance of their survey findings. New
research teams should arrange meetings
between potential impact villages and
experienced CHWs in areas where the
scheme is already in progress.
Administration of CHW Scheme
A state level steering committee
should oversee the development of the
CHW scheme. The steering committee
should comprise the state health minis
ter and hctih secretary’ (who should
act as committee co-ordinator) and at
least two health education experts from
of srcial'*and~ preventive
departments c_ ____ _
medicine in state medical colleges, two
social scientists representing the state
Replication
level community diagnosis research
training centre, two nutrition experts,
CHWs from impact villages should
an
expert in indigenous medicine and
each familiarise the populace of two
neighbouring villages with the scheme members of voluntary agencies support
and assist the leaders of these villages ing different aspects of the CHW sche
in the planning of meetings towards me or similar alternative health care
The Committee
the formation of village health commit delivery programmes.
tees. They should be assisted by the should be backed up by a staff of three
community diagnosis team now in its public health officers with health plan
ning and management experience re
last stage of work in the taluk. The
CHW grand panchayat should suggest cruited through the civil service. Each
changes in the training curriculum and of the three public health officers
should plan on playing an active part should eventually be assisted by an ex
perienced community diagnosis team
in the field training of new candidates.
They should offer support to new can leader. A staff of accountants responsi
didates in much the same way as com ble for the administration of medical
munity diagnosis staff did in phase one. co-operative funds and supplies, and
The second batch of candidates clerical staff responsible for dissemina
the
should be trained no sooner than five tion of information pertinent to
CHW programme should also provide
months after the training of the first
batch of CHWs has been completed backup.
Tie central steering committee should
allowing time for an initial evaluation
of phase one activities, the creation of have two district .level staff officers in
a grand panchayat, and the introduc each district covered by the scheme.
These officers should eventually be re
tion of medical co-operatives.
With the start of phase two, some cruited From former CHW (medical)
training staff. They should be assisted
s.xteen months after the initiation of
the scheme, core staff from the com by two to four former community dia
gnosis interviewer trainers. The role of
munity diagnosis staff should split into
two or three groups depending on the these representatives and staff should be
number of team leaders undergoing ap- to oversee the planning of training
courses and regional CHW grand nanchayat activities.
They should, more
over, be responsible for the selection
of CHW trainers and organisation of
CHW training schemes.
A
community
diagnosis research
training centre should be established in
each state and should come under the
secretary,
control of
the health
The purpose of this training centre
will be to train project leaders
in
field
and impart administra
tive skills necessary tor initiating re
gional community diagnostic studies,
The centre will be rural based and. its
initial goal will be to train one team
leader for each district in the state.
These leaders will then train future
team leaders who will work in other
taluks through an apprenticeship sys
tem. The centre should be a repository
for regional data bases on nutrition,
health, and medical ideology and be
haviour. The centres should sponsor
and co-ordinate ongoing research and
should take an active part in the field
evaluation of the CHW scheme as it
proceeds during
different stages of
development. It should also assist in
the evaluation of other national and
state level community welfare sche
mes.
This would provide an in-field
feedback mechanism which would fa
cilitate community expression, in as
much as regional research teams are
primarily composed of local candidates
.
whose job
it is to movethe
within
community.
The work of CHW should be com
plementary to that of PHC field staff.
However, a CHW is responsible to the
community not to the health bureau
cracy. PCH staff may request the as
sistance of CHWs in planning vaccina
tion campaigns,
disseminating infor
mation about family planning camps,
etc. At no time, however, should PHC
staff members have the authority to
pressure CHWs into fulfilling targets
or participating in campaigns without
the expressed
consent of the CHVV
grand panchayat. CHWs should have
the mandate to request PHC staff to
participate in vaccination camps which
they organise and to take part in vil
lage health committee sponsored pro
grammes
such as first aid courses,
children’s weigh-in days, etc.
Local
PHC staff should attend village health
committee meetings
when requested,
and PHC senior staff members should
attend bi-monthly afternoon meetings
of the CHW grand panchayat and a
CHW grand panchayat liaison commit
tee should be set up to co-ordinate
the joint activities of the two comple
mentary health resources.
Most im
portantly, the CHWs, the PHC field
41
I
fl
staff and government doctors must
verk together m forming a medical
iifefine. a mage system from the vil
lage to rhe hospital.
Some Conclusions
How difficult would it be to carry
out the envisioned scheme on the
ground?
While comments cannot be
made about
implementation on the
state level in respect to the health
bureaucracy, a few comments can be
made concerning the feasibility of im
plementation at the local level. These
comments are made on the basis of
three years of ethno-medical analysis
of rural health arenas in South India
by the author, numerous discussions
and interviews with Indian colleagues,
and a ten-month exploratory communi
ty diagnosis project recently conduct
ed in the North and South Kanara
districts of Karnataka.
Community diagnosis teams, it was
found by experience, could construct
data bases of essential health ideology
and behaviour
patterns
within the
time frame prescribed. They were able
to generate relevant
dialogue about
community felt needs and propagate
•he concept of the CHW and village
health committees. This was only pos
sible after first gaining the confidence
of the community by their hard work,
culturally appropriate method of ask
ing questions, and their ability to de
monstrate the benefit of co-operative
action in other spheres.
cross-section of villagers
A broad
overwhelmingly
surveyed
favoured
CHW scheme’s autonomy from the
PHC, the idea of a local medical co
operative, the concept of a
CHW
charging 10-20 paise per service and
rhe waiving of such charges to those
in dire need as defined by the village
health committee.
In areas having different socio-de
mographic patterns, ideas about who
the CHW should be (age, sex, married/single), how the CHW should be
selected (open meeting, by caste lead
ers. by pancha> at, etc) and how a village
health committee should be constitu
ted
(membership,
terms, etc) were
significantly different, thus laying em
phasis on the need for a flexible CHW
implementation scheme to meet the
needs of the people concerned.
Regional trends exist in respect to
the different types of medicine villag
ers prefer for a variety of common
illnesses (of biomedical as well as
ethno-medical origin).
The populace
expressed a desire for CHWs to be
trained in medicine according to their
preferences when feasible. If such me
dicine proved to be non-effective they
established. and PHC staff attempted
noted that this would soon become
to mobilise community support by apclear and CHWs could be requested
While govproaching '’.oca! leaders',
to provide alternative forms of medi
eminent reports were full of self
cine.
praise, investigation by project staff
Potential CHWs expressed a general
found the programme to have had
preference co be instructed by young
little positive effect on the community
doctors as opposed to established doc
and in fact to have had a number of
tors who they perceived as being dis
negative ramifications.
The most se
tant from them.
rious ramification was a further loss of
Interviews with final year medical
credibility by the health department
students from several medical schools
and increased suspicion of government
revealed that many of those young
health programmes which provided spo
doctors who once considered rural
radic health activity without continuity
practice (for two years or more) were
of care.
The services of government
now cold towards the prospect pri
staff were not maximised (although the
marily because (a) of the ambiguity of
presence of a doctor was welcomed)
what
rural work
entailed, <.b) rural because staff were perceived as outsiders
work was generally perceived as sit
scrambling for targets while having no
ting alone in a rural clinic without a
responsibility to the community.
The
reliable supply of basic medicines, (c)
issue then is not simply greater cover
in respect to government service, the
age but more responsible coverage of
amount of paper and administrative
rural areas facilitating the organisation
work w;.- overwhelming.
It may be
of a workable triage system.
noted that many of these students had
Qualitative measures used for the
visited or talked to
PHC doctors
evaluation of programme did not reflect
about the
reality of village
work.
the reality of government health acti
When confronted with the concept vity in the villages.
Let me cite an
of the CHW trainer, many young doc
example.
Checking vaccination statis
tors considered the idea good and tics (which are generally grossly exag
expressed interest in the program gerated), project staff found that less
me.
To our surprise, many par than 20 per cent of villagers receiving
ticularly liked the idea of gaining vaccination in a sample of 300 house
ini‘al orientation and experience by
holds had any idea of what vaccinations
spending time in a rural area with
they had received. None had received
diagnosis team members
community
explanations about the way in which a
who would act as their guides, and
vaccination, worked or what its purpose
direct them to priority areas of con
was outside of being told it was ‘good
for health’.5 This finding from ‘model
sideration.
Interviews with district health and
total health care villages’ was cross
PHC staff revealed
that they were
checked in villages where PHCs were
only too happy to disentangle them
located and where ongoing activities
selves from the added burden of ad
had been present for many years. The
ministration
and supervision of the
same results were found.
CHW programme.
AU
senior staff
The last point highlights the need
members
interviewed noted that it
for both community diagnosis and pub
would be better to focus their atten
lic participation in the evaluation of
tion on clearing up their own house
government health services. In order
before accepting new responsibilities.
for the government health service to
While some staff members spoke fa
evaluate and plan its activities in the
vourably, of the philosophy of the CHW best interests of the community, it is
programme a large majority had seri
obvious that local feedback is necessary.
At present, the occasional spot visits by
ous doubts and misgivings about its
the DHO and ADHO do not provide
worth (aside from the issue of imple
the kind of feedback which is required
mentation) and could not be consider
for evaluation purposes. PHC fieldstaff
ed as the most appropriate motivators
continue to exaggerate the extent of
for the scheme.
Many doctors still
their work and are reluctant to critically
felt that the scheme was misconceived
and that what was really needed was evaluate the programmes for tear of
targets or
reaching
reprisal for not
more mobile units and PHC workers.
interests
statistical
satisfying
the
With respect to the last comment,
of their superiors. It is time that
a few words may be said about the
we look beyond statistics as a meamisconceived notion that
increased
sure of the value of the present health
coverage by PHC staff will improve
services. A qualitative dimension must
the quality of health care.
Recently
the Karnataka government carried out be added to regional health planning
a ‘total health care scheme’ in model and the evaluation of programme out
villages in each district. PHC staff was comes; and the community diagnosis
increased to the optimum, mobile cli team and CHW could provide this di
nics (or temporary sub-centres) were mension if some degree of autonomy
42
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1 '7»A'
STANDARDS, LEGISLATION AND ENFORCEMENT ISSUES
Mr. D. Ryan
Mr. Ryan began by saying that considering the severity and global nature of the
problem, we need a joint project of global dimension incoiporating the partnership of
both the Govt, and Private sectors.
He spoke about how the issue on lead poisoning and prevention had progressed
over the years.
> In 1990 there was an initial focus on health hazards related to lead.
> In 1992 a plan was developed that raised the priorities for lead.
> In 1994 the first international conference that focused on source control and
prevention of poisoning was held.
Mr Ryan said that he was amazed at India’s clarity & consensus on project Lead
Free and that it had accepted it as a serious problem. He said that while planning
strategies at the national level, priorities have to set among the source, but also cautioned *
that all the sources are equally important. He also said that policy making isn’t very
smooth in India and that it is also held back by other problems which compete for
resources.
Mr Ryan said that we need to have a realistic picture of what success looks like
and give our strategies enough time(10 to 15 years) to bear fruit.
He gave a list of 7 strategies to tackle the problem.
1.
To expand base:
To recruit potential allies like the computer industry, religious
groups, teachers and universities so as to muster enough support to
convince the government.
2.
Press Strategy:
The press has a tremendous capability to put pressure on the
government and hence there is a need to keep it engaged regarding
the lead problem
3.
Education Strategy:
To educate people as well as policy makers regarding the lead
menace so as to convince them.
'I
i
4.
Strategic use of Leaded Gasoline:
5.
Local crisis strategy:
The need for local support as the problem is widespread.
6.
Trans-national strategy:
The need to make strategies broad based covering many countries
through an alliance network.
7.
Boldness strategy:
The courage to be wildly creative and design ways like instituting
awards to the first oil company that produces unleaded gasoline.
Controversies regarding law suits on behalf of victims also
increase awareness.
i
!
I
Regarding resources, he suggested that organisations headed by people who can
bring together doctors and scientists should be formed and action plans prepared.
He concluded by saying that he was optimistic and confident that a movement
powerful enough to place lead poisoning on the national agenda and hold the government
and industries responsible would come out very soon. He finally praised Dr. George for
creating an opportunity for such a movement.
DEVELOPING
AND
IMPLEMENTING
A
NATIONAL
PLAN
DISCUSSION POINTS
Dr. A. GEORGE
The goal of this conference is to develop and implement a plan to
get rid of lead in a developing country like India and some of its
neighbours. This includes plans to prevent and treat all aspects of
lead toxicity. The solutions should be practical and not theoretical.
>
In our effort to find solution this conference will enable to
transfer knowledge in to some practical plans that could be
implemented with limited resources pur country has. These plans
should give maximum results with minimal expenditure, so that
too much resources are riof'wastedjAs;- the Government is not a
total solution to any probicm,; this plan should include the active
participation of various citjzens.gom,various constituencies in lead
prevention program.
■
There is no need to \yai.^^^ptlie^idy-as 'the present study
shows that almost 50%mf§iiWiiipogulatipn have high blood lead
level. Time has come
‘
A NATIONAL LEAD PREVENTION PROGRAM
<<
BY
Dr. WILLIAM A.NITZE
USEPA
8^
limit set by WHO Emphasis was
special meyntion°n SSgeTdcX
od ,ead levels above the acceptable
a"
Of
eXp0SUre with a
metabolic and ‘devetopment’al defects. PDuring 91976-lU^thVe" hasT9'03 neurological,
—
been ina J.
S?Aa?°hnrdP ,rOm 88?4 ,0 m b'00d Lead levels a™n9 chwen (5
5; years")
900000 children ^years^M 'suffer r"56 f°h lln'eaded 9aso,'ne but even then,
political decisions for Lead Phaseout
Workshop 1
Screening standards, laboratory requirements and coverage in a National Program
was conducted by the George Foundation on day 3 of the international symposium
on lead poisoning and prevention.
The following persons and participants discussed the issue;
Dr. R Kaufmann, Mr. A Frost, Dr. P. Parsons, Dr. Chaudhary.- Webb, Dr. R. Reigart, Dr. R. K. Chaudhary,
Dr/. W. Matson, and Dr. T. Venkatesh.
Dr. R. Kaufmann was the coordinator.
The workshop was attended by a good number of delegates. The following conclusions were made during
the workshop and presented by Dr. Venkatesh.
National screening program is appropriate for India at this stage, after seeing the incidence of lead
poisoning in various parts of India presented by TGF during the conference.
The panel felt that cord blood at the time of childbirth should be evaluated for blood lead level as a
national program and should appear in the birth certificate. Apart from this during the first and
subsequent immunization visits blood lead levels of the child should be evaluated to monitor the risk of
exposure. Schools should insist on the above information at the time of admission
Targeted screening was recommended to the high-risk group irrespective of age.
Toddlers in urban environment especially if located closely to lead based industry should be
considered as a high-risk group. Other risk factors should include parents’ profession etc.
Irrespective of cost it was recommended that every child should undergo blood lead test. The use of
ASVZ portable lead care system was recommended for screening.
It was suggested that testing should be carried out during visits for immunization.
With regard to personnel and training existing lab staff to be exposed to the method as it appears
simple and precise. All to undergo training in one of the established centres.
$
With regard to the accuracy and precession it was recommended to adopt uniform methodology and
quality control samples in all centres.
Mass education to be taken up through mass media and involving popular cine artists in program
similar to pulse polio campaign. Apart from this NGO’s , child to child educational program, ICDS,
parent teacher meetings, symposiums and seminars to be used a media.
•
Following suggestions were made for developing guidelines for blood lead screening to all developing
countries.
1.
Increasing level of awareness through highlighting the adverse effects of lead toxicity through
publications. Various levels of awareness at National, State, Taluk, Institutional, and family levels.
2.
Training facilities to the concerned to be made available at both Govcninjoqtal and
level.
WORK SHOP ON PUBLIC HEALTH POLICIES ON TREATMENT
PROTOCOLS AND AVAILABALITY OF SERVICES.
The session started at 11.00 a.m. and ended at 3.50 p.m.
The participants were:
Dr. Markowtiz
Dr. X.M Shen
Dr. S Tandon
Dr. T Rozema
Dr. SJS Flora.
There was active participation from the audience
Treatment plan for childhood lead poisoning in India -By Dr.Markowitz
1. Identification
Based on symptomatology
Based on targeted screening high risk groups
Biochemical assessment-blood lead, EP
2. Identifying sources of exposure-responsibilities of government to do assessment and
enforce elimination
3. Education- at all levels beginning with physician who are <experts educating
'
’._.o rpeers
educating public health nurses, community outreach workers and parents and all
Indians.
Information handouts, videotapes, television and conferences
4. Chelation-should be: safe effective at removing lead, easy to administer, inexpensive.
Available drugs: EDTA, BAL, D-PEN
Needed drug: DMSA
CDC regimens
Relative costs D-PEN >EDTA, ?BAL, DMSA
5. Adjuncts: iron, calcium, ?magnesium, zinc,B-vitamins, vitamin C? fat?
6. The behavior modification: cleaning changing clothes, teaching non hand to mouth
behavior
7. Follow up depends on initial blood level 1-3 months
8. Support services: coordinator of care
Medical care
■ Nutritional support
■ Social services
■ Medical services
9. Laboratory supports
I
i
!
10. Centers:
■ fortraining
■ for resources (laboratory, expert personnel)
■ research
SUMMARY OF THE WORKSHOP: MONITORING
ENVIRONMENTAL SOURCES, SETTING STANDARDS AND
LEGISLATION
Members present : Dr. B. Sonawane
Dr. J. Schwartz
Mr. D.C. Shanna
Dr. R. Par
Mr. Carter Branden
The following were discussed:
1. Key sources of exposure include:
Milk
Infant Formulae
Spices
Food Stuff
Water
Cosmetics
General Dust
Local industry
G^
Cottage Industry
Food colours
Pottery
Cooking Utensils
Petrol
Paint
Fly Ash
Recycling Plastics
2. Who is responsible for what?
1Food stuff: Agmark is responsible for setting standards for the food supply. Under
the Director General of Health Services the Prevention of Food Adulteration Act
(PFA) is responsible for the various standards of food stuff.
Cookware: There is no standard set and there is no regulatory agency which is
monitoring the standards of cookware. The Bureau of Indian Standards (BIS-similar
to ASTM) has a few specifications for products and not for the production process.
But these are not strictly adhered to.
Water: There are about 30 parameters, which are looked into by the Technical
Advisory Committee. They have to decide whether the waste water has to go to the
surface or to a river. This can be under the control of the Central Pollution Control
Board (CPCB) or the State Pollution Control Board (SPCB).
Regarding drinking water the Local Government can be the advisory committee and
set a policy control. The same standards have to be implemented for both urban and
rural areas.
I
I
/
-2-
i
Air: This comes under the control of Central Pollution Control Board (CPCB)
(CPCB)115 aIS°
I
C°me UndCr thC C°ntr01 °f Central Pollution Control Board
3. What do we Iknow about the level of lead in various sources and their
contribution to human exposure?
I
“ Bo“^ bXa?Xe“ri“ “d 1150
I
I
P0"U,i°" C»"trol
X ST??" regarding most of the sma11 industries may not be available
Control Boeard6(CTCB)°U,le‘S °f poll“,io" com's under the
lh' Central Pollution
Pollution
Uldmately impaet of all ihese pollution sources on human beings and the link
sources on human beings and the link
between exposure and toxicity has not yet been arrived at
<=o
cXed50™ lim“ed da,a WhiCh " aVailable bnt s°™ more data needs to be
Not much of data is available regarding rural areas.
Data regarding lead levels in milk is veiy much limited
soXs"88"',0 d°
th<: S‘UdieS °”“ a8ain ““ 100k »'
To conclude the following key recommendations were
fOT
iddi“0M'
e8peciall>’
le»l lovols in various
put forward by the committee:
level In milk, Up
Need for epidemiological studies to identify important sources
Need for coordination of data
Need for regulatory agencies with respect to cookware, pottery etc
Need for establishing a National task force involving the follo^ng:
Government
Industry
«> NGO’s
40 Citizens
>,A f!’“onal/S“,e "vH site providing information
lead levels
and toxicity
should be setup and the same should be monitored byregarding
the esublished
Nali^l
-------- 1 task
J WORKSHOP ON EFFECTIVE IMPLEMENTATION OF LEADED
7
FUEL PHASEOUT IN INDIA
PARTICIPANTS:
1)
2)
3)
4)
5)
Ms M. Lovci - Moderator
Mr P. V. R. Ayyar
Dr. C Prakash
MrS.N. Jha
Mr Muralikrishna
Commitment :
There was common agreement among all participants about the need to phase out
lead from gasoline as soon as possible in India.
Production of ULG:
The ml industry in India is committed to stop the use of lead additives by April Is'
Necessary arrangements have already been made to produce ULG.
Fuel Quality Issues:
The refining industry agreed to mutual consultation with the association of the
Indian Automobile manufacturers, bureau of Indian Standards and others about
future fuel quality requirements including total aromatics, RVP and other fuel
properties. The oil industry is planning to decrease the benzene content of
gasoline from 5% to 3% by 2001, but no specifications have been set yet on
limits on total aromatics.
J
Impact of ULG on vehicles:
Vehicle manufacturers, in collaboration with the oil industry will continue
monitor the perfomiance of old vehicles running on ULG. They are confident of
finding answers to potential problems which may be encountered.
Public Education:
Vehicle manufacturers will undertake to disseminate this information through
publications, booklets, instruction manuals.
DAy 3
SUMMARY OE
OR PANEL DISCUSSION ON
\L)
WORKER SAL El Y AND HEALTH AND REGULATORY ENEORCEMEN I”.
PANELISTS:
l.Dr. M. Hernandez
MODER.A TOIL Dr. G. Noonan
Environmental Scientist
US Centers for Disease Control and
Prevention.
2 .Dr. T. Matte
3. Dr. Li Zhu
4. Dr. D.J. Parikh
5. Dr. H.N. Saiycd
fhc panel started with introduction of respective panelists and subsequent presentation.
1. Dr. M .Hernandez presented three case studies from Mexico
i)
A large print shop following the minimum hygiene recommendations where the
employers did not provide minimum health facilities like showers, masks, gloves etc.
hich is regulated under Mexican law.
ii)
Uvel
S,h°PSt With S™ilar findin8s described above and the intervention at this
level will need education and training.
MeraniiCS WhiCh
UndCr " VCI7 P°Or enviro^ent, generally family
P
df Mex‘can government has rssued a norm prohibiting the use of this type of
iii)
<0 Spiyr “
S
The "On"is ade<1“,e 1>u, “
COnSUmi”S
He closed hrs presentation with points regarding issue and application of norms.
2. r//SPOke ab0Ut thC Challenge of cottage / informal industries . Studies of cottar
lead aerd battery reparr/recycling operations show that they can cause chronic lead
.ntoxlcatlo in adults d when Iocated on
premiseysevere acXXnino
chrldren. Conventronal means of exposure control are not practical in these operations and
at res3^00) °|C 3026 W°rl< practices can Probably only have limited impact. Such operations
residential premises are probably inherently dangerous for children. Contamination from
p
operations may render sites hazardous even after operations cease. In Jamaica the
economic vab.hty of cottage operations was due to in part to high tariffs on imported
batteries high battery pnees, and a lack of incentives for organized recycling This
uggests that in addition to efforts to educate operators in safer work practices a mandatory
X “ “rlX",EOae'hnC,r“Se t
«r
cycled id .he fonnal secw
ght be effective. Each type of cottage industry needs to be studied to understand
pa hways of exposure and identify potentially viable interventions.
3. Dr. Li Zhu spoke about IcarTpogbrniig in’ china . He was referring to the government
winch reenuted
! 980’s and 1990's .0 protect women front poisoning He wa
ntenttomng about the ignorant people building new houses next to the batte™ facto™ and
ptmuX
wXs J.™,
"7
"ir"CrCrS ““ WOrkC<l Wi"'
mvn^ed wh,, lhi ,ypc
I < 1 s w KIL no money is spent on occupational health programmes.
personal
y^” Z
Dr. D.J. Parikh described some sources of lead exposure in small scale cottage industries
in India like battery re-conditioning and accumulating shops, welding shops, garage shops
where workers and children arc working in a very pathetic conditions, in small work places
and arc exposed to lead fumes / dust. These units arc not covered under the Indian Factories
Act and ESIS (Employees State Insurance Scheme). Their safety, health and hygiene
conditions are very poor. However, he said that the big and organized industry like smelting
and refining, pigments, paints, printing etc., covered well by the regulatory authorities. They
do have certain engineering control technology and personal protective equipments to
minimise the lead exposure. He feels that much more is required in these units for control
and prevention of lead hazards. The factory inspectorate of each state are supposed- to
inspect and monitor these industries and advise them to keep the lead levels within the
prescribed threshold limit value. (TLV) and suggest remedial measures to minimise the nsk
of lead in these industries.
t 4.
!
He brought out the following issues that had to be included in the recommendation.
i)
ii)
Awareness and education related to the lead hazards / poisoning (through audio visual
means) in local languages for workers working in small scale cottage units and small
shops.
Hazardous small shops and cottage units should be covered under the Factories Act.
A need for environmental cum medical survey in such units where lead levels arc very
high.
5. Dr.H.N.Saiyed first introduced about regulatory provisions to deal with Occupational
Health & Safety in India. He mentioned that there is a Factories (Amendment) Act 1987, to
safeguard the health and safety of workers in all hazardous occupations including lead
exposure. Under “Model Factory Rules” there is special schedule to deal with certain work
processes involving lead exposure. The major features of the Act and rules are as follows:
The workers and surrounding community have right to know about the health hazards
i)
from the work process
Pre-employment and periodical medical examination of workers including estimation of
>i)
blood lead levels and environmental lead levels and keep the levels below the
permissible lilmits.
However, the enforcement is poor because of lack of infrastructure in the factory
inspectorate which includes lack of equipments, trained man power and necessary' chemicals,.
Moreover, the factories Act is not applicable to small and cottage factories which are more
hazardous and there is problem children’s exposure, because many of them run by the families
in their own houses causing exposure of more susceptible population like children and pregnant
women (fetus).
Recommendations:
Strengthening of Factory Inspectorate to enforce the existing law - the industrial hygiene
i)
laboratory of each state should have equipments and other infra-structure necessary for
measurement of lead levels
Education of general population and workers about “Right to Know”
ii)
Campaign
to educate workers regarding health effects of lead including that on children
iii)
and importance of “carry home exposure” and its adverse effects on susceptible
population like fetus and young children.
iii)
r
WORKSHOP ON ROLE.. OF MINISTRIES OF
NATIONAL AND
Mi) HEALTH J^D^ g
!
!
STATE
PARTICIPANTS:
Dr. S. Cummins
Dr. I. Romieu
Dr. Jagadeeshan
Dr. R.K.Chandoke
J
Dr. S.P.Reddy
Moderator: Dr. H. Falk
i
The workshop w questions were prioritized
important of them were discussed.-
and
the
most
What are the major elements that must be
included in the
plan
(consider
primary
and
secondaryprevention
and
treatment,
research,
training,
environmental and worker
protection, education and outreach, etc.)?
Following were the suggestions made:
1 . Define
the
role
of
different
agencies
and
responsibilities
2. Inter-agency’ co-ordination
3 . Standards and regulation
4 . Professional and public education and awareness
5 . Include specific activities with time-line
6 . Strengthening local implementers
7. TT
Build inter-national
and ---inter-sectoral
,
------ resources
8 . I’.- .’ n
’’ ‘
utilize
outside advisory groups and stake holders
9 • S Packaging the plan::-:
10 .
Budget considerations
!
their
Workshop on Role of’NGOs, Foundations and Private Sector
Moderator:
Dr. C. Petrowski
Panelists:
Dr. H. Needleman
Dr. P. Nair
Mr. J. Rochow
The session started with two panelists presenting their experiences and personal opinions
on the role of NGOs. Mr. J. Rochow introduced his organization “Alliance to end
childhood lead poisoning,” and expressed his view on NGOs role to advocate a lead
poisoning prevention program, to participate in policy development and program
planning, to monitor and evaluate program implementation and to set up a network of
NGOs in different countries at different levels (e.g. National and Local)
Dr. P. Nair emphasized strategies in preventing lead poisoning particularly related to
Indian society. He advised that the solutions for prevention of lead poisoning should be
culturally compatible, recognize the economic realities of the country, and be sustainable
in the long term. He also stressed on the use of oxygenated gasoline instead of leaded
gasoline.
The panel was open for discussion:
To develop a plan for the implementation of a national program for lead poisoning
prevention and treatment in developing countries and which should be
1. Feasible
2. Sustainable.
3. Culturally acceptable.
The First Question:
What NGOs and foundations currently in India might be interested in lead poisoning
prevention and why? How can their interest be engaged?
NGOs was considered in a broad sense to include hospitals, unions, community groups,
religious organizations, and women groups.
Possible pit falls for NGOs were recognized as
1. Duplication of effort
2. Fragmentation of activity/ resources
3. Isolation (especially in rural areas).
NGOs can be engaged by
1. Sending mailings to NGOs.
2. Use environmental NGOs directory.
3. Use core groups to engage smaller organizations.
4. Use existing networks.
!
The Second Question:
What proportions of private sector in India might be interested in lead poisoning
prevention and why and how can their interest be engaged?
Private Sector that can be used in lead poisoning prevention were sorted out which
included computer industries, professionals (Doctors, engineers, lawyers etc.), film
industry and media regarding industries that use or produce lead, NGOs need t find out
what issues are of industry. Some may be potential allies. These people can be engaged
by:
1. Use of exhibitions and meeting by industries
2. Use occupational health groups
The Third Question:
What community organizations can participate in lead poisoning prevention activities?
The answer for this question won’t be discussed here since it was already covered in the
previous discussion.
The Fourth Question:
What contribution could be made by NGOs and foundations? At what levels local or
national?
To be in a position to coordinate and monitor
To assist in determining priorities for monitoring
To network with international counterparts
For resource mobilization, information dissemination, education and training.
To advocate education efforts.
As a bridge between people and Govt.
To use their expertise on other issues e.g. immunisation to help launh poison
prevention efforts at grass root level.
To assist in determining priorities for monitoring
To focus on cottage industries
To translate economic benefits to general population
For public interest litigation
The Fifth Question:
What special contribution could be made by the private sector? At what level local or
national?
To use private organizations to develop specific control
To support research
To explore alternative to use of lead products
To encourage public awareness
To interact more directly with politicians
For environmental and social auditing
For occupational health activities.
To encourage industry to publicize good practices.
Help access resources
/
i.
>
Implement Govt, policies.
The Sixth Question:
NC0' '■““"“O"
pri«.= SOCO,
Complicated issue
“ NCOS to organize themselves and develop activities
engage pnv.te sector, Govt, and other partners for prevention
General Comments:
>
To recognise three levels of prevention.
• Personal e.g. avoiding traditional medicines.
2. Political e.g. legislation
3. Implementation of policies
> Need for National Level Centre point that
can help co-ordinate activities of various
INUUS.
> NGOs should not address lead in isolation,
need to consider other problems as well.
Attachment with specific groups:
>
>
>
>
>
Hospitals and universities
Unions
Rotary and Lions
Environment and Women Groups
Consumer Forums
Political Groups?
Professional Societies
Women and Youth Groups.
1
20. Source:
Holland WW, Stewart S. (1990). Screening in health care; benefit or bane.
Ch.1: Screening: a general view.
Ch.6: Screening in adult women.
London: The Nuffield Provincial Hospitals Trust.
SCREENING:
A GENERAL VIEW
Some knowledge of the principles of
screening and of what it entails in practice
should form part of the intellectual
equipment of all concerned with the control
of disease and the maintenance of health.
(WILSON AND JUNGNER, 1968)
INTRODUCTION
THAT MEDICINE AND HEALTH CARE HAVE PROGRESSED
dramatically since the beginning ol this century can be
seen by glancing at the subjects ol papers in the British
Medical Journal over the years. In 1900 the concerns
were with topics such as Convalescent Homes for
Soldiers, The Mechanical Origin ol Carcinoma, Deaths
from Diarrhoea, Rifle shooting as a National Past-time,
the Insane and their Treatment. In 1940, the BMJ
contained papers on topics such as Drug Traffic in
Egypt, Chemotherapy of Gonorrhoea in Women and
Children, Anthracite Dust and Tuberculosis, and Porta
ble Apparatus for Electrical Convulsions. But even in
1968, the year of publication of the Nuffield Provincial
Hospital Trust's collection of essays entitled Screening
in Medical Care: Reviewing the Evidence, volume one of
the BMJ contained only three references to screening
—one in relation to anaemia in non-pregnant women,
one on glaucoma, and one on phenylketonuria.
Since then screening has become an extremely popu
lar concept. Advances in medical skills and technology,
together with increasing knowledge about and expecta
tions of health care among the public bring us into a
very different health arena in 1990 from that in 1968 let
alone 1900. The concept of screening in health care
that is, actively seeking to identify a disease or pre
disease condition in people who are presumed and
i
o
3
J-
(
19.
Changing belief in iridology
after an empirical study
Paul Knipschild
Department of
Epidemiology and Health
Care Research,
University of Limburg, PO
Box 616,6200 MD
Maastricht, The
Netherlands
Paul Knipschild, md,
professor of epidemiology
l98*>;299:49l-2
(
BMJ
volume 299
Many empirical studies test the validity of a hypothesis.
Their results have an impact on the reader’s opinion.
My paper on iridology presented evidence against its
validity as a diagnostic aid.1 I report the results of an
inquiry into how doctors’ beliefs in irdiology changed
when they were confronted with this evidence.
Subjects, methods, and results
1I penornicu
4uuy -.uu..
performed u.e
the u.
inquiry
among5 the »•«
first authors of
recent papers in the BMJ, the Journal of the Royal
-•
•
-----■~
e
College of General Practitioners, and three journals of
alternative medicine (British Journal of Homoeo. ‘thy,
Allgemeine Homoopathische Zeitung, and Acupuncture
and Electro-therapeutics Research). In all, 100, 40, and
60 authors respectively were invited to state their belief
in iridology by indicating, as a percentage, their belief
in the hypothesis that “for certain diseases iridology is a
useful diagnostic aid" on a visual analogue scale three
weeks before the paper on iridology was published.1 To
prevent bias I selected only authors who did not know
me, and all of the information was gathered by post.
Of the 200 authors contacted, 83 responded. The
paper was sent to them with the request to read it
carefully and afterwards reassess their belief. Five of
them did not reply in spite of two reminders. The
response rate was therefore 39% (40%, 50%, and 30%
‘or authors of papers in the BMJ, J R Coll Gen Pract,
and the journals of alternative medicine respectively).
The figure summarises the data on the 78 respondents. Fifteen authors (10 of papetj in the BMJ, four
of papers in J R Coll Gen Pract, and one of a paper in a
journal of alternative medicine) who did not believe in
iridology before they read the report (belief <10%)
did not change their opinion after reading it. Three
491
19 august 1989
of the four who believed strongly in iridology initially
(belief >90%) also did not change their opinion. Most
respondents, however, were less decided before they
read the report. Thirty eight (20 of papers in the
BMJ, 11 of papers in J R Coll Gen Pract, and seven of
papers in the journals of alternative medicine) were
uncertain (belief 40-60%) before reading the report,
but two thirds of these (14, nine, and three respectively)
did not believe in iridology (belief < 10%) after reading
Four authors indicated that their belief before
reading the report was 0% and one that his belief after
reading it was 100%. The paper’s impact on the 73
other authors was expressed as a likelihood ratio,
was calculated by dividing the odds of belief
after reading the report by that before reading it.
For example, if a reader’s belief changed from 60% to
10% the likelihood ratio=(0 1/0-9)/(0-6/0 4)=0 07.
The median likelihood ratio was 0 07, with the second
quartile=0 03 and the fourth quartile=0-28. The
curved lines in the figure that represent these likeli
hood ratios fitted reasonably well with the data,
especially at beliefs below 60% before the report was
read. The median likelihood ratios for authors of
papers in the BMJ, J R Coll Gen Pract, and the
journals of alternative medicine were 0-06, O'06, and
017 respectively.
Comment
I restricted the inquiry to authors in medical journals
as they may be better able to judge empirical evidence.
The respondents’ beliefs and their propensities to
change them may have been different from those of the
authors who did not respond. Regression to the mean
was not a problem, especially among the authors who
reported a previous belief in iridology of about 50%:
1 00^ ; • BMJ ( n»40 )
, ■ J ft Coll Ceti Pract ( n-20 I
0 80
i ▲ Journals of alternative
medicine ( n-18 I
/
^7
I
I
c 0 60
^7
•
5
f/ •
//
i040
J/
0 20-
0 00
■
0 20
040
■
/-•
A
0-60
0-
i bo
Belief before reading report
Belief in iridology as a diagnostic aid among 78 authors of papers in
"BMJ. ” "J R Coll Gen Pract," and three journals of alternative
medicine before and after reading a report that gaz>e empirical
evidence against its validity. Curved lines indicate median, second
quartile Pjs) and fourth quartile (Prs) likelihood ratios
their change to strong disbelief was impressive. Parti
cipation was lowest among doctors of alternative
medicine. The report’s impact on such doctors was
large but less pronounced than that on other doctors
(likelihood ratio closer to one). In general the likeli
hood ratio seemed to describe the results reasonably;
its usefulness for measuring the longer term impact ofa
publication needs further study.
I KnipxhilJ 1‘. Looking for gallbladder diwase in the paticnl** iris. Br MedJ
HSt;’97:l578-lfl.
(Aneped 16 Muy list'
2
I1
'
SCREENING: A GENERAL VIEW
presume themselves to be healthy—is one that now has
wide acceptance in our society. In this chapter we
would like to take a general view of screening, what we
mean by it, what principles we should apply to it, and
what criteria should be used for evaluation.
McKeown (1968) defined screening as medical inves
tigation which does not arise from a patient's request for
advice for a specific complaint. Screening so denned
may have one or more of three main aims and the
requirements for its acceptance may be quite different
in each case. First it may be the subject of research, for
example in the validation of a procedure before it is
introduced more widely; secondly, it can be used for the
protection of public health—sometimes compulsorily
_ to identify a source of infection as, for example, with
the search for the source of an outbreak of food
poisoning; and thirdly, screening can have as its main
aim a direct contribution to the health of individuals. J,t
is with the third aim of 'prescriptive' screening that we
wifi deal mainly, although not exclusively, in this book.
SCREENING FOR PREVENTION
Screening stands apart from traditional medicine in that
it seeks to detect disease before symptoms present and
before an individual decides to seek medical advice.
Screening therefore carries considerable ethical res
ponsibilities since it contains the potential to move an
individual from the state of supposing himself or herself
to be healthy to the state of having some disorder or
potential disorder. As Rene Dubos (1960) has pointed
out, complete freedom from disease is almost incompati
ble with the process of living. But we must be sure that
screening is not being used to identify conditions that
are either untreatable or insignificant since at either
end of this spectrum lie anguish and anxiety. As Wald
and Cuckle (1989) state:
Screening must be principally concerned with the pre
vention of disease and the recognition that it is only
SCREENING FOR PREVENTION
3
worthwhile screening for disorders which lend them
selves to effective intervention.
Simple and obvious as this may sound, it is by no means
always the case although it is, in our view, fundamental
to the integrity of the screening process.
To screen or not to screen?
Opinions in the health professions on the value of
screening remain mixed. Enthusiasts point to the poten
tial for reducing morbidity and mortality. There has
been a resurgence of private screening clinics which
advertise general health screening programmes for men
and women. The new contract for general practitioners
in Britain (Health Departments of Great Britain 1989)
takes its cue from this consumer-led phenomenon and
includes a 'lifestyle check’ for newly registered pa
tients, despite the lack of evidence for the efficacy of
this. Particular pressure groups and lay groups, to
gether with the media, may excite a public demand for
screening for a specific condition, often on the basis
of personal experience unsupported by scientific evi
dence. One fundamental point, raised in the preface to
the previous Nuffield Trust book on screening (1968)
and which remains very relevant today, is the possibil
ity of well-intentioned doctors, patients, and pressure
groups leading a kind of crusade against a particular
disease or diseases and persuading governments to
provide a screening service before a comprehensive
and scientifically respectable assessment of its benefit is
available. In these circumstances the act of screening
runs the risk of acquiring respectability almost by
virtue of its existence. There is, it seems, a tendency to
assume that if you are screened, all will be well. That is
a damaging and dangerous fallacy and every screening
proposal must be rigorously examined against clear
criteria. In the United States, where law suits have been
filed against physicians who failed to detect cancer on
screening, there has been a marked increase in defensive medicine.
4
SCREENING: A GENERAL VIEW
Opponents of screening cite that harm it can do in
terms of misuse of limited resources, over or misdiagno
sis overtreatment, and the provocation of anxiety and
fear. Skrabanek (1988), for example has re-sta ed
recentlyTm VfeW that 'screening healthy fie^ple with
out informing them about the magnitude
^here
risks of screening is ethically unjustihable. Resuh^ of
one-recent study have shown a significant increase in
psychological distress in healthy adults who have beer
screened for coronary heart disease risk factors (Stoate
1989) This author emphasises that advocates of screening tend to assume that the process has only two
possible outcomes—benefit or no effect The possibility
that it may actually cause harm is largely ignored.
Stoate further argues that
the debate about who to screen and for what conditions
should be widened to take more account of its effect on a
person's mental state and subsequent behaviour.
The balance of opinion today seems to he somewhere
between the extremes of enthusiasm and doubt in a
cautious and rigorous approach to screening practices
^Chambertein (1984) has summarised the benefits and
disadvantages of screening and these are shown in
Table 1. The benefits are clear. Some patients identified
will have an improved prognosis because of early
intervention. Disease identified at an early stage may
respond to less radical treatment. There should be
savings in health service resources by treating diseases
before they progress. Those with negative test results
can be reassured.
,
The disadvantages of screening are more complex.
They include longer periods of morbidity for patients
whose prognosis is unaltered in spite of diagnosis, and
overtreatment of insignificant conditions or abnormali
ties that are identified. In a randomised s udy of
steelworkers with diastolic pressure greater than 95
mmHg, Haynes and colleagues (1978) found that absen
teeism from work increased after they had been told
SCREENING FOR PREVENTION
Table 1. Benefits and disadvantages of screening
5
BENEFITS
DISADVANTAGES
Improved prognosis for some
cases detected by screening
Less radical treatment which
cures some early cases
Longer morbidity for cases
whose prognosis is unaltered
Overtreatment of questionable
abnormalities
Resource costs
False reassurance for those
with false-negative results
Anxiety and sometimes
morbidity for those with
false-positive results
Hazard of screening test
Resource savings
Reassurance for those with
negative test results
‘From Chamberlain (1984) and reproduced by kind permission of
the author and publisher.
they had hypertension. 'The increase in illness absen
teeism bears a striking relationship to the employee's
awareness of the diagnosis but appears unaffected by
the institution of antihypertensive therapy or the
degree of success in reducing blood pressure.' There are
resource costs in finding more illness in terms of the
screening tests themselves, the manpower resources,
and the subsequent management of whatever is found.
There is the certainty that some individuals with false
negative results will be given unfounded reassurance.
Conversely, those with false-positive results will be
subjected at the least to needless anxiety and at the
worst to unnecessary and disfiguring surgery. Finally
there is the question of possible hazard from the
screening test itself.
Thus screening should be a hard-headed professional
exercise rather than a form of evangelism. Stringent
examination of the practice of screening and its implica
tions is essential in any society which takes the health
of its citizens seriously. 'The mere existence of unre
cognised cases of illness is, by itself, insufficient reason
to screen. Disease has many faces, and the hunt is not
benign' (Berwick 1985).
(
6
SCREENING: A GENERAL VIEW
Cost, resources, and audit
It is an inescapable fact that, under the present or any
foreseeable system, we cannot do everything we might
wish in terms of health care. Screening is costly in
terms of man hours required to run the programmes
carry out the tests, and act on the results. Limited
numbers of skilled professionals are available and this
is a problem that will increase in severity as the
current demographic changes lead to a smaller work
force. With the explosion of expertise and technology,
things are now possible in medicine and health caie
that were in the realms of science fiction 20 years ago^
We have an increasingly informed (and sometime
misinformed!) public who, when made aware of what
can be done, expect that it should be available for them
and their families. As in other areas of life, we are
moving away from the simple quantity issues-routine
health care available to all-lo the far more complex
quality ones—the best and most advanced health care
available to all. There is an important change in
emphasis from need-led to demand-led health care
which has very wide implications. People are also
developing a mistrust of high-technology medicine and
are demanding more attention to their complex emotional needs.
It is vital therefore, that there is a proper assessment
of the resource implications of any screening or preven
tion proposal both in terms of primary and of secondary
workload, and that screening is included in medical
audit. This implies the examination of whether effec
tive recognised screening has been undertaken as we
as consideration of unnecessary ineffective screening
procedures. In the South-East London Screening Study
(1977) for example, it was found that multipha
screening increased the work of general practitioners
by 10 per cent without a corresponding benefit in health
terms. Where a screening test is recommended and
available, as for example with screening for cancer of
the cervix or breast, this should be considered during
the normal medical audit procedure.
Screening for prevention
7
Self-responsibility
A properly informed public is a vital and often forgotten
ingredient in any analysis of screening. The recent
Government White Paper Working for Patients recog
nises this as one of its central themes (Secretaries of
State 1989). One of the major weapons in preventive
medicine today has to be the persuasion of individuals
to take more responsibility for their own health, to seek
and accept information on health-damaging and health
enhancing forms of behaviour, and to cooperate in
appropriate screening programmes. It is necessary also
to keep a sense of balance in the idea of self-responsi
bility for health. Certainly individuals should be pre
pared to take reasonable responsibility for their own
health. But, given the strong economic, social, political,
and environmental influences largely outside the con
trol of the individuals they affect, governments cannot
avoid a large measure of collective responsibility for the
health of their citizens. It is important too to seek a
balance on health awareness. Morbid pre-occupation
with health can cause as many difficulties as a lack of
awareness of health-damaging behaviours, although, as
Acheson (1963) has pointed out, there is little evidence
to support the view that the examination of apparently
healthy people will turn us into a nation of hypochon
driacs. One of the problems with screening is that it
does tend to focus on disease rather than health, and it
also creates a 'safety-net' philosophy of reliance on the
ability of the health professions to identify and solve
health problems.
At last in Britain we do seem to be moving towards a
more positive concept of health rather than illness, but
there is a long way to go. The United States Govern
ment has recently set out a list of 21 National Health
Objectives for the year 2000 and these are shown in
Table 2. They certainly reflect the more aggressive
American approach to health care and prevention. At
first glance they may also seem too general to be of
value, and of course screening is only relevant to those
conditions that can be treated. But we in Britain must
8
0
SCREENING:
SCREENING: A
A GENERAL
GENERAL . iEW
T
able 2.
2. US
Table
US Public
Public Health
Health Service
Service nahonal health
objectives for the year 2000----------- -------1 Reduce tobacco use
2 Reduce alcohol and other drug abuse
3
4
5 Reduce environmental health hazard
6 Improve occupational safety and heall“
7 Prevent and control unintentional injuries
8 Reduce violent and abusive behaviour
9
10
11
12
13 Improve maternal and infant health
14 kXSl-Tpregnancy and improve reproductive
15
Prevent detect, and control high blood cholesterol and
16
high blood pressure
17 Prevent detect, S control other chronic diseases and
18
19
20
21
disorders
of life o( older peopie
Maintain health
the educalion and access to preventive health
Improve L—
Improve surveillance and data systems
consider such an
XXcepftl
some
as advocated more than 10
national hea
P
There have been recent
years ago by Ston I
health education and
moves towards this
England the Health
public health are c°ncer?edh^ rec8ently published a
I SCREENING FOR PREVENTION
tion; Nutrition Education; Family and Child Health
(including immunisation). And the report from an
independent multi-disciplinary committee entitled The
Nation's Health: a Strategy for the 1990s states the belief
that a public health strategy should be directed towards
three overall health goals—longevity, a good quality of
life, and equal opportunities for health (Smith and
Jacobson 1988). Members of the committee identified
17 priority areas of action as shown in Table 3. While
they claim there is sufficient evidence to merit action in
each of these areas, they concede that the evidence is
stronger in some cases than others. On the basis of six
criteria, they selected 11 of the 17 priorities for which
they believe plans for action can currently be justified.
These can be grouped into the two main categories of
lifestyles for health and preventive services for health,
as shown in Table 4. We do regard the setting and
stating of national priorities for health as extremely
important and will return to this in the final chapter.
Table 3. Priority areas of action in public health strategy*
NUMBER
PRIORITY
1
2
3
4
5
6
7
8
9
10
11
Reduction of tobacco consumption
Promotion of a healthy diet
Reduction of alcohol consumption
Promotion of physical activity
Promotion of road safety
Promotion of health at work
Effective maternity services
Child health surveillance
Early cancer detection
High blood pressure detection and prevention
Reduction of psychoactive drug misuse
Services for the elderly
Maintenance of social support
Promotion of dental health
Promotion of a healthy sexuality
Adequate income
Safe housing
12
13
acquire and mainta
for health educadesignates seven mam programm
(1990-95):
tion during the five-yearp^riodoOHh^P^YU9r
C^BduSumSmoking Educalion; Alcohol Educa-
14
15
16
17
*From Strategic Plan 1990-95 and reproduced by kind permission
of the Health Education Authority.
I
iO
SCREENING: A GENERAL v
Table 4 Eleven currently justified priority areas ol action
in two categories
lifestyles for health
preventive services for health
Maternity
Dental health
Immunisation
Early cancer detection
High blood pressure
detection
_____ _____
■-7^^^199071^?CM by
*From The Nation's
oftheHealth:
Editors and the King Edward's Hospital Fund
kind permission c
for London.
Tobacco
Diet
Physical activity
Alcohol
Sexuality
Road safety
^N/NG ANU HEALTH PROMOTION
11
instrument to improve health care and reduce morbi
dity and mortality.
In this monograph, we will try to examine the present
status of screening in health care in the United Kingdom
with research examples as appropriate from elsewhere.
We will go on to suggest some ideas for the develop
ment of screening in the future, drawing on experience
in the United States where the concept of positive
health is much more firmly established and where the
US Preventive Services Task Force has recently pub
lished its Guide to Clinical Preventive Services with an
assessment of the effectiveness of 169 interventions.
We will begin by restating the definitions and principles
of screening and its evaluation.
SCREENING AND HEALTH PROMOTION
Screening today is ^creasingiy
certain types of beh^f0Urre^mple cigarette smoking,
modern health care
consider health as a
compartments ol the p
..
|herlhandsa senes
whole and the person as
which can be diseased
of interconnected organs any of which can be^
in isolation. Jhus
^ich have not been traditionally
promoting activities^w
{all wilhin the view of
regarded as screening b
mentioned earlier. One of
screening in Proven
tract of service for general
the strengths of the 19
.
prevention and
practitioners is its emphasi^ on ‘1
^P^^
health promotion as ,Parl °’
B1989). Many
(Heath
t,y “
,hal slreean8
’s“Xo“esda
“ “ “ "8e,ul' "llab"
DEFINITIONS
The United States Commission on Chronic Illness
Conference on Preventive Aspects of Chronic Disease
defined screening as 'the presumptive identification of
unrecognised disease or defect by the application of
tests, examinations, or other procedures which can be
applied rapidly. Screening tests sort out apparently
well persons who apparently have a disease from those
who probably do not. A screening test is not intended to
be diagnostic. Persons with positive or suspicious
findings must be referred to their physicians for diagno
sis and necessary treatment' (Commission on Chronic
Illness 1957).
Various types of screening were defined by Wilson
and Jungner (1968). Mass screening is the large-scale
screening of whole population groups. Selective screen
ing describes screening of certain selected high-risk
groups in the population. Multi-phasic screening en
compasses the administration of two or more screening
tests to large groups of people (Wilson 1963). Surveil
lance implies long-term observation of individuals or
populations. Case-finding is usually taken to mean
screening of patients already in contact with the health
PRINCIPLES
SCREENING: A GENERAL V.-W
service lor the main purpose «Uleieclio
aStoi^S'eVlo Xrto.il types ol screening in a
eT[X“ tant to o-Ph’X^aS’Sa XS
screening where groups, o p
1°Holland
7™
iSme“
19/d) wnere
contact and U>e OPP“
?
j
(Sackett and
lhe h“llh
suggest various
‘'J^eKureinent ol
other appropriate tes ,
s:ons it has become'
blood pressure. Since these discuss „„s >1
simple questions
apparent that asking J.unpte
questi^
behaviour id
i_ Tegihlim'considered^nder lhe definitherefore be 8 A good example ol this is in chrome
tion of screening, the only valid screening test is the
bronchitis where smoke?' (Colley 1974; Holland 1974).
question 'do you
5. There should be a suitable test or examination.
6. The test should be acceptable to the population.
7. The natural history of the disease, including latent
to declared disease, should be adequately understood.
8. There should be an agreed policy on whom to treat
as patients.
9. The cost of case-finding (including diagnosis and
treatment of patients diagnosed) should be economi
cally balanced in relation to possible expenditure on
medical care as a whole.
10. Case-finding should be a continuing process and
not a ‘once for all1 project.
Cuckle and Wald (1984) have summarised the basic
requirements of a screening programme under eight
aspects and these are shown in Table 5.
Table 5. Requirements for a worthwhile screening
programme *___________ ________
ASPECT
PRINCIPLES
Despite all lhe changes in e«r approaches lo hnahh eare
basic principles
over the last two decades, the
disease” detection remain and we
screening or early u— pealing them here. In reviewing
..........
-- screening in
StL^ra^S^yolputlleaUon^en
is still being
and without
certain fundamental principles.
reference to
--summarised these prmWilson and Jungner (19bo)
ciples as follows:
important
1. The condition sought should be an
health problem.
ted treatment for patients
2. There should be an accep
with recognised disease.
and treatment should be
3. Facilities for diagnosis
available.
.
,
4. There should be a recognisable latent or early
(
symptomatic stage.
13
1 Disorder
2 Prevalence
3 Natural history
4 Financial
5 Facilities
6 Ethical
7 Test
8 Test performance
REQUIREMENT
Well-defined
Known
Medically important disorder lor
which there is an effective remedy
available
Cost-effective
Available or easily installed
Procedures following a positive
result are generally agreed
and acceptable both to the
screening authorities and
to the patients
Simple and safe
Distributions of test values
in affected and unaffected
individuals known, extent
of overlap sufficiently
small, and suitable cut-off
level defined
‘From Cuckle and Wald (1984) and reproduced by kind permis
sion of the authors and publisher.
EVALUATION
14
SCREENING: A GENERAL
.EW
In the interests of simplicity we have grouped these
screening principles into four categories.
Condition. The condition sought should be an important
health problem whose natural history, including deye1'
opment from latent to declared disease, is adequately
understood. The
The condition should have recognisable
understood.
latent or early symptomatic stage.
Diaanosis There should be a suitable diagnostic test
wE ts available, safe and acceptable to the Popula
tion concerned. There should be an agreed policy,
baid on test findings and national standards, as to
whom to regard as patients, and the whole process
should be a continuing one.
Treatment. There should be an accepted and proven
treatment or intervention for patients identified as
haX the disease or pre-disease condition and facilities for treatment should be available.
Cost The cost of case-finding (including diagnosis and
treatment) should be economically balanced in relation
to possible expenditure on medical care as a whole.
EVALUATION
Evaluation of screening is of vital importance and has
too often been neglected in the establishment of screen
ine programmes. Screening for cancer of the cervix in
the United Kingdom, which we will deal with in more
detail in Chapter 6, is one example of a
*
was started without proper provision for adequate
scientific evaluation. Once again we make no apology
Lf repeating the list of seven criteria which Cochrane
and Holland (1971) suggested for assessment or evaluation of any screening test.
1 Simplicity: a test should be simple to perform, easy
to interpret and, where possible, capable of use by
paramedical and other personnel. With increasingly
IT""
complex technology certain screening tests, particu
larly for example in the antenatal and neonatal periods,
can only be performed by doctors.
2. Acceptability: since participation in screening is
voluntary, a test must be acceptable to those undergo
ing it.
3. Accuracy: a test must give a true measurement of
the condition or symptom under investigation.
4. Cost: the expense of the test must be considered in
relation to the benefits of early detection of the disease.
5. Precision or repeatability: the test should give
consistent results in repeated trials.
6. Sensitivity: the test should be capable of giving a
positive finding when the person being screened has the
disease being sought.
7. Specificity: the test should be capable of giving a
negative finding when the person being screened does
not have the disease being sought.
As Wilson (1963) has stressed, one of the main
objections to screening is that tests have frequently
been used without knowledge of their scope and
limitations. In the early days of screening matters were
simpler. The natural history of the conditions being
sought, such as tuberculosis and syphilis, was well
understood and lines of treatment were clear. The
emphasis now is on chronic diseases about which much
less is known, and the area of uncertainty is greatest in
those conditions which take many years to develop and
in which there is no clear boundary between the
healthy and the diseased. ‘Unless the ground is first
cleared by epidemiological studies, it is difficult to see
how harm by indiscriminate screening can be avoided'
(Wilson 1963).
THE PRESENT MONOGRAPH
Because of the immense scope of the subject, we have
divided the present monograph in terms of life-cycle.
SCREENING: A GENERAL f
16
THE PRESENT MONOGRAPH
.W
We have divided a life-cycle into six ..screening seg^merits as shown in Table 6; Segment I includes he
antenatal and neonatal periods and infancy. Segment II
deals with childhood. Adolescence and early adul
thood, segment III, covers the years 12 to 24. Segments
IV and V contain adult men and women respectively,
and segment V relates to old age.
TABLE 6. Life-cycle screening segments______
SEGMENT
i
I
II
III
IV
V
VI
qtacp OF 11FE
STAGE OF LIFE
Antenatal, neonatal, infancy
Childhood
Adolescence and early adulthood
Adulthood (men)
Adulthood (women)
Old age
AGE RANGE
-1
1-11
12-24
25-64
25-64
65 +
established and clear. Our working
ins is that it entails inviting an individual lor an
examination which may identify a condition at a s age
when it can be treated effectively to inhibit or retard its
development. At some stages of life however our
definition of screening has been stretched a lit
cover what purists might consider to be routine clinical
practice. Thus in Chapter 2 we include mention o
measurement of blood pressure or examination of
fundal height of the uterus during pregnancy which
some will claim is simply good medical practice rathe
than screening. In Chapter 3, the problem arises as to
what is screening and what is .surveillance with the
danger of trying to assess surveillance activities by
screening criteria. Given the broad objectives of health
care in this age group-the identification and if possible
17 —.
correction oi any physical, mental, developmental
difficulties and the establishment of good health habits
for the future—we would claim that both screening and
surveillance are relevant and necessary and too great
an insistence on the distinction between them is un
realistic in practice. In Chapters 5 and 6 we have had to
make arbitrary decisions on where to include certain
conditions such as diabetes, psychiatric disease, and
indeed coronary heart disease which affect both men
and women.
Because we believe that screening today must
attempt _to_consider the whole person, with the em
phasis on health rather than disease, the life-cycle
approach, despite its imperfections, is the most practicat“and realistic. We will consider the present status
of screening in each life-cycle segment in certain
major diseases or conditions. A number of conditions,
such as neuroblastoma and ovarian cancer, have been
excluded either because the problem is small in popu
lation terms or because there is as yet insufficient
evidence of benefit. Other conditions, most notably
tuberculosis, are omitted because screening has
achieved its objective.
The book is not intended as a comprehensive review
of screening for the specialist in any particular field of
medicine or health care. Nor is it intended to be a
British version of the US Preventive Services Task Force
Report (1989) which was the product of over four years
of intensive efforts by a panel of 20 medical and health
experts. Our aim has been to try to pull together the
academic and practical strands of screening to provide
information for average practitioners, both general and
specialist, who can use the text and references to
examine in greater detail the basis of our conclusions
and draw their own. The book is intended also for
health service managers and members of Health Au
thorities and Boards to try to provide an overview of the
current position in screening and highlight some of the
present deficiencies and potential strengths of the
system.
19,
18
SCREENING: A GENEka
/IEW
?a” l„?s Sem to sl‘nd out. The hrel is that the has been a
KU U ^XX-pTaXSThe
Esae-KK
REFERENCES
ACHESON, R. M. 'Thoughts on aul7h7e Pr1eJ^mptOinatiC
diagnosis of disease*. Public Health (1963) 77.261 73.
Berwick, Donald, M. ‘Scoliosis screening: a pause in the chase .
Am J Publ Hllh (1985) 75:1373-4.
CHAMBERLAiN, Jocelyn, M. 'Which prescriptive s^eemng pro
grammes are worthwhile?' J Epidemiol Comm Hllh (19a4)
38‘270—7
Cochrane, A. L. and Holland, W. W. 'Validation of screening
procedures’. Br Med Bull (1971) 27(l):3-8.
Colley, J. R. T. 'Screening for Disease. Diseases of the lung. Lancet
Commission o^Chronic Illness. Chronic illness in the United Stales.
Volume 1. Prevention of Chronic Illness, p. 45. Cambridge,
Mass: Harvard University Press, 1957.
Cuckle H. S. and Wald, N. J. ‘Principles of screening .
and Neonatal Screening. N. J. Wald (ed.) Oxford: Oxford Uni
versity Press, 1984.
Dubos, Rene, J. Mirage o/ Health. London: George Allen and Unwin,
Hay^R B„ Sackett, D. L. Taylor, D. W„ Gibson, E. S. and
XevaXed. Thl designation 01 one^senior person
SXXKe" SS iorward iMmproving
XXXhUXdHolland wrote:
1978, 299:741-4.
,
Health Departments of Great Britain. General Practice m the
National Health Service. The 1990 Contract. August 198
Health Education Authority. Strategic Plan 1990-1995. Londo .
HEA, 1989.
, , .
, 107.
Holland, W. W. 'Screening for Disease. Taking stock . Lancet, 197 ,
We believe that there f
ii-1494-7
McKeown, Thomas. 'Validation of Screening Procedures In
Screening in Medical Care: Reviewing the Evidence. Oxford.
Oxford University Press for the Nuffield Provincial Hospital
‘"r? r?n“«r v%J have “Ldusive evidence that
screening can alter the natural history ol iho disease in a
significant proportion of those screened.
Thirtv vears on we would contend that screening y
Is Ycan prodde bo answer to anything. Only >1 it .s
itself can provide
1 . .
efficiently and humanely, leads to an
contemplated.
o
Johnson, A. L. 'Increased absenteeism from work alter detec
lion and labelling of hypertensive patients . New Engl J Med
SACKEnj d'kaND Holland, W. W. 'Controversy in the detection of
disease'. Lancet, 1975, 2:357-9.
Secretaries of State. Working for Patients. White Paper. CM 555.
London: HMSO, 1989.
nvUH
Screening in Medical Care: Reviewing the Evidence Oxford: Oxford
University Press for the Nuffield Provincial Hospitals Trust,
SkrabTnek, Petr. 'The physician's responsibility to the patient'.
Lancet 1988, 1:1155-7.
■
20
SCREENING: A GENERAL VIEW
2
antenatal
and neonatal
SCREENING
New methods of screening... hold out the
hope that, with only the rarest exceptions,
every fetus that is carried to term will be
born alive with the prospect of surviving
into adult life physically and biochemically
whole.
(SIR RICHARD DOLL, 1984)
INTRODUCTION
96:389 96.
e screening'. Lancet 1963, ii:51-4.
Wilson' j ’ M G and Jungner, G. Principles and Practice of Screening
W /o1Disease Geneva: World Health Organization, 1968.
THE MONTHS BEFORE BIRTH AND IN THE FIRST YEAR OF
life are those in which most individuals receive _more
attention from the health care professions than at any
other time during their lives. As Muir Gray ( 984J has
nointed out, most screening services available during
this period are based on sound scientific research and
have been developed rationally. The initial develop
ment of a particular technique has normally been
experimental, as a clinical trial, with careful evaluation
and monitoring. These services have therefore been
developed in a much more satisfactory way than many
other current screening procedures which were mtr
duced during the 1950s and
was more evident than evaluation (Holla
ANTENATAL SCREENING
Screening at this stage of life relies increasingly on the
use of complex technology and st°P1Jlstl7^ale^L
ment The advantages of this are that potential pr
lems can be clearly identified. The use of scans^rat
than vaginal examinations is less invasive and u P
ant for the woman as well as providing fuller inform
21
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