HEALTH ADVOCATE ARTICLES BY RAVI NARAYAN, CMJI , 1992-JUNE 2004

Item

Title
HEALTH ADVOCATE ARTICLES BY RAVI NARAYAN, CMJI , 1992-JUNE 2004
extracted text
Will There Be
Mission
Hospitals In
2000 AD?

w

Dear Friends,

Various

developments in
the country’s health

policy, as well as
disturbing trends

within the voluntary
sector, have led the

author to question
the permanence of

mission hospitals

Havlng been closely H
Involved with health ®
action for over two de­
cades — especially in
the voluntary sector of the country, both Christian and non-Chrlstlan — I have gladly agreed to
reach out to all the CMJI readers
through this column, “The Health
Advocate’’.
I will be regularly bringing to
you my concern about tire crises In
the health missions, unmet needs,
distortions In health care and dis­
turbing trends In the emerging
health policies, all of which could
become obstacles to our commit­
ment to Heal tli For All by 2000 AD.
I believe our concern should be
supported by collected reflection
and collective action in solidarity.
Reflective action Is the key to
change and I hope this column will
stimulate such a process among
CMJI readers. Please write and let
me know your own experiences
and perceptions about the Issues I
will be raising in this column, so
that I can weave them Into subse­
quent columns and build further
reflections In an Interactive way.
In this first Issue I would like to
share one of my growing concerns,
which would be of particular inter­
est to you. It Is a question that Is
beginnings loom on the horizon of
voluntary heal Hi work In the coun­
try because of various develop­
ments in the country in the health
policy, and also because of various
CMJI? 16

1S

^1

disturbing trends within the vol­
untary sector and In the large so­
cietal universe around it — will
there be ‘mission’ hospitals in 2000
AD?
Some 20 years ago, on a visit to
Kerala, I was told by a group of
young, committed social workers
that mission hospitals in Kerala
would disappear In the lOOOsll It
seems, as they explained it to me,
that most mission hospitals in Ker­
ala were customarily referred to in
the 1960s as St X’s Charitable
Mission Hospital. The social work­
ers reckoned that Value orienta­
tion’ or saintliness had eroded in
the 1960s, the charity dimension
was disappearing In the 1970s
and the ‘mission’ thrust would
evaporate In the 1980s, leavingX’s
Hospital without ‘saintliness’,
‘charity’ and ‘mission’ in the 1990s
— no different from the large num­
bers of private sector, profit-ori­
ented hospitals which have devel­
oped in response to the market
economy.
While this was said In utmost
seriousness, my own understand­
____ _________of____
ing and field observations
mlsslon hospitals were too limited at
that time to assess the ‘prophetic
nature’ of this concern or to reject
It as mere fancy! As the years went
by, In my Increasing contacts with

THE HEALTH ADVOCATE
the stall
staff of
of mission hospitals
ine
Th^ugbsemInars and workshops,
I have been picking up many Inter.
the havej)een^told
number nft d by many that
indbren^nnti ftPH0Ii' needy^d
by mission hospitSs^g
going
down rapidly, not because the pur­
chasing capacity of the poor In­
dian has gone up through post­
Independence economic development, but because the only way
P°
enough money to run the
hospital without regular doses of
foreign donation Is to shift the
focus on the paying patient.
_

-

Somehow the
thought that the
'mission of healing9
finally gets experi­
enced only as 'clean
floor and white
sheets9 has always
disturbed me

I have been told that the ways to
balance the budget in order to
continue tire vocation has been to
Increase iunnecessary
------------investlgatlons under the euphemism of ‘routine tests’ to Increase unnecessary
prescriptions, even promote
. sur­
gery and Increase the length of
hospital
.
' stay
J — especially of payIng patients!!
I have been told that many
mission hospital pharmacies are
stocked not only with banned,
bannable and hazardous drugs
but also with inessentials of high

costand cosmetic embellishments.
- -------------------

This is evidently not by accident, (that
’
mission hospitals are dlsapbut for the simple reason that they pearing from the national
- -----------1 scene provide better profit margins , lntake a look at the membership
esse1nllals belng ^owed a higher statlstlcs'of associations'su'ch as
mark-up in
present
ln the
1,16 P
resent irrational
Irrational CMAI and CHAI. But membership
Pacing policy and thus; comof an
an association
association is
is one
one thing,
thing, com com­ of
°.dUC.lng them offer
°ffer mltment
to
a
mlsslon
panies Pr
producing
mitment to a mission ls
is quite
greater ‘unethical’ trade discounts. different matter.
I have heard that in many
Ifyou consider some of the ‘con­
institutions doctors are paid larger fessions’ — even though they were
and larger sums‘over’and‘under’ not based on rigorous study but
the table since they are the best werehearsay evidence (maybe only
contributors to the profit margins
partially true) — then the question
while paramedicals and auxllla- posed does not seem Just fancy.
do I11,081 of J11,6 work
A If mission hospitals continue to
generally underpaid by govern­ close down because of the short­
ment standards.
age of funds or committed person­
On the contrary, I believe that nel at the rate they are closing
many institutions are also closing down at present (a CMAI estimate
down because they are not able to I believe is 10 a year).
generate enough money to meet
If others opt out of the‘mission’
the increasing costs of medical sector into the ‘market economy’
care and, what seems even more for the sake of survival.
significant, they are unable to get
If still others opt out of ‘prefer­
committed professionals to work ential option for the poor’ because
in situations that are more periph­ Itjust doesn't work ‘to rob Peter to
eral and designed to serve the pay Paul' today.
needy and underprivileged!
If still others accept unquestion­
Some, on the oilier hand, are ingly the ‘unethical practices’ that
linking up with ‘big business’ so are bound to balance their bud­
that they can survive the pres­ gets.
sures of the market economy and
And still others are known only
many are dreaming of attaching a for
- their
■
‘clean
floors and white
self-financing or capitation fee for sheets’ and nothing else.
medical/nursing colleges to their
... then will ‘hospitals’ with a
institution to help them over the ‘mission’, as we have known them
crisis — inot' recognising
' ‘
the value all through these years, actually
crisis they may
be“ Inadvertently
” u
‘ •’r survjve till 2000 AD? I wonder!
moving into through such an ini­
tiative.
Ravi Narayan
Coordinator, Society for Community
One of the most interesting
feedbacks that I have had, when Health Awareness. Research and Action,
326, V Main, I Block.
asked why people prefer mission
Koramangala. Bajxgalore - 560034,
hospitals to government or other
Karnataka, India
Institutions is apavlovlan response
HEALING
OF
CREATION
about the former being 'cleaner
If our earth Is to be protected
and more efficient'. Somehow, (he
adequately, guardianship must
thought that the ‘mission of heal­
be exercised in every field, lake
ing' finally gets experienced only
or sea, on every hillside or reef,
as ‘clean floor and white sheets'
from every village or city. Suc­
cess will come only when ordi­
has always disturbed me.
r
~
nary people assume that
As__
I ponder
over these
confessions
I often wonder whether tlae young
guardianship.
social wo’rk^s in K^we^b^
Reu Boyd Lotvry
Executive Director, Codel
Ing prophetic. There are no signs
------------------- ——

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CMJI?I7

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slcCuiicate

The
Great
Indian
Medical
Education

SCAM
Dear Friends,
Recently the papers have been
full of the Stock Exchange Scam.
Mr Harshad Mehta of Growmore
Incorporated and his network of
associates In all our ‘not so na­
tional' banks managed to get Rs
3,078 crore to reach accounts they
were not legally meant to
reach. Or have I got the
implications all wrong?
Anyway ‘Stock Exchange^,
bulls’ and ‘banker's re­
ceipts’ have never been my
cup of tea and whatever
the final extent or nature
of the swindle, there is no
denying that the matter Is
under effective scruUny to­
day — what with public
debate, parliamentary de­
bate, policy debate, legal
acdon, media hype, police
action etc.
The entrepreneurs are
in the ‘Jug’. The. ‘naUonal
psyche' Is recovering from
a rude shock. Public fears
8

about the health of the banking
system are being systematically
allayed by the Government. The
detailed Investigations are on. May
our deposits rest in peace!
However, there Is another ‘scam’
rather well entrenched in the sys­
tem, that is aided and abetted not
by unknown bulls of Mr Mehta’s
kind but actively by the decision­
makers and the powers-that-be.
This is presently not being sub­
jected to policy debate, nor public
debate; it Is nowhere near the fringe
of legal action, leave alone police
action. This ‘scam’ is reported in
the papers nearly ev^ry day but is
beginning to lose its newsworthi­
ness and to affect our health and
the future health of the nation. It
goes by the name of The Great
Indian Medical Education Scam’
and, one day, when It is recognised
for what It is, the stock scam will
be pushed into pale Insignificance.
But will this happen?
Interestingly, this month, I and
my team of co-researchers are on
the final phase of a two-year project

co-sponsored by CMAI and CHAI
and supported by the emerging
Christian Medical Colleges Net­
work. For over 24 months, we have
searched for social relevance and
community orientation in the medi­
cal education experience in India.
The final output of this study (now
an Impressive 600 sheets of typed
and photocopied manuscripts) fo­
cuses on the efforts of about two
dozen forerunners’. Including the
three CMCs ( Vellore, Ludhiana
and Bangalore), and Is definitely a
cause for great satisfaction. How­
ever, It Is the Increasing evidence
about the wider world of medical
education picked up by our study,
not the Innovators but the
malnstreamers’, that has con­
vinced us of the existence of an
entity far greater than the current
stock market one.
Here are some bits of Indirect
evidence to sour your daily morn­
ing cup of tea:
■ The ICSSR/ICMR study group
recommended In 1981 that there
should be no new medical colleges
and po Increase In the Intake of
existing colleges’. By 1992 there
has been an unchecked growlli (!)
from 125 to over 170 (mostly pri­
vate capitation fees colleges). This
Is an official ‘guesstimate’, since
even the Planning Com­
mission Itself has not been
able to keep pace with the
phenomenon.
■ Three states, in the
country, Karnataka,
Maharashtra and Tamil
Nadu, have been vying wi th
each other for ‘top of the
league’ status in promot­
ing these Institutions
through political patron­
age, state subsidy and
cabinet fiat’. While politi­
cal coffers get donations,
the state treasury falls to
receive crores of rupees In
payment for ‘state-pro­
vided’ clinical facilities.
■ An MCI Bill passed In
CMJI

2-

THE HEALTH ADVOCATE
Parliament, explicitly to control
tills commercialisation of medical
education, has failed to make the
grade, the ‘official’ support of U iree
recent governments in these past
months notwithstanding!
■ Leaks in the test papers of tin
dergraduate or postgraduate ex­
aminations are now far too com
mon to raise any eyebrows, least of
all those of the examiners.
■ The deliberate postponement of
a PG entrance test by a few weeks
to allow a high official’s daughter
to complete her internship and
attend the examination (a recent
scandal), takes the cake In official
indulgence in the midst of medical
education reform.
■ While MCI, the watchdog body
on quality and standards In medi­
cal education, is caught up in a
web of legal action and writ peti­
tions, the Indian Association for
the Advancement of Medical Edu­
cation is fast sliding into irrel­
evance due to a mixture of mem­
bership apathy and internal ’syco­
phancy’, <111 too common In the
culture of our times.
■ Every oilier day, heads of gov­
ernment at the central and state
levels and politicians of lesser stat­
ure, declare open high technology
diagnostic centres and corporate
medical enterprises for the‘classes’
of India. During the Inaugural
rhetoric the pious promise of doc­
tors for the ‘masses’ of Bharat is
made with predictable regularity,
unmindful of the obvious paradox
involved therein.
■ A report on who pays for medic ;d
education in India clearly demon
strafes that after massive state
investment in health, 75 per cent
of the graduates reach the private
sector. The same study computed
tliat the number of graduates mi­
grating ‘westward ho’ in 1986 87
Is 40.8 per cent.
■ A report from West Bengal, on
the mainstreamers in the slate,
admits candidly that‘the teachci s,
admonition against Indiscriminate
CMJ l

In the conflict

BETWEEN THE PURSUIT

OF SCIENCE AND
COMMERCIAL GAIN,

THE LATTER

GENERALLY PREVAILS
use of antibiotics or random use of
steroids cuts little ice with the
student when the latter discovers
that very teacher’s Indiscriminate
and random prescription In pri­
vate practice. The student thus
learns the difference between
theory and practice and in the
conflict between the pursuit of
science and commercial gain, the
latter generally prevails’.

id as If to give a final confir­
mation of the diagnosis of scam in
the system, two reports, one on the
quality of graduates being churned
out by the mains I reamers and the
second, on the quality of care beIng dished out to the people Impart
very little comfort.
K A recent study (1991) on Interns
of Bombay medical colleges dis­
covered the shocking fact that 70
per cent of the interns of 1991
prescribed wrong dosages of drugs
lor leprosy; 71 per cent could not
give a correct prescription for an
adult male suffering from symp­
toms of flu; 72 per cent did not
understand the concept of Primaty Health Carr 12 years after
the Alma Ata Declaration.
KI A young doctor couple from the
t rl bal regions of C en (ral India wrote
to us that medical graduates from
Madhya Pradesh and Bihar colicgvs vvorking in their hospital are
poor diagnosticians and. what is

worse, they do not worry about it.
They admit patients without any
diagnosis...the prescribing prac­
tices include syrups, tonics, antidiarrhoeals and multivitamin in­
jections. The patients have to pay
an enormous bill for drugs.
Where are we heading in the
great enterprise of medical education today? Will the dozen
frontrunners have any influence
in the years to come on the
mainstreamers who are caught up
in the new corrupting market
economy of commercialisation,
communalisation and corporate
competition?
Some of the CMAI and CHAI
member institutions are themselves being tempted to Join in the
medlcal education game with over­
tures from the corporate network
and the new ‘money bags’ for per­
mission to use their quality insti­
tutions for the new initiatives! Dear
CMJI readers, this is an appeal to
look at the proposition squarely in
the face, and identify its inspira­
tion. God or Mammon, I ask?

Ravi Narayan,
Societyjbr Community Health
Awareness, Research & Action,
326, VMain Road,
IBlock, Koramangala,
Bangalore560 034.
A HEALER’S HUMAN TOUCH
AND A PATIENT’S RESPONSE
Recently it was necessary for me to report
for another series of X-rays. These cold and
impersonal events are no joyous occasions.
Usually I am ushered into a chilly room by an
insensitive technician who orders me to lie
down on a frigid table and hold my breath
while they lake a series of pictures. Imagine
my pleasant surprise to find that a friendly
lady technician had warmed the X-ray table
with a heating pad before I came in. That
simple act of kindness in the midst of imper­
ceptive technology brought tears to my eyes.
This lady cared about the people she served.
Rebecca .4. Egbert, Washington, USA. tn Chris­
tian Medical and Dental Society Journal

9
COMMUNITY D ■ ‘
V Main, .

Uanu a i □ r

60

•

. , CELL

7^
HOSPITALS
and health

looking
WITHIN

Ill
A:

The model of health
services that we have
uncritically adopted from
the industrially advanced
societies of the West has its
inherent fallacies. It tends
to distort the basic values
of life and ultimately
affects the happiness
of the people

Dear Friends,

As a young doctor.
professional career lnJ^e ml
1970s, I remember reading
__
emment of India policy reP0!1
■Health Services and M^dic^Ue_
cation - a programme for 1mm
dlate action'. This repor^more
commonly known as the Srlvastava
intriguing
Report of 1975, had an
paragraph that came as a rude

the HospitalDoctor-DrugHigh Technol­
ogy model that
our education

i

questions about Its urn 7
ability was unthinkable.
The dictum that had been n-‘'I
impressionable i
rfrained In our 1-- *
minds was that health was medimedi­
cine' medicine was hospitals, doc.
Ss drugs and techn^gy,
that health care was reaching these
rather uncritically the model of packages to as many, as soon, an
health services from the Industrl
a^ effectively as possible.
Shy advanced and consumption^
That paragraph has conUnued r
oriented socleUes of 016 West. TWs to wX me 111 these years as my
has Its Inherent fallacies, he
involvement In community he<dth
Sts wrongly defined In terms of grew and matured and found x ml
ous professional expressions, am
not sure I sUll understand the true
impact of that paragraph buna
mialitv get distorted, over
creaslngly some questions have
SrofessLnallsaUon IncreasescosU holered me about hospital based ■
and reduces the autonomy ol the health care. May be these bother I
individual; and ultimately there^ snme of you as well:
an adverse effect even on the hexdm • Why are hospitals so preoc
andhappinessofthepeople.These
...........
■
flrPnow nied
pled with
With an understanding
undsry|aod,n2 ^

I

i

1

we«iato.e3.es
of to
^n-^sedin
-be
'
__ ll.g 1
being
West and attempts — Remedy them ... It Is therefore a
U^edy thatwe continue to persist
with this model even when those
we borrowed It from have begun to physical d^enslo™
have serious mis­
disregard the p
.logics ||
givings about its clal, cultural, spiritual, ecology
utility and ulti­
■ a'/A
mate viability."
The conclusion
was particularly fesslonal activities as the o ^
Lmifirt surprising since of properly organising ah
■I
all through my • Whylsthereanover^emp^^
medical educaUon
teclmologZ
on drugs and tec
hn°1O^on-dif H
in the late 1960s complete disregard for n
„|
and early 1970s therapy and other sk ’
<!$ DiA
not one of our • Why is there a watei| .
teachers
had slon of responsibilities m dci(.toT^|
the faintest indication that
there were any ‘in­
herent fallacies
‘weaknesses’ or
‘misgivings' about

II

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8

THE HEALTH ADVOCATE

e
1id

se
id
- 4

ny
Lth
rlim
■ue

inave
sed
her

xul ,
tjeci ; K

mo- j
hole 1
ithel J?
ethe, j
ian^ |k
so- K'
jgical K
■altli?

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1fproJWI“fc
Dhasi|

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team and to the people at large?
9 Why are we so preoccupied with
Not one of our teachers
the allopathic system of medicine,
ignoring the existence or uUlisation
had given us the faintest
of the beneficial culture and prac­
indication
that there were
tices of other systems of medicine
any ‘inherent fallacies’,
and healing?
© Why are we so preoccupied with
‘weaknesses’ or
providing services, rather than en­
‘misgivings’ about the
abling patients to play a greater
Hospital-Doctor-Drug
role in their own health care ?
High Technology model
• Why is it that our hospitals are
so westernised and elitist that they
that our education was
produce a culture shock’ to many
based upon. That anyone
of our patients, particularly those
could have questions
who come from the lower
about its utility or
socioeconomic classes — the poor
whom we want to serve?
viability was unthinkable
During my travels all over India
as a ‘Health Evangelist’, I have
often been asked by committed
people working in hospitals and report menUoned in 1975.
dispensaries; Can hospitals be­
Through this process of‘looking
come more health oriented ? Can within one may discover, as many
hospitals become more commu­ all over the countiy are discover­
nity health-oriented?
ing, that if hospitals have to be
I believe they can, but I also part of the new ‘primary health
believe that they need to look at the care’ movement, then there is an
above questions seriously if they urgent need to evolve new policies,
want to know why they cannot, at new attitudes, new skills and new
present. Somewhere in the answer approaches. Thesewumuniucdit
would Increase
to these questions, through collec- the subservience of medicine, tech
11X7
1
—tlve ml
reflection,
one can r*.find the nology, structures and professional
in^erent fallacies’, the ‘misgivings’
andtheXveaknesses’iheSriS;

Sp^l

I

i

(Post Script
THE INDIAN MEDICAL
EDUCATION SCAM

I
I

Friends,
|| Dear
in me
last issue 1 shared my !
In the last issue I shared my
concerns about the way the great '
I enterprise of medical education I
| was progressing in the country. |
| Three events in the last month i
. have injected a greater slgniflcance to my concerns and I I
I thought you must know about it. |
|
The Andhra Pradesh Govern- I
| ment has permitted the starting .
of 12 private medical colleges with *
I a total intake of 1200 students I
| through one controversial gov- |
i emment order on July 28 (SCAM i
. positive).
The Supreme Court in a sig- I
I nificantjudgement, has ruled that |
| ‘Capitation Fees’ in any form is I
| not permissible because
it violates the right to educa- I
I tion under the constitution;
|
it is wholly arbitrary;
I
|
it is unconstitutional accord■ Ing to article 14 — equality before I
' law;
I
I it is evil, unreasonable, unfair I
I and unfit;
|
it enables the rich to take «
admissions whereas the poor have '
' to withdraw due to financial in- I
| ability (SCAM negative).
|
The medicos and Junior doc■ tors of Tamil Nadu are on strike
ner^e’
r,
against
commercialisation
of of
'
! against
commercialisation
Prolessor D. Banerji of the I medical education; student I
Jawaharlal
Nehru “Starting
University
in Andhra have
challenged
put it succinctly;
ashas
an I| groups
the AP Government
order
through !I
put it succinctly; “Starting as an
Ar>^------------ ”
public Interest; students in ‘
inward looking, market-domi­
nated, technology-oriented insti­ I Karnataka have been holding I
tution, a hospital opens itself to | anticapitation fees rallies show- I
the community, to respond to its I
1116 younger generation I
• still have a commitment to social j
requirements, bringing about the I
Doc- I
necessary reorientation in its I' tors and professional
associations •I
technology, organisation and man­ | have mostly either stayed quiet or |
agement. ” How many of our hospi­ | at best made fervent pleas i
tals are ready for this challenge ? . through letters for privatisation
Ravi Narayan
' of medical education Justifying I
____________ I ‘capitation fees’ in various |
Ravi Narayan is the co-ordlnator for I arguments.(SCAM positive)
j
the Society for Community Health |
°n which side are you going to .
*
—
.
stand c
Awareness Research & Action and & •
Ravi Narayan I
regular columinst for CMJI.

i

P~S=£

The Health Advocate
looks forward to receiving
letters from you on the
issues raised in the col­
umn. You may disagree
with me
which is most
^elcome-butwe would
e to know why. You may
^gree with me which is
so okay, we would still
t0
why.

So doTpCteJs no dialo£ue-

ct0f3
°n dd'l

4

I

Vour
down to putting
Wait^0Ughts on PaPerin anticipation.

'L
!

8

JJ
■

9

I

■

fc> I HP

NGOs AND THE GOVERNMENT

Working Together
Dear Friends,
not heralded by much fanfare by
The Government has recently the voluntary or ‘mission’ sector.
announced its intention of review­ However, a decade has passed
ing the National Health Policy enun­ since the policy was outlined.
ciated in 1982. This policy docuA time has come to examine
mentwas significant in many ways, whether this has been ‘populist
It was the first time in post-Inde- rhetoric’, ‘pious resolution’ or ‘re­
pendent history that the country alistic partnership’ at the local,
outlined its hopes and aspirations regional and national level.
in health and health care with
This is the right time to look at
some clarity and in some detail. It this proposition seriously and to
was also the first time that a policy assess whether it has been an
document was self-critical and ac- opportunity or a threat,
knowledged some of the failures
Some issues and questions that
and shortcomings of our health come to my mind, which the CMAI
membership and the CMJIreader­
care deliveiy system and policy.
However, for a group like CMAI ship could reflect on, are:
and its membership, the docu- fl How successful has the volun­
ment was particularly relevant, tary (including ‘mission’) sector
since it recognised the active part- been in receiving organised, logisnership of voluntary agencies in tic and financial support from the
the challenging tasks ahead — Government to invest in curative
towards the goals of Health For All. and health field services as promVoluntary agencies, including ised in the 1982 policy document?
mission hospitals, had played a ■ IftheNGO-Govemment collabo­
role in health care in pre-Indepen­ ration has not been a successful
dence times but, in the first three experience, has this been due to :
decades after Independence the ✓ the lack of attempt by this sector
linkage between them and the gov- to tap the tax-payers’ money for its
emmenthealth service could prob- effort, since it has continued to
ably best be described as ‘peaceful have access to a steady infusion of
co-existence’. Each worked within ‘foreign donations’ to meet its re­
its own framework and there was quirements;
occasional dialogue, some com­ / any bias or prejudice on the part
munication, sometimes even local of the authorities who suspect the
competition, but very little active ‘voluntary sector’ of hidden mo­
tives, or consider it no longer as
collaboration.
The policy statement of 1982 ‘voluntary’ as it claims to be?
perceived a rather different sce­ ■ If the NGO -Government collabonario. The 19-page document was ration has been successful
interspersed with references to ✓ has this success been at local or
voluntary agencies/NGOs and regional or national level?
suggested various ways in which ✓ has this success been at the cost
this collaboration between the two of ‘values’ being sacrificed to the
sectors could take place.
demands of‘corruption’ and ‘leakHavlng been used to over three ages’ that are in the system?
decades of non-interest and non­ ✓ has this success led to a reduc­
interference by the Government, tion in the reliance on ‘foreign
these new policy statements were infusions’ since the Government

has become an ‘alternate’ and ‘de­
pendable’ source?
■ Does the ‘voluntary sector’ see

National Health
Policy, 1982
■ There are a large number of
private, voluntary organ­
isations active in the health
field all over the country. Their
services and support would
require to be utilised and
intermeshed with governmen­
tal efforts, in an integrated
manner...
■ With a view to reducing
governmental expenditure
and fully utilising untapped
resources, many planned
programmes may be devised,
related to the local require­
ments and potentials, to en­
courage the establishment of
practice by private medical
professionals, increased in­
vestment by non-govemmental agencies in establishing
curative centres and by offer­
ing organised logistical, finan­
cial and technical support to
voluntary agencies active in
the health field...
■ Organised effort would re­
quire to be made to fully utilise
and assist in the enlarge­
ment of the . services being
provided by private voluntary
organisations active in the
health field. In this context,
planning, encouragement and
support would also require to
be afforded to fresh voluntary
efforts, specially those which
seek to serve the needs of the
rural areas and also the ur­
ban slums...

10

CMJI

C'^J'b c=,c^"

'^c-c-'

I

THE HEALTH ADVOCATE

i

the increasing realisation, in policy
documents, of the need for Gov­
ernment-voluntary agency collabo­
ration, as a threat to their au­
tonomy, style of functioning, inde­
pendence, or belief systems?
Or do they see it as an opportu­
nity, a welcome, supportive part­
nership, an encouragement, and a
recognition of their efforts?
H Some broader issues have also
emerged in the debates that have
been recently stimulated.
Js the Government consciously
trying to blur the difference be­
tween the voluntary sector or the
mission sector (non-profit sector)
with the private sector (profit sec­
tor) by using the term NGOs for
both collectively, rather than sepa­
rately use the more meaningful
term ‘voluntary agencies’?
*r I las the Government purposely

■

We invite you to help us document your experiences of
NGO-Goveminent collaboration in the following areas:
1. How much financial assistance has your institution received
from the Government (State and Central) since 1982? For
what projects?In retrospect, has this assistance been benefi­
cial or not?
2. Do you receive regular information about government
schemes? Have you used government schemes?^
3. Do you get drugs or other supplies from the Government?
If so what?
4. Have government personnel participated in your training
programmes?
5. Have you experience of the Government delegating either a
geographical area or a particular activity to your NGO? What
has been your experience?
Editor
focused on voluntary agencies only
as ‘alternative service providers’
rather than as 'alternative trainers, alternative issue raisers, al-

■

WO’

Bi p i - ’

if

■

■

3^“

-

’
‘
—allot
temative policy
generators
roles the voluntary sector is
vwhich
------------------beginning to play?
Is the motivation for increasing
partnership with voluntary agen­
cies truly a recognition — in plan­
ning circles — of their potential or
contribution or is it at the behest
or compulsion of the bilateral or
multilateral international aid agen­
cies who see them as more amen­
able to their game plans ?
In the 1980s this policy led at
least to the Government’s recogni­
tion of NGOs as alternative service
providers and the NGOs recog­
nising the Government as an alter­
native funder. Can collaboration
in the Health For All Strategy in the
1990s mean more than this ?
As we enter the last 100 months
for achieving Health For All by
2000 AD, a time has come for the
‘mission sector’ to seriously reflect
on the options and be actively
involved in the emerging debates
and dialogue on the evolving part­
nership between the Government
and the voluntary sector. Are we
gearing up for the task ?
Dr Ravi Narayan

- *** ,
CMJI

•

Dr Ravi Narayan is the co-ordinator for the Soci­
ety for Community Health Awareness Research
and Action and a regular columnist for CMJI.

11

Robbing?)';;'
Deor Friends,
Dr Paul’s letter in an earlier
CMJI (Vol 7, Number 3, July-Sep­
tember 1992) was a very welcome
response to my reflections on the
question “Will there be mission
hospitals in 2000 AD?" I apprecia ted the very relevant steps which
hospital was taking to get beyond the looming crisis, so that
they could continue to serve all
those for whom the mission hospi­
tal was set up in the first place.
However, the last line of his let­
ter... ‘And by attracting richer pa­
tients, more poor patients are
helped...’ set me thinking and it
also provoked this column of the
Health Advocate.

Robbing Peter to pay Paul — has
it helped?
All mission hospitals without
exception were started by their
Inspired founders to reach medi­
cal care to those sections of society
that were not being served by the
available services of their times.
sported by large grants from
iw<eign missions and regular infu­
sions of donated drugs and hospi­
tal technology, they managed to
reach hospital care to many who
would have been denied this ser­
vice as they could not pay.
For long, the ‘mission economy’
managed to beat the market econo­
my’ that operated in the wider
world around it. However, as times
changed and these foreign infusi ons’dwindled, due to a variety of
factors, local mission hospital man­
agements were forced to explore
alternative methods to make bud­
gets balance. Tapping local re­
sources became imperative.
The most popular initiative was
8

/ -J

There are more and more Pauls
in the general ward (whichi are no
longer free but include part-payment) who have to pay more than
they can afford leading to greater
indebtedness, social stress and
family crisis.
The Peters, belonging to more
literate and demanding sections of
the society, are constantly press­
urising hospital leadership and
staff to provide better services,
greater variety of facilities and more
luxuries in the pay-wards, so that
the subsidy factor for the Pauls
has drastically reduced now. Most
of the pay-ward cost recovery gets
reinvested in pay ward facilities.
Not surprising when you find
coarse cotton sheets in the general
nursery and terrycot kiddy cloth
in the pay-ward ones
□The Peters make greater demands
on the time and skill of the hospital
staff, which is not at all surprising
Patients in private
since we health professionals re­
late more easily to the growing
wards are charged at
.middle class elite who constitute
rates that help to
the pay-ward patients.
Many Junior staff complain that
subsidise the cost of
the seniors are more pre-occupied
treatment in the
with the neurotic demands of the
general wards
paying Peters while they are left to
manage the life and death crises of
the Pauls in the general ward.
Gradually as general wards beThe growing dilemmas have
been shared by health administra- gin to look duller and shabbier due
tors and hospital staff over and to constraints in maintenance
over again in our interactions. What funds, the Peters wards grow in
are these dilemmas?
cosmetic embellishments in com□ Over the years the number of petitlonwlth the for-profit private
poor and indigent patients being sector. The glamour of technology
cared for by mission hospitals has and super-speciality also begins
come down drastically. While ser­ to creep in.
As the profit margins from services to Peters have increased,
Pauls find it increasingly difficult vices to Peters are Increased, the
to avail of the same.
staff of the hospital are motivated

the adaptation of the Robin Hood
principle — robbing Peter, the rich
man, to
I pay for the^nedical care of
Paul, the poor man.
The tradition of pay-wards and
private wards was introduced and
Peters in these wards were charged
for services at rates that helped to
subsidise the cost of Pauls in the
general ward. For some years the
proposition had a very effective
response. The mission economy
beat the market economy once
again! But not for long.
A review of mission hospital experience and realities currently
highlight a new development. The
paying ward introduced as a relevant move, towards self-suffi­
ciency and sustainability, stimulated the market economy forces
leading to surprising results.

CMJI

t

HEALTH ADVOCATE
managers ol mission hospitals all schemes, friends schemes — so
over the country are experiment­ that the subsidies for the Pauls
ing to stay with the mission come from a multi-pronged strateconomy rather than surrender to egy of tapping community sources
the market economy. Scattered and resources.
examples of creative initiatives ★ Mission institutions changing
abound. In my travels, I have dis­ the western cultural embellish­
covered at least four propositions ments that have crept into the
hospital culture which increase
on trial.
★ Mission institutions trying not to costs of services and facilities and
discriminate in quality of services instead bringing them more in line
between Peters and Pauls, at the with Indian grassroots realities.
same time encouraging Peters to For example, one hospital in Tamil
pay for Pauls as well (Dr Nadu got rid of all the hospital
Jesudasan’s experiment CMJI, Vol beds and decreased overall mainte7, No 3, Page 25).
nance costs, recognising that all
★ Mission institutions exploring their patients anyway slept on mats
financial support by methods other at home, be they Peters or Pauls.
than payment for services — for ★ Mission institutions introducing
.
____
example,
insurance
schemes. a rational drug technology and
cooperatives, health funds, bank investigation policy in their hospitals to cut costs and to use avail­
able resources more efficiently so
that more Pauls could be treated
without subsidies from Peter.
I believe Robin Hood of Sherwood
5INPABAP THE -SAILOR
Forest and his merry men, were
AND THE OLT)
OP TH£ SEA
successful in their efforts in rob­
Crc-vifite<!)
bing Peter to pay Paul since they
chose not to provide their services
to Peter. The mission economy has
thought otherwise. So the emerg­
ing way to make this principle
work, it seems to me, is to accept
these four new commandments:
✓ Thou shall not discriminate be­
tween Peter and Paul
Z)
we veACh there/
' I/\ /
-.-avid
✓ Thou shalt look beyond Peter’s
/
I
—
fvvu-ru
if
IDCTCnl
1
purse
✓ Thou shalt adapt hospital cul­
ture to the realities of Paul and not
the whims of Peter
✓ Thou shalt investigate, inter­
vene and treat both Peter and Paul
rationally.
Maybe accepting these com­
mandments will give the mission
economy another chance.

overtly and covertly to prescribe
more, investigate more, intervene
more and even visit more — lead­
ing, not surprisingly, to a culture
of over-investigation, over-pre­
scription, with its resultant
iatrogenesis.
□ Gradually, as all aspects of the
growing dilemma set in, the mar­
ket economy wins the battle over
the mission economy. While Pe­
ters feel robbed and get more
iatrogenesis, Pauls find it more
difficult to avail of the services.
Conclusion: It does not pay to
rob Peter for the needs of Paul in
the long run.
A question that has been put to
me persistently about this result
is — is it inevitable?
1 believe that it isn’t. Crisis

ft

Jin

Dr Ravi Narayan

HE

Dr Ravi Narayan is the coordinator for
the Society For Community Health Aware­
ness Research and Action, and a regular
columnist for CMJI.

aaarketj
MISSION HOSPHAL-

CMJI

9

I

I

I

-

I

/icCw^caite V i
7

The "Virus" Of Communalism:
What Will Be Our Response?

igoediit of
d to
the
. ac■ther
)me.
ique
;ing.
ig is
ince,
rying
ity to
em/,but
$ who
2aste,
scale
cases
*n not |
rwork

In Germany, the Nazis came first
for the communists and
I did not speak up because I was
not a communist.
Then they came for the Jews
and I did not speak because I
was not a Jew.
Then they came for the trade
unions, and I did not speak up
because I was not a trade
unionist.
Then they came for the Catho­
lics, and I was a Protestant and
so I did not speak up.
Then they came for me, and by
that time there was no one left to
speak for any one.
Martin Niemoller (1892-1984)

is.

)O

a
^rd
■

ed

?r

cMJ11

Apvil--jMY>e \^°\3

HEALTH ADVOCAl E

j
In the last few months, we.have
witnessed the re-emergence <rfa
narticularly virulent form of an old
the virus' of communaitom, with explosive outbreaks a 1
over the country. The recent ep demic even reached pandemic di­
mensions , spreading rapidly to our
immediate neighbours
Middle East and finally^aUUae
wav to the UK as well. Bom nay,
among the most cosmopolitan of
Xur metropolises, also^suffered
a particularly vicious attack the
acute phase of which lasted for

j

“^Sinceindependence, this virus'
has been localised to a ew■
innocent victims of these
-demic pockets lowing sporadic
tacts
outbreaks. However, in recen
It thrives in urban pockets Par
vears, it has seen a re emeJfg
larlv m over-crowded slums,
with greater severity, and the
- Meeting young people, who are
cember-January outbreaks h
nre-disposed towards violence due
proved beyond doubt that the viru- P^ uneI^ployment, urban lumpenlkmt‘virus’ is going to be with u
While males
a long, long time.
usually affected, the recen
Much histime.^
been written about ar^usual
recent
episode
I towards female
this viru
__ weeks
r,f its and
dtetobing
trend
months but our knowledge of its
affliction as well.
□ The virus’ thrives in an

i n- V '

11

Is'

Iit

It is the darkest night that
prepare the greatest dawns.
Sri Aurobindo

_____ __— I I

10

■

reflected on what we are going to |
do - each of us as 4ndiv4d^’ 1
each of us as members of an insU |
Stion and all of us as members of fe g
anconal network, invoked wUh ®|
^health of the peopk^at^K

unchecked by------ Q«‘nmild
health action, this virus couM oart of the century, similar epi
well prove to be the greatest threat Si °L.e keen .een !„ lr»
to the physical, mental and social recently, and in some states ot
well-being of the Indian peopfe RusTia'and parts of eastern Euthat we have had to face in the last
r0^1eSmMt disconcerting
feWFor e^mple. it is now relatively
of the available epidemiological evi
well-established that

people, especially the young, and
makes them indulge in
toted acts of violence, especiaHy
directed towards ‘"nocent and
defenceless
defenceless people
people of
ofcommuniti
and faiths perceived as dlfferen
d4^"
from their own. Epidemics
th
EP4^"1109.^
"
create the double burden not only
affected youth, but

h

Ii

✓ We could get im---£
Ls between
I
building effor
efforts
between
W1h.
munities of all faiths anu^
.
------ , efforts
using educational
formal and non-formal.
dia^
We could initiate coUecbve M
togues to build new atbto J
ffLid^pect^tweendiffl

mosity and unhealthy

hcle
distrust, anxiety,
y
deep antipathy.
6
should be adequate evi
apnce to iolt us out of our usual
,Jd it is time we sat up and

reorientation of our educ

g

system.
would
I'S
By
. onnd|
By doing
doing this,
this. we
helped to create an envi

i

E

HEALTH ADVOCATE

If left unchecked by con­
certed public health action,
this ‘virus' could well prove
to be the greatest threat to
the physical, mental and
social well-being of the
Indian people

KM
that immunises minds against the
effects of this ’virus’.
Our efforts would have been
focussed on primary prevention,
that
that is, health promotion and spe­
cific protection. We could get in/ns.
volved in pastoral and counselling I
ndo
level
initiatives at the community level,
reaching out to affected communi­
ties of patients and victims, providing a
------”
'hand to the
ng to
~ .su
PPorfing
devastated; couragelo the affected! .. .
uals,
ins ti­
comfort to the distressed, and vari­
ous other supportive services that
ers of
would help families and commu­
I with
nities to come to terms with the ; . ___
at will
crisis and get beyond it. Our eferadi| forts would have been focussedI on
However, there is still another
possi- |j secondary prevention, that is,, on type of response, which seems to
I early diagnosis and treatment.
be unfortunately and inexplicably
brid£e I
COuld £et lnvolved in the
more popular than the alternative
com- L .active provision of the palliative’ outlined above. It is a i
response
iltures 1 and patch up’ services that our characterised by the combination
-both ®||*nstitutions are now fairly re- of the following types of reactions:
| ^ovnied for, all over the country,
• 'This is none of my business!
Lve dia- Jt ^’^ing out to victims ofthe acute • It does not affect me or my
itudes. liS
I
deniics’we could provide holis- community!
reasin^ iT
care — primarily curative, but • I do not have time to do much,
t differae™ atjnosphere of concern and because I am so busy!
eff CC sensitivity. Our • 1 have neither the skill nor the
^g^orts would then have been fo- inclination!
ce,
*reotyP'
S OH the
'Ability limitation and reha- • Inere are people better quali­
hevah* [! r^'io
^vZ'1’ A" ,b<‘ three levels of fied and skilled to deal with it!
cation! fftbltck °n
t^le sheet anchor of • It is only a passing aberration!
th?
101
^e
urgently required
It is this response that allowed
lld bav<; ?dth,
era e 'Challenge is getting great- the virus’ of casteism to strike
roninefJ O y by day.
deep roots in the country. It is the

s

istt..

I■«X2!!S‘£I :
a

I

same response that allowed Na­
____
_ devastate Europe in the
zism to
early part of this centurv
J. It is the
same response that allowed apartheid to affect the mental health of
generations of South Africans. It is
the same response that for .gen­
erations, and through the centu­
ries, has allowed man’s brutality
against man.
What will be our response?
Healer and Samaritan or pharisee
and levite? The choice will face us
squarely in the days ahead.
Dr Ravi Narayan

Dr Ravi Narayan is the coordinator for the
Society for Community Health Aware­
ness Research and Action, and a regular
columnist for CMJI.

11

B

i

HR. II I M fl vn
•5

DRUG PUSHER OR HEALER
V/hai are you ?
♦ DR RAVI NARAYAN ♦

The commercialisation of the medical system today has led to
many doctors overprescribing costly drugs
or recommending unnecessary tests, even within the voluntary
came up with an assessment of the reais- health care sector. This article raises some questions to
fl N 1980, THE ICSSR-ICMR ‘HEALTH
For All’ study group re­
viewed the drug and
pharmaceuticals situation in India and
s and a clear warning against the overmedicalising of the health system. They
identified the doctor-drug producer axis
as the major villain and the prescribing
practices of doctors as the key culprit.
Two years later, at an MFC meeting, I
had raised 10 questions, as a kind of
checklist for participants, helping them
to decide whether they or their health
institutions could be classified as ‘drug
pushers’ or ‘healers’ (rational prescribers).
A decade later, I discover that those
questions are still relevant. What is even
more disconcerting is that even within
the voluntary sector of health care, drug
pushers still far outnumber the healers.
This is particularly shocking since much
has been done since the early 1980s to
tackle the situation:
) the evolution of the All India Action
Network;
® the publication of banned and
bannable drug lists;
® the outlining of rational formularies
(the CHAI-CMAI formulary is a case in
point);
® numerous workshops
on the theme and innu­
merable books, booklets,
bulletins and handouts;

■-CT
❖ Dr Ravi Narayan is
the Coordinator for the
Society for Community
Health Awareness
Research and Action,
and a regular columnist
for CMJI.

12

differentiate the drug pushers from the healers
9 public interest litigation to control abound in the market today?
irrationalities in the drug situation.
□ Have you accepted the concept of
The questions, some of them reworded generic prescribing to prevent ‘misuse’
in today’s context, are:
*•- and‘misinformation’by pharmaceutical
□ Have you accepted the concept of an companies on brand specialities, formu­
essential, selected, restricted drug list in lations and bio-availability claims ?
your practice to help select efficacious, □ Have you stopped prescribing drugs
safe and good quality low-cost drugs whose only additional advertised value is
from the over 60,000 formulations that — a cosmetic embellishment, for ex­

ISfllSi
5“-

■
‘

- h

hl

* A fcfi

If
r® J

HEALTH ADVOCATE

MMV

>00 KNOhf

NUMIBCJI ONE

pro&le-m !H
|
KAriQN\L TMERAPy^l

rr^f

apathy
* i
aka
>

i

sor/m

* I'—

ample, a special flavour; elegant packing
for example, a nice container; or an
irrational combination?
□ Have you stopped promoting ‘tonics’
whose only present value is the vitaminising effect on our sewage systems? Do
you accept that what the poor need is
food and what the rich need is health
education to prevent overeating?
□ Do you have a policy against accept­
ing physician’s samples and other forms
of inducement, both refined and blatant,
from medical companies, including un­
ethical trade discounts and offers?
□ Do you propagate simple home rem­
edies, home-based preparations, phar­
macy-based low-cost preparations and
even locally available herbal remedies
that are not totally integrated with the
‘market economy’? Have you closed all

your efforts at the local ‘cottage
industry’?
□ Does your health centre prac­
tice also offer people various forms
of non-drug therapies, including
holistic health, counselling and car­
ing techniques?
□ Does your select ion of drugs for
prescribing depend on rational is­
sues like management practices; .
costing rationale, standardisation
and so on, and not, by the craze for
'phorerimultinational, private and large
companies, or the equally irrational em­
phasis on the lowest priced drug in the
market?
□ Have you stopped having a ‘colonial
western, ethnocentric’ policy towards
alternative systems and therapies and
adopted a more open policy of enquiry

Aspects of Over-medicalising
♦ Vigilance is required to ensure that
the health care system does not get
medicalised, that the doctor-drug pro­
ducer axis does not exploit the people
and the abundance of drugs does not
become a vested interest in ill health.
♦ One of the most distressing as­
pects of the present health situation in
India is the habit of doctors to over­
prescribe glamorous and costly drugs
with limited medical potential. It is
also unfortunate that drug producers
always try to push doctors into using
their products by all means — fair or
foul. These are responsible for distorCMJI

lions in drug production and con­
sumption more than anything else.
♦ There is now an. over-production
ofdrugs (often very costly ones) meant
for the rich and well-to-do, while the
drugs needed by the poor people
(and these must be cheap) are not
adequately available. This skewed pat­
tern of drug production is in keeping
with our inequitable social structure
which stresses the production ofluxury
goods for the rich at the cost of the
basic needs of the poor.
Health for All: An Alternative Strategy,
ICSSR-ICMR Study Group 1981

Li
■ j

here are two types of
physicians — those who
promote life and attack
diseases; those who promote
diseases and attack life
Cbaraka Samhiia

and evaluation to use traditional medi­
cines and other therapies in a plural
practice?
□ In spite of your preoccupation with
medical care, do you promote:
★ Clean water rather than antibiotics?
★ Food rather than pills?
★ Immunisation rather than high-tech
diagnostics?
★ Mothers’ milk rather than manufac­
tured infant foods?
★ Primary- health care rather than ter­
tiary super-speciality?
★ Health rather than medicine?
The answers to these questions may
help you determine what you really are:
a drug pusher or healer (rational pre­
scriber). If you have 10 affirmative an­
swers, then you are the model CMA1
member for 2000 AD. If you have 10
negative ones, it is perhaps time to stop
paying your CMA1 membership since you
now qualify for the membership of the
ever-expanding ‘MMC’ — ‘Medical Mar­
keting Club’.
If you are somewhere in the middle, it
is time to sit up and reflect collecnx ely in
your group. What would you like to be —
drug pusher, or healer?
13

C^p-

iN

Vi'x

Overcoming
New Challenges
j

DR RAVI NARAYAN ♦

h

| NTHFJULY-SEPTEMBER ISSUE OF
;
CMJI, 1 read an obituary
2S
of Dr Denis Burkitt, a
I famous mission hospital doctor and medih| cal researcher from Africa, who, for many
I years, directed the Medical Research
se
I Council of the UK and promoted a re­
Hd
ft blinking in the focus of medical research
ny
1 - from a preoccupation with * intracell u■1 lar research’ to a new commitment to
1- ‘behavioural and societal research’. His
leona- j I own exploration of the aetiology of what
a small j I is well-known as ‘Burkitt’s Lymphoma’
e their
B and later, his participation in establishing
fathers |«he relationship between the western,
when a” low fibre, processed diet and the diseases
ispital’s | |of‘civilisation’ (which included diverse
jreitto I | conditions such as diverticulosis,
<”
intesti|.nal cancer, varicose veins and heart dishe hos- | pse), was significant to this new vision.
ling the I | As a young postgraduate student of
licy. An j [Public health in 1973,1 had the opportucn leave
pty fa listen to Dr Burkitt’s lecture on
uidoned ’a w hire directions and challenges in rel^h’. The core of this lecture was an
F off‘ce,3 l^poriant question he presented to all of
to w ork- J
luy0Un8SlerS’ aS a cha,lenge our
e mobii®
vocation. This question has been a
the s'teS‘O
stimulus to me for the last 20 years,
faerstandlj
me explore a new meaning for
irQen can 1
eof the doctor and a new vision for
.-t.Anob'J jg^lth ministry. In memory of this late
)reas(f^| rWuh’ ProPhet’ I share this question
pportan31
( ^readers of
using an illustrawhich he used in that

jets

oubnl

Are the healers in the ministry ready to
become tap turners-off or are they going
to continue to ‘floor mop’ in the old
tradition, getting distracted and carried
away by the glistening versions of floor
summer of the year 1973.
mops being produced by the multina­
Imagine a room with a wash basin. On tional medical industry today?
entering the room, you find that water is
For many in the ministry, this question
pouring out of the tap, the sink is over­ will be a very disturbing one as it was for
flowing and there is a mess on the floor. me 20 years ago. Brought upon the white
What would your first response be to coal, stethoscope and Pavlonian pre­
tackle the situation? Will you be a floor- scribing reflexology of orthodox medi­
mopper or a tap tumer-ofl?
cine, I failed to understand what tap
The medical and nursing profession turning-off meant and its relevance to the
have long been floor-moppers, using medical vocation, when 1 first heard
drugs and teclinology to floor-mop the about this idea. Today, two decades later,
overflow of illnesses and disabilities in
1 have become a little wiser.
the community. With the knowledge of
The floor-mopper in me had stressed
preventive medicine being limited, this the relevance of coronary care units and
seemed the most logical response and promoted coronary bypass surgery, till
therefore, the clinically-oriented drug­ the lap turner-off in me took over to
technology-dispensary-hospital-oriented promote exercise, cycling, diet modifica­
healing ministry developed.
tion, reduction in smoking and various
As we reach the end of the millen­ other lifestyle changes.
nium, medical knowledge has grown and
The floor-mopper in me had stressed
our knowledge of diseases has also im­ trauma surgery and neurosurgical care as
proved greatly. Many more of the pre­ a response to the increasing epidemic of
ventable causes of illness are known and accidents till the tap turner-off in me took
tap-tuming-off skills developed to vary­ over to promote road safety, occupa­
ing levels of competence.
tional hygiene, helmets and belts.

Are jou a floor moppera

or

a tap turner off ?

NaraVan is the
I ^rbmiinL°r for the Society for
health Awareness
I ^ni^001 Act,on> and a regular

1^1

MB

I

°r CMJI
ocA; - jxo-

11

HEALTH ADVOCATE

Ir

I'i
r
E ■

|

f

ii

il
Hi
• I-!
T§ II

I

II

The floor mopper in me had pro­
moted vitamins — pills, tonics, enriched
and fortified foods in response to the
continuing problem of malnutrition — till
the tap turner-off in me took over to
promote low-cost, local food mixes, veg­
etable gardens and efforts to make our
institutions more baby-friendly!
The floor-mopper in me had stressed
intravenous fluids and antidiarrhoeals for
the treatment of childhood diarrhoea till
the lap tumer-off in me took over to
promote home-based ORT, clean water
and environmental sanitation.
As a medical college teacher for a
decade (1973-83), and as a community
health trainer in the next decade (198493), I discovered an additional challenge
in Prof Burkitt’s question. Could educa­
tion of the health team geared to the
floor-mopping tradition of orthodox medi­
cine be reoriented to the lap turning-off
challengesarising out of the new medical
knowledge of today? Was socially rel­
evant and community-oriented educa­
tion of such a health team possible?
Today, two decades after hearing that
disturbing question, I can unrepentantly
affirm that floor-moppers among us can
become tap tumers-off. But floor-moppers
need a new understanding of medicine
— a ‘conversion’ if you please.
This new vision calls for a paradigm
shift in our thinking — a shift to a new
people/community-centred, pro-life, ho­
listic health programme promoting
people’s empowerment, behavioural and
societal processes, and creating autonomy
and awareness-building.
The Vatican Cor 11num document on
the new orientation to health care calls us
to ‘a true conversion of our hearts and
also of our methods’.
The Christian Medical Commission
study on ‘Health and wholeness: the
Christian role in health’ emphasises the
same need for conversion in a different
way. Its study recognises a simple fact:
“From around the globe, the 10 re­
gional grassroots consultations on Health,

12

THE NEW DOCTOR
The new doctor will consider his or
her service as an agent of social im­
provement. So he or she will under­
stand and be aware of the social and
ethical foundations of medicine.
The new doctor will be conversant
not only in the language of science but
in the language of the people as well.
He will be comfortable with people
from all walks of life — not only in
doctor-patient relationships but in so­
cial relationships as well.
The new doctor will not be afraid
to act on evidence that is available J,.?'
today and will not only know how to^g
do things, but why.
The new doctor will be aware that
the patient and nature are the ingredi­
ents, not merely the medium, of ex­
pression of technique. He will regard
natural supports of health, such as the
• family, as having supreme importance
in the healing process.
The new doctor will treat the whole
person in the context of the family as
well as the religious and social system.
The new doctor will heal with
himself and prescribe himself in gen­
erous doses: meaning that he or she
will use all resources of personality
and human caring possible.
The new doctor’s use of guilt will
motivate people to healthy habits rather
than frustration and fear.
The new doctor’s honesty will ex­
tend to denying modem medicine’s

1 lealing and Wholeness’ wove a tapestry
depicting their understanding of health.
The major recurrent thread throughout
that fabric is the fact that health is not
primarily medical. Although the 'health
industry’ is producing and using progres­
sively sophisticated and expensive tech­
nology , the increasingly obvious fact is
that most of the world’s health problems

I

'll
■>1

w fl
mythical claim that everything can be J
cured, and no matter how you messi
yourself up, the skills of the doctor can j
put you back together.
The new doctor will be knowl-j
edgeable in unorthodox methods of1
treating diseases, including nutritionalfl

therapy, acupuncture, kinesiology,!
chiropractice, homoeopathy, etc. |
The new doctor will protect pa-j
tients against excesses by specialists^
The new' doctor will be conimitt^M
not only to putting the specialists out 1
of business, but to putting himself
of business as well.
Robert S. Mendelsohn,
Confessions ofa Medical 1

cannot be best addressed in
T wenty years ago, I was ask J
question: Are you a floor-mopper0fB|
turner otP Today, the question 1 W
like to put to you for serious refl1-111 .
Can the healing ministers continu^M
floor-mo[)pers when they are I?eing
nged to become tap turners-of •
ready for this conversion?

No. 9

What Will Prevail: Science Or Prejudice?

Integrating Medical Systems
❖ DR RAVI NARAYAN ♦

A

MS A POSTGRADUATE AT THE ALL
India Institute of Medical
Sciences (AIIMS), New
Delhi in 1977, I chanced upon an an­
nouncement ofa workshop on‘Ayurvedic
concepts and nomenclature’, being
organised by the Advisor to the Govern­
ment of India on indigenous systems of
medicine. Some of us thought that it
would be an excellent opportunity to
explore an area that our undergraduate
and postgraduate studies, based on
modern scientific medicine, had ignored.
To our surprise, all the other participants
turned out to lx? pharmacology profes­
7^3 ndia has a rich historical
sors and researchers from American uni­
diversity of medicine. We
versities. Not a single Indian professor or
must integrate all that is
researcher, including from the host insti­
tution, had cared to participate!
' I best from every system:
The excellent discussion, for instance
ayurveda, naturopathy,
an exposition of the Tridosba concept —
unani, homeopathy and
vatta, pitta and kapha — and the prin­
Tibetan
medicine
ciple of balance, were very thought­
provoking. However, the absence of lo­
cal professors and researchers was very begin to take- our own plural medical
disturbing. Had the glamour of* western’ inheritance seriously,
medicine so mesmerised us that we were
The diversity and plurality of medinot ready to explore the science of ideas cine in India is a historical fact. A WHO
from our own heritage, that which was so report in 1983, quoting Government of
integral to our history’ and culture? Or India sources, estimated that this pluralwas it inevitable that, as in most aspects ity was symbolised by the presence of 8
of scientific and technological develop- lakli practitioners of which only 2 lakh
ment in our country, the medical profes- were allopaths; eight systems of medision in India was awaiting a Textbook of cine — ayurveda,
ayurveda. siddha, yoga,
A ncient Indian Medicine, by a collective naturopathy, unani, homeopathy and
of American professors and published by Tibetan medicine and allopathy; 108 un­
McGraw Hill or Wiley, before we would
dergraduate training institutes, fwo post’
graduate training institutes, 21 postgradu❖ Dr Ravi Narayan is the
ate departments and one university in the
Coordinator for the Society for
other
systems; 215 hospitals and 14,000
Community Health Awareness
dispensaries offering services of other
Research and Action, and a regular
columnist for CMJI.
systems, four central councils of training
■

12

and research to determine standards; and
50 institutes and 200 research units un­
dertaking research in these systems. To­
day, a decade after this report, the quan­
titative and qualitative situation of this
plurality must be much richer.
The historical prejudice of the pro­
moters and practitioners of allopathic
medicine in India is also an indisputable
fact. In 1833. a committee appointed by
Lord William Bentinck opined that all
medical teaching in India be on “the
principles and practice of medical sci­
ence in strict accordance with the mode
adopted in Europe”. One hundred and
sixty years later, the situation has not
changed, and the brown sahehs who
dominate our medical colleges, professional associations and health care institutions, have remained faithful to this
dictat. The mission health sector is no
exception to this rule.
The prejudice of professionals trained
in ‘modem western scientific medicine’
towards till the other systems that do not
come in American or British ‘packages’ is
more symbolic of the ‘cultural colonial­
ism’ of the transplanted medicine rather
CMJI

HEALTH ADVOCATE

Towards A National
System Of Medicine
np HE COUNTRY HAS AIARGE
i slock of health manpower
comprising private practitioners in
various systems ... This resource
has, so far, not been adequately
utilised. 'Hie practitioners of these
various systems enjoy high local
acceptance and respect and, con­
sequently, exert considerable in­
fluence on health beliefs and prac­
tices. It is therefore necessary to
enable each of these various sys­
tems of medicine and health care
to develop in accordance with its
genius. Simultaneously, planned
efforts should also be made to
dovetail the functioning of the prac­
titioners of these various systems
and integrate their services al the
appropriate levels, within speci­
fied areas of responsibility and func­
tioning in the overall health care
delivery system, specially in regard
to the preventive, promolive and
public health objectives. Well-con­
sidered steps would also require to
be launched to move tow-ards a
meaningful and phased integra­
tion of the indigenous and the
modern system ...
National Health Policy, 1982-83

than its scientific ethos. How
else can one explain the fact
that the majority of care-provid­
ers within our network regard
other systems with disinterest,
apathy and often hostility. Many
club the alternate systems of
medicine under ‘traditional su­
perstition’ and as an ‘inferior
health culture’ waiting to be
transplanted by a better, ‘super
system’.
A tmly scientific approach to
medicine would require us to
CMJI

have a rational, open attitude to accept­ mies and CCU’s, all of which are yet to
ing ideas from ‘modern’ or ‘traditional’ prove their efficiency, on rigorous scien­
systems that have proven to be effective, tific review.
on the basis of scientific enquiry. Such an
Are we ready for this open altitude to
attitude, free of professional or cultural all systems of medicine including our
prejudice, would be willing to accept:
own? Will we promote the integration of
® garlic and Bengal gram as protection all that is lx?st from every system and
against heart disease;
tradition, and weed out all that is not of
O salt water gargles, steam inhalations proven value?
and yogic breathing exercises as belter
The Shrivastava Report (1975) had
antidotes to upper respiratory’ infections recommended the “need to evolve a
than all the overused and often unneces­ national system of medicine for the coun­
sary antibiotics;
try through the development of an appro­
0 home based kanji, rich gruel or ORT priate and integrated relationship be­
as a Ixj'tter antidote to childhood diar­ tween modern and indigenous systems
rhoeas rather than the range of irrational of medicine”. Hie ICSSIVICMR Health
antidiarrhoeals available in the market For All Report (1981) has exhorted that
today or even the over-mystified intrave­ the “alternative model of health care ...
nous fluid therapy;
will strive to create a national system of
0 acupressure, homeopathy and acu­ medicine by giving support to synthesising
puncture as useful adjuncts to allopathic the indigenous systems".
practice;
What will be the contribution of the
0 the need to depromote irrational in- mission health sector to this goal?
In the 1990s, non-allopathic systems
jection/lonic practice and be less enthu­
siastic alxnil episiotomies, lonsilleclo- • are getting a new lease of life. The factors
for this revival and increasing popularity
are many. There is growing disillusion­
71 any still regard alternate
ment with the excesses and hazards of
medical systems with
allopathy: there is a nationalistic revival
i
' apathy, and often
that is promoting all that is ‘old’ as gold;
the market economy has discovered the
W 8 hostility. They are
profit potential of investing in the ‘back to
clubbed together as
nature and tradition’ fad; there is the
superstition or inferior
(misplaced) economic common sense
health systems
which promotes other systems in the
mistaken belief that they
are necessarily cheaper;
there is the popul ist rheto­
ric that seeks to promote
such systems because
they are more acceptable
2
A
to the people. Much of
4$
what is going on is either
populist politics or the
forces of ‘market’ or tra­
dition’.
What will be our atti­
tude? What will be our
policy? What will prevail:
science or prejudice? 0

^4

13

(J

UPDATING THE HOSPITAL HEALTH TEAM

Are We Investing Enough?
♦ DR RAVI NARAYAN ♦

The author issues a heartfelt plea for
continuing education for medical personnel

W1

■ F YOU WERE TO CONDUCT AN IN
their company product’s role in medical
HI
formal survey in your treatment, supported amply with the para­
own hospital — big or phernalia of calendars, diaries, pens,
small, rural or urban, primary, secondary torches, stick-me-ups and other such
or tertiary care oriented — and if your ‘tabletop glitterati’ that now adorn the
findings were:
hospital clinics.
▲ That the doctors (a majority of them, at ▲ That the only continuing education
least) who were working there had not they had received, in recent years, was
gone back to a workshop, seminar or the monotonous monologues of young
professional update at a medical college aggressive medical reps, presented to
or their nearest local IMA or even a CMAI- them at weekly or fortnightly intervals,
organised one for over a decade since Hipping Hip charts and flashing flash
their graduation!
cards, full of subtle medical misinforma▲ That the only professional reading they tion about their company products that
had done was the glossy literature, hand- increased indications; soft-pedalled contraouts and newsletters provided by medical indications; suppressed caution; and discompanies full of high pressure advertis- regarded reported side-effects for the
ing of ‘tall claims’ and ‘half truths’ about sake of profit margins and sales.

W
yi

iwa

ft 4

* »’

I,

A MAJOR failure of our entire
education system, including that of
medical education, is that it is a
once-for-all phenomenon. Whether
it be the doctor, nurse or paramedi­
cal worker, there is neither the facil­
ity nor the incentive for further
education after passing the qualify­
ing examination. This leads to stag­
nation of knowledge and skill. Ex­
penditure on providing facilities and
incentives for continuous training
would be amply repaid in the im­
proved quality of services rendered.

National Education Policyfor
Health Sciences,
The Bajaj Report, 1989

▲ And that the nurses, who were mem­
bers of the hospital and health teams, had
no opportunity to refresh their knowl­
edge at all, except through:
• The routine supervisory weekly meet­
ings of their stern nursing superiors;
• The chance information of a stray
comment by a consultant, on a patient
round, as they stood at the periphery of
the circle; or
. • The occasional perusal of company
literature that was focussed more on
doctors — ‘the curbs’ — rather than
the nurses — ‘the carers’.
♦ Dr Ravi Narayan is the
coordinator of the Society for
Community Health Awareness
Research and Action, and a regular
columnist for CMJI.

CMJI

13

A^nl-

HEALTH ADVOCATE

here is no facility or
incentive for further
education after passing the
qualifying medical
examination. This leads to
stagnation of knowledge and
skill. Our investment in
continuing education of our
hospital teams is still
abysmally poor and
shockingly inadequate

▲ Some of the standard routines of treat­
ment and regimens of medication in many
departments of your hospital had long
been discarded in many other, more
updated, ethical centres of healing either
because they had been proven to have
unacceptable side-effects or to be of little
value except for their placebo effect.
▲ Your hospital had:
• No policy of continuing education of its
staff;
• No policy that promoted ‘updates in
professional knowledge’ as a preiequi­
site for promotion;
• No policy to invite resource persons for
in-house refresher sessions or orienta­
tion workshops;
• No policy of investment in a minimum
but adequate library facility with basic
journals, newsletters and recent text­
books for the use of staff;
• No regular weekly or monthly in-ser­
vice training programmes;
• No policy of membership or participa­
tion in programmes organised by pro­
fessional organisations, like IMA, CMAI,
CHAI and VHAI and the CME of CMC,
Vellore.
Would you be surprised? Would you

Would you be shocked? Would you be be shocked?
Frankly, I would not at all be surprised
surprised? What would your response be
by your findings since I am convinced
if you were to further identify via your
that the situation described above would
survey that:
be very truly representative of the; sce­
▲ All the rest of the hospital staff allied,
nario in most centres of care — mission,
who couiu
could nui
not be
para or auxiliary, wno
ia, clasi--- --------sified into the above two genera of ‘mis- private
In spite of some efforts by national
informed doctor’ or uninformed nurse —
coordinating agencies like the CMAI, VHAI
had no continuing education worth men­
and CHAI, the initiatives of some IMAs
tioning at all, except perhaps the Sunday and professional bodies, the efforts of
magazines of national newspapers or
CMC, Vellore (CME Department), and the
radio and TV jingles devoted mostly to
regular, periodic rhetoric of government
consumerist medicine.
why a particular remedy policy reports - the state of co"tl™‘n|
▲ The reason ' ,
being prescribed
abundance in
was being
prescribed in
in abundance
in education of our health care
serious embarrassment.
your hospital, had little to do with the
It has been aptly described by the
latest advances in medical knowledge
National Education Policy for Health Sci­
and more to do with unethical trade
ences as “restricted to sporadic efforts
discounts or other perks or inducements
made at undefined intervals and unspeci­
that a specific company had offered your
fied locations”.
hospital purchase section.

IN the system prevalent today, any
doctor who goes out of the system
of medical college has little oppor­
tunity to come back to update his
medical knowledge and skills; and
no facilities exist outside the system
of medical education to achieve this
objective...
In the modem world, where a
virtual explosion of knowledge is
taking place in most sciences and
the existing stock of knowledge is
being doubled every seven years or
so, a programme of continuing edu­
cation assumes immense signifi­

cance.;.
Continuing education for physi­
cians must concern itself with those
issues that are of deep significance
to the health of the community and
also with educational activities for
mixed teams of health workers. In­
ter-professional education is of criti­
cal importance for the members of
the health team to learn together
how to solve problems.
Report of the group
on Medical Education
and Support Manpower,
The Srivastava Report, 1975

Our investment in continuing educa­
tion of our hospital teams is still abysmally
poor and shockingly inadequate; in fact,
continuing education as a policy is prob• *lowestt on our hospital policy
ably the
makers’ agenda.
I believe that in 2000 AD, when we are
likely to discover that the HFA goals were
not reached, the evaluation would defi­
nitely identify the lack of continuing edu­
cation of the health team as the main
stumbling block. Are we waiting lor this
indictment? Or are we going to do some­
thing about it in the interest of patient
care, quality service and our mission? ■
CMJI

14

>

CRISIS IN SHANGRILA
EUPHORIA AT HOME

%

♦ DR RAVI NARAYAN ♦

The author takes a hard look at
the health care crisis in the Americas
■■■ RAVELS IN 1993 IN THE EAST
'
Coast of North America
(regarded for a whole
generation as the Shangrila of modern
western medicine) proved to be a rather
thought-provoking experience for me.
Having grown up in the dominant
medical culture of the Indian health ser­
vice — which believes, with an unshaken
faith, that 'tubal is goodfor New England
is good for us’ — the experience of the
growing crisis, the debates, the sobering
facts and harsh realities of medical care in
Shangrila were both, al the same time,
prophetic and disturbing!
A few snippets from the statistics, the
debates, and the public outcry will giveyou a feeling of the state-of-the art available on the East Coast today:
• The American health care budget is
$912 billion but the American health care
system is able to immunise only 50 per

cent of its under-twos. In 1981, the cost of
immunising a child was $6.69; in 1991, it
increased to $90.43 — an increase of
1,250 per cent.
• A recent Newsweek poll found that 81
per cent of Americans feel that doctors
charge too much and 60 per cent blame
the doctors for today’s crisis.
• A routine appendicitis, which years
ago would be associated with only about
six pre-operative tests, now has at least 31
such tests — the technological imperative, as it is called.
• Forty per cent of doctors in a poll said
they would not enter the profession, if
they had to do it all over again. The
a
profession feels that a *population
that is
getting older, sicker, more violent and
more litigious is the cause of the crisis.
• Solutions to the medical crisis being
debated include, among others, emphasis on prevention; employment mandated

insurance; malpractice reforms; and, fi­
nally, reorientation towards general practice and family medicine.
• Doctors are being exhorted to think
not only of what is good for their patients
but what is best for society, when they
make treatment decisions. Simultaneously,
patients are being weaned away from the
idea that good care means more care and
that they need a CT-scan for their recur­
rent headaches!
Just across the border, the Canadian
Ministry of National Hhealth and Welfare
was promoting an expert document on
‘Achieving Health For All’ which had
most interesting observations and goals.
The report recognised that there were
three important challenges not being addressed by the health care system:
■ Groups at a disadvantage having significantly lower life expectancy, poorer
health and a higher prevalence of disability than the average Canadian.
■ Various forms of preventable diseases
and injuries continuing to undermine the
health system and the quality of life of
many Canadians.
■ Many thousands of Canadians suffer­
ing from chronic diseases, disability of
various forms of emotional stress and
lacking adequate community support to
help them cope and live meaningful,
productive and dignified lives.
The report, therefore, stressed not the

♦ Dr Ravi Narayan is the
Coordinator for the Society for
Community Health Awareness
Research and Action, and a regular
columnist for CMJI.

CMJI

24

- ---

3

HEALTH ADVOCATE
pursuit of more high-tech medicine, but
efforts to reduce inequities; widen pre­
vention strategics and initiate efforts to
enhance people’s abilities to cope.
By the end of my travels, it was clear
to me that the East Coast was coming to
terms with the harsh truth that market
economy-determined, high-tech hospital
medicine was a major stumbling block to
the ‘Health For All’ revolution. The state,
the profession, the institutions, the policy­
makers and the consumers were all there­
fore gearing themselves for some farreaching reform in the years ahead.
Back home from my travels, I chanced
upon an interesting full-page advertisement in a national newspaper that shocked
me out of my wits! The ad was celebrating
the first decade of a well-known private
hospital group and after listing out nearly
17 urban centres where it had established
(or was on its way to establishing) hightech hospitals, it claimed to have trans­
formed the health care scenario in India.
It then prophesised that India would
emerge as the medical mecca of the world
because it has the doctors to make it a
sterling leader in the field. The advertise­
ment, with euphoria and perhaps mis­
placed revolutionary zeal, exhorted all
the readers to come and join the revolu­
tion and lead a historic movement in the
Indian health care industry. Inject India
with the power to lead the medical world!

CMJI

Accelerate the revolution!
sober appraisal in a book which was the
Coming so soon after experiencin^the last testament and legacy of a respected
crisis in Shangrila, I was rather disturbed. and humane physician, world-renowned
Whom would we need? The depressing epidemiologist, committed Christian and
prophets of Shangrila or the euphoric inspiring teacher — the late Geoffrey
prophets back home?
Rose. In a chapter entitled ‘In Search of
Having been associated with the fu­ Health’, he notes with deep sincerity,
ture of mission dialogue that preoccupies after a life-time of commitment and scholthe mission hospital network today, I arship, that in the age of scientific optibelieve that this dilemma, will soon be­ mism it was believed that medicine had,
come central to the debate. Caught on the or was soon to discover, the answers to
horns of a dilemma, the network has our health problems.
hard, and perhaps uncomfortable, choices
Thus, for example, if the President of
ahead. There is a need for a calm assess- the United States gave enough millions of
ment of the network of hospitals, their dollars, then cancer would be conquered,
role in health care and health promotion That optimism has passed (except in the
and their contribution to the health of the popular media) and we are starting to
poor, for whom we claim a preferential sober up. Medicine has indeed delivered
mission. I believe there is a role, though effective answers to some health prob­
this may be more limited than the expec­ lems and it has found the means to lessen
tations of the early pioneers. However, the symptoms of many others. But by and
even this limited
mission--------------needs sober; large,
1
------------we remain with the necessity to do
appraisal and rigorous situation analysis, something about the incidence of dis­
Last week, I came across one such ease, and that means a new partnership
between the health services and all those
whose decisions influence the determi­
nants of incidence.
e need to choose
The primary determinants of disease
between the pursuit of
are mainly economic and social and there­
fore its remedies must also be economic
high-tech services and
and social. Medicine and politics cannot,
enabling the marginalised
and should not, be kept apart. A time has
to fight for basic rights
come for more of the leadership of the
central to their health
mission sector to make such sober reap­
praisals of what they seek to achieve
through their institutional investments and
their professional exertions, and to dis­
cover what the future mission will be:
□ Bone marrow transplants or initiatives
in building community capability for health?
□ Magnetic resonance imaging or family
life education?
□ Organ transplants or caring/counselling services for AIDS victims?
□ The pursuit of high-tech services or
enabling the marginalised to fight for
basic rights, central to their health?
The choices are hard. But choices
have to be made. The question is: are we
ready for the task?
25

HP-liL

ii

i

THE HEALING MINISTRY AT THE CROSSROADS

Towards A Paradigm Shift
♦ DR RAVI NARAYAN ♦

Dear Friends,
It’s three years since this column was
Th^s article is the last of
initiated and this is the 12th advocacy in
the series. We have explored many ideas
a series of critiques of
on the way...
the present-day health
✓ Will there be mission hospitals in
2000 AD with a preferential option for the
scenario. Dr Ravi
r-^r and a commitment to ethical, lowNarayan was the
and quality' health care?
✓ Will the mission hospitals resist the
Coordinator of the
medical education scam and prevent the
Society for Community
co-option of our quality institutions by
the corporate network and the ‘new money
Health Awareness
bags’, who propose to float questionable
Research and Action,
commercial ventures?
✓ Will the mission hospitals be willing to
and has been a regular
bring about the necessary reorientation in
columnist for the CMJI.
the current technology, organisation and
management practices, to respond to the
He is at present based
continuing and emerging health needs of
in London
the poor?
✓ Will the mission hospitals be able to
offer critical collaboration to the govern­ facilitating the more urgently required
ment in the emerging Health For All tap turning off health strategies — to
strategy, and not just be co-opted by the make ‘Health For AU’ a reality
tiir.c---- /some
----------rp-nonsibility’ strategy of the new govc lent economic policy?
✓ Will the mission hospitals be willing to
adopt newer and bolder options to make
the ‘robbing Peter to pay Paul’ strategy
work to the advantage of the poor ?
✓ Will the mission hospitals and their
health staff recognise the new spreading
virus of communalism as one of the
emerging public health threats of our
time, and respond creatively to build the
community ^ough all efforts?
Z Will rational healers outnumber drug
pushers and irrational drug prescribers in
mission institutions in the coming years?
✓ WU1 mission institutions move from
providing floor-mopping technologies to

b

IL A
in the 1990s, the leadership of the
CMAI member institutions will be con­
fronted with s?me uncomfortable ques­
tions about the present or future roles of
mission institutions. No one is denying
that ethical, good quality, low-cost medi­
cal care, accessible to the poor and the
marginalised in our society, can remain
an important mission of the Healing Min­
istry. But the questions before us are
twofold. The first, whether this itself will
continue to be the ’ ‘mission’ of most
members of the network or will they drift
away to a new mission, engendered by
the market economy — that of providing
the latest high-tech care to those who can
afford to pay? The second, whether just
providing institutional health care can
remain a sufficient response of the Heal­
ing Ministry in the 1990s or are we all
being collectively challenged to see the
healing mission in a new light?
At the root of our problem lies the fact
that most of the leaders of the ‘Healing
Ministry today have failed to internalise

'! *

■

I

j

!!

*

i-

‘A «T*. . .

✓ Will mission institutions try to integrate health care, that is, challenging the ‘medf
different medical systems or will preju- cal• orthodoxy
’ at its very foundations.
dice continue to win over science in our
Trained in the old ‘biology’, they are
attitudes to the other systems of medicine
unable to fully comprehend the paradigm
and health care?
shift that has taken place in the emerging
✓ Will mission hospitals invest adequately ‘social biology’ of health.
in the updating and continuing education
Research efforts in the last few de­
of our health teams, to prepare them to
cades, supported by behavioural science
meet the emerging health/medical chal­ inputs and management sciences, have
lenges of the decade?
completely revolutionised our understand­
✓ Will mission hospital leadership learn
ing of the concept and goals of health
from the disturbing realities, the sobering care. TUI the 1950s by wHch toe a'laree
facts and the hard choices that face the - - - - 8
majority of the CMAI hospitals now exist­
leadership of simUar institutions, in areas
ing had been established, health was seen
of the world from where we inherited
as being synonymous with medical care.
much of our medical/health framework
In this milieu the Doctor-Drug-Dispen­
and thinking?
sary-Hospital model evolved in the In­

J

CMJI
27

!

-Vec-A^i^-

HEALTH ADVOCATE

dian situation with the mission sector
its ‘mechanistic orthodoxy’ to its more
playing a pioneering role.
Let us remember that two-thirds
creative social metamorphosis.
In 1948, the WHO defined health as
of the world’s people are under­
This has meant that we all have slowly
physical, mental and social well-being
privileged, underfed, underhealthy,
began to accept the paradigm shift, the
and not the absence of disease or disabil­
under educated and that many mil­
key components of which are:
ity. This was a revolutionary first step in
lions live in squalor and suffering.
• moving from problems of individuals
the paradigm shift from a negative con­
They have little to be thankful for
to problems of communities
cept of disease to a positive concept of
save hope that they will be helped
• moving beyond the limited patho­
health as well-being. However, the medi­
to escape from this misery.
physiological, intracellular understand­
cal profession dominating the scene failed
These [problems] are symptoms
ing of disease to the more dynamic
to recognise the creative challenges thrown
of a new evolutionary situation and
behavioural/societal context of health
up by this new definition. So till the 1970s,
these can only be successfully met
• moving from the concept of illness as
institutional drug-oriented technological
in the light and with aid of a new
a disease process requiring treatment to
responses continued to be seen as being
organisation of thought and belief,
that of ill health as a social process
synonymous with health care. Some more
a new dominant pattern of ideas
requiring a care system and strategy
CMAI member hospitals were set up
relevant to the new situation.
• moving from a preoccupation with
during this time as well.
Julian Huxley, 1961
providing packages of services to a more
Thirty years following the WHO defi­
dynamic enabling/empowering process
nition, there emerged the ‘Alma Ata Dec­
where the individual/community exer­
laration’. Health care was described in a ration — equitable distribution, commu­ cises its rights to health and its responsi­
new framework and as a new process, nity participation, multi-sectoral approach bilities for its maintenance
where people and the community were and appropriate technology — further • moving beyond the concept of pa­
not just beneficiaries of a professionally emphasised the paradigm shift.
tients as just beneficiaries of professional
determined and directed system but ac­
Since the 1980s we have all had to intervention to people as participants of a
tive participants of a jjoint partnership, grapple with this evolving, radical change joint operation, where consumer control
The four principles stressed in the Decla- in our understanding of medicine, from and autonomy of consumer decision­
making has become more significant
• moving from the concept of the doc- .
■ ■ * e all have slowly
tor/nurse being the centrestage of the
process to the doctor and nurse being
■
■ begun to accept the
part of an expanding health team work­
■Win paradigm shift—
ing together for a common social goal.
WW moving beyond the
The Healing Ministry of the 1990s
cannot remain in the myopic bio-medical
concept of patients as
model of health. It has to respond to the
just beneficiaries of
emerging bio-psycho-social understand­
professional
ing of health and respond to the ‘para­
intervention to people
digm shift’.
I believe it will and it can — if more of
as participants of a
us have the courage to see the new
joint operation, moving
demands and the new challenges not as
from the concept of
something that is beginning to destroy
what we have built so conscientiously
the doctor/nurse being
over the last four decades, but as a
the centrestage to
welcome stimulus and leaven for a new
their being part of a
transformation, and a new healing of our
team oriented toward^
‘missions’ as well.
We are at a crucial crossroad in our
a common social goal
common histories. Will we grasp the
opportunity?
■
28

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Health Advocate

Finally,

a Strategy to
Control Malaria
4- Dr Ravi Narayan

The resurgence of malaria as a majoi public heal

problem has posed serious concern foi
health policy makers and planners
“J1" HE resurgence of malaria as a maI jor public health problem has
I posed serious concern for health
policy makers and planners. In 1994,
serious malana outbreaks and epidem­
ics were reported in Rajasthan,
Nagaland, Andhra Pradesh, Manipur
and West Bengal. A number of districts

in /Vssam, West Bengal and Maharashtra
experienced malaria outbreaks wit a
high morbidity and reports of deat a
in 1995.
The voluntary health sector began
concerted and collective initiatives af­
ter serious epidemics in Rajasthan and
the North East. VHAI had initiated a dia-

The Public Health Crisis in India
trol strategy. The focus has been on the
^-j-^HE re-emergence of malaria
mosquito, the parasite, the health care
I as a significant public health
deliver)' system, the environment and
J- problem since the 1970s and
ecology.
The patient and the commu­
the increasing occurrence of out­
nity
at
risk
have been neglected. The
breaks and epidemics, especially in
expertise
of
the behavioural sciences,
the 1990s, is leading to an urgent
especially
the
socio-anthropological
reappraisal of the county’s public
and the socio-psychological dimen­
health policy And also a deeper un­
sions at work in malaria, have been
derstanding of the larger public health
grossly neglected.
crisis that has been evolving in the
© The Political Economy of Health
country over the last two decades.
Health planners and policy makers are
Some elements of this crisis are:
concerned that the market economy of­
@ The Socio-Epidemiological Link
ten drives policy decisions. This also
Strategies to control communicable
means that the approaches and priori­
diseases have focussed primarily on
techno-managerial aspects. Only
ties often promoted are at variance
analysis and solutions that link
from the recommendations of national
socio-economic and cultural-politi­
expert committees and technical evalu­
cal contexts of the problem will help
ation reports.
to evolve a more comprehensive, ef­
Before evolving strategies and
fective and sustainable malaria conprogrammes, it is vital to understand

logue on ‘rational malana care' in 1995
by bringing together a working group
to look at various aspects of malaria
treatment and to review the recently
evolved guidelines of the National Ma­
laria Eradication Programme (NMEP),
To take this process further, an expert
group on malaria was convened in April
1995 to seek wider opinions on the ma­
laria situation and suggestions on how
to tackle the problem.
What followed was an interactive
and participatory process initiated
by the Society for Community Health
Awareness, Research and Action on
behalf of the Voluntary Health Asso­
ciation of India from April to
January 1997.
The six-member expert group and
a reference group of 44 from the voluntary/NGO sector has chalked out an
alternative, community-oriented, socially-relevant malaria control strategy.
Through a review of existing policy
documents and guidelines, the group
has identified key issues of concern

■s

fj

V

the national and the international, po­
litical economy of health.
@ The Challenge of Decentralisation
To respond to regional needs and dis-.
parities in the health care situation, a
concerted effort toward a framework
of decentralised planning is needed.
© Primaty Health Care —• Beyond
Rhetoric to Grassroots
Ultimately, the health infrastructure of
the grassroots must be strengthened
through community-based approa ches.
© The Threat of the New Economics

T
|

>

■

|

There is growing concern that the genf
eral health infrastructure and human
I
power situation is continuously wors- . |
ening. The culprits are the larger eco- j
nomic issues — the corruption, the J
trend towards privatisation and com- 1
mercialisation, and the cutbacks in gov- I
ernment expenditure on welfare.
m
The effects of the new economic
policies need to be monitored carefully

.

A

28 • CMJI
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12/30/21,2:45 PM

HEALT H ADVOCATE
!

Contribution
India’s'
, unenviable share of
• • ice of malaria...
[IK S'
••• -- cases arc remillion
of which thc fa$ (alciiww1” or cerebral malaria
1.000 lives. India
, about 40 per cent of
cases outside Africa,
JI in;’.Lire1
fibres ilo '’Ol reveal the
These
'"...nicuire though the virtual

.T.ns o'’er

of

tlie

llCalth

sun'
cil‘

C‘1 . „w| information systems in
led to gross manipulan'md under-reporting of data
"‘’lhe authorities concerned.

gcsicd some alter natives for action.
The ‘Expert Group Process' has
tried to move beyond just a critique to
biing together the complementary ini­
tiatives and processes in the voluntary
seen a; I hereby collectively strengthen­
ing the emerging efforts.
Among other things, the expert
gioup highlights the problem ol under­
estimation o! malaria; thc need to
>ilengthen the behavioural sciences
dimension in planning and research;
the challenges ol rationalising malaria
diagnosis and treatment, including the
potential misuse of mefloquin; the al­
ternatives m wetor control strategics;
and the need to rediscover thc com­

munity dynamics and dimensions in
malaria control - including commu­

..b ]rlVe not been adequately conjn the recent planning process
‘"Lemented by their own field exf ences and that of fellow travellers
^Hield workers, activists, trainers,
'^■irchers and awareness builders in

X
‘ )nii'nifv he;llt,L Thc group has Sllg'

nity capacity building, health educa­
tion. role ol the voluntary sector, gen­
eral practitioners and the panchayat
leadership. Thc group recognised
the urgent need to decentralise plan­

ning and to assess the role of the in­
digenous systems of medicine.

Ollier areas ol locus are policy issues
— health, human power dcvclop.in(! die distortions in the planning
pnxess produced by market forces

ment and research, monitoring and
forecasting, corruption and political

great lesson for humanity — that
we should be more scientific in our
habits of thought and more

practical in our habits of

government. The neglect of this
lesson has already cost many
countries an immense loss oi Hie

and of prosperity”
Ronald Ross (1911)

SYNERGY BETWEEN POLITICAL AND
HEALTH LEADERSHIP
Till the mid 1960s, there was an effec­
tive synergy between the political lead­
ership and competent and assertive
public health leadership in the coun­
try so that malaria control was sup­
ported by strong political will and fa­
cilitated by crucial public health com­
petence at all levels.
O Devise local solutions in response
to local realities and constraints.

Iiced to be countered.

interference. Centrc-Staic rcsponsi-

& Right to Information
Public participation has floun­

bilitics and international public

© Recognise (he economic advantage
of national health programmes. Effec­

health co-operation.

tive anti-malaria operations converted

dered due to inertia and red:

“The history of malaria contains a

the Terai in I’uar Pradesh, Wynad in

Wpism linked to thc absence of

LESSONS FROM HISTORY

critical information. A process of

OF MALARIA CONTROL

Kerala and Malnad in Karnataka into
the granaries of India.

demystification linked to the right

From a review of the malaria control

t

to information can garner com-

activities from the 19.30s onwards, the

:

munity participation.
Widening Dialogue and Partici­

most significant lessons are:
The potential for sustained public

® Recognise and monitor significant
factors.

Drawing from these lessons of his­
tory, the malaria expert group suggests:
© Inform planners and health action

health action.

pation in Planning
f By taving on thc resources of an

© Competence in a diversity of ap­

initiators of the experience and strate­

' altenwrive sector — a wide network

proaches.

gics of the past.
© Make information and documents

■ of individuals and groups eager to

Before the advent of DDT, we were

I share their experiences and per­

competent in bio-environmental meth­

available to them.

spectives — the voluntary sector, by

ods, anti-larval operations and other

© Identify and involve some of the

evolving indigenously determined

supplementary action. However, when

’veterans’ of the battle against malaria

responses, has contributed to strat-

DDT became the sheet anchor fol­

to evaluate and review the current chal­

’ cgies to tackle malaria and actively

lowed by other pesticides, further de­

lenges. So that we do not 'reinvent the

. supplement the efforts of the natio­

velopment of competence in other

wheel’ but learn from the past in our

nal malaria eradication programme.

methods was disregarded with unfor­

efforts to harness action for the future.

“The history of malaria contains

tunate consequences.

29 ® CMJI
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HEALTH ADVOCATE

a great lesson for humanity that
we should be more scientific m
our habits of riiought and more
practical in our habits </f govern­
ment The neglect of ihis lesson
has already cost many countries
an immense loss of life and of
prosperity" KohM
b
MALARIA SITUATION:

THE PROBLEM OF UNDERESTIMATION
Malaria is grossly underestimated. 'J he
existing epidemiological information is
based on inadequately validated data
i’lanning at all levels must be iKiscd on
more reliable and valid data.
The expert group on malaria has
suggested compulsory notification of

J<cfcrcn't'S WAV, N<^i- bt'lbi ’ //■cw/x''/'
!7A \y-r^
Lank Jun/' W
* ()th('r> iu the (Vjj/'rl
Indn/h^l
!)r
Sehttal, con.uliani.
nr ^ir-a !>bh.-r/. head. Puhllt. /v>//rj
I. nil Vf/lurildty Ib-allh A-y,( ialion 'ff
Jndi a; /' ) Ami!ahhu r. and
S 'provde further udormatto:
metit f/J J'aradtolf^y. fddcutia '■/
i
Am >r g -he indoor, a
I oflrojdcal Medicine. />r f^JdrabM,n
Ahei, bead, Id USA beparlment f,j
m£JI „ent, aotve ™ u- ; rhndicif! Medical (/.dleae ami
Ln p^vetawdetenmn. ..nd
tai. Vellore and i.)r ■■unit Kaul
other indicators
! ciation of Voluntary Ayern
jf)r
The .•xpet t group h:.'. ■..odJi-’CS • ■ ■ ' red Dei.elopuieni. Worth l:a-.l lAVAP.I)
during duphtation ol daia
' ' ' WE). Jorhai. Ae-am

I

n.Jan;. CB® 3r,'J (le;ll,‘’' (.'."'.'d
vemems in the survudkn-c
td.PHC.sudTandp^e P^‘"
bt motivated to prov.di
r«.
(]oCal situauon of tnaUna

2X check

■

/

and record tepW 111,35 Pwt

Kk,ls (J| bow to integrate rerords o

solve the 'itw many registers on
dtotne at the front line worix-r s end

Df

.-S

The Lord's Parameters

1

❖ A.A,Jacob
-When I was. hungry

you gave mt fcxxiWhen I v/:ls thirsty

you gave me drink

Whcri I was j stranger

you lo'/f' me in

Ji

When I whs nakvd

you dot bed me

When i v,,'s '.id:
you visited ii:i"

When I v..i> in po >'<n
you came i< > me

Does hunger ihifM. nakctiocs-. t- kn:
Or do uc need funds, f nee gt ’up’,
Jr; Ihi m.il

lornruj -f II'

M !

I!’’:’-'\i s1-’-'’.-

•. ! HJiU

io -s < m m< ? k,;;': ? 10 UH : 0 I

When touched by reoihy.
:,
;■.!<. !1V. vssitfei •

n ■:
Ittk nt •■ ihViU; pcOj ■ ' ."h

t h - 1 ' -ving r/Hhing behind
p ■ ■‘
- • ‘f- • hik ■ ' OU: '->.i / huve

known such xhcfsim v.:mh frtm; :■ .t-mlonubiv drome O

Hunger durM, tukednc^

or Hiipnsonrneni .<;<■ the !x?rd s punmeicn

cvaluui-ing our cak
R A. JscoC- ;rkfcd e^r-CMAj

30 eCMJI
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i

The People's Charter For Health
— Does It Mean Anything To You?
♦ Dr Ravi Narayan

People's movements across the world are working to identify and demonstrate that
the path to sustainable development does not lie in neoliberal globalisation but in
alternative models for people-centred and self-relevant progress

Ko
Dr Ravi Narayan

t

1

The People's Charter
for Health is a
rallying point
around which
the global health
movement can
gather

TT early 24 months ago, 2500
\l health professionals and activ1 ists reached Kolkata in four
People’s Health Trains from all over
India, for the first National People’s
Health Assembly. They brought with
them perspectives, enthusiasm and in­
spiration from months of mobilisation
for the ‘Health for All Now’ campaign
launched by 18 national networks on
7,h April 2000 (World Health Day, now
People’s Health Day from 2000) at
Hyderabad.
The mobilisation included state, dis­
trict and taluka level meetings,
kalajathas, people’s health enquiries,
policy dialogue and the most significant
of all, the publication of five consensus
documents on the health situation and
challenges in India.
• These booklets included a wide
range of concerns brought together un­
der five titles, (1) What Globalisation
does to People’s Health! (2) Whatever
happened to Health for All by 2000 AD?
(3) Making life worth living (meeting
basic needs) (4) A world where we mat­
ter (health of women, children and the
marginalised in society) (5) Confront­
ing commercialisation of Health Care.
• These booklets are now available in
most Indian languages and appreciated
all over the world. These five little book­
lets - the distilled wisdom of decades

of working on ‘Health for All’ issues rep­
resent a phenomenal consensus not only
of health networks like Medico Friends
Circle, Catholic Health Association of
India, Christian Medical Association of
India, All India Drug Action Network,
and Voluntary Health Association of In­
dia, but also the science movements,
women’s movements, nations! alliance
of people’s movements and groups like
the forum for creche and child care ser­
vices and even the Federation of Medi­
cal Representatives Association of India
and others’
• After two days of interactive work­
shops and solidarity-oriented plenaries,
a health exhibition, a celebration of the
diversity ofkalajathas and cultural ac­
tivities in health, a public march for
health and a public rally, aft Indian
People’s Health charter was evolved.
Then nearly 300 Indians went across by
bus and other modes of transport to
Savar, Bangladesh to participate in the
first global People’s Health Assemblya 5-day multicultural celebration and
reflection on ‘Health for AH’.
• At the end of it all there evolved
the People’s Charter for Health - the
largest consensus document in Health
since the Alma Ata Declaration on Pri­
mary Health Care in 1978. The People’s
Charter for Health, now translated into
several of the world’s languages, is ‘an

31 • CM.JI

GcA'. - Pec_-

X-

r
/ 'Health Advocate, /

/ Z<../O ' X

health needs of the people and the
expression of our common concerns for
socio-economic-cultural realities of
healt h? a vision of a better and healthier
their lives. It’s time to absorb the new
world; a call for radical action, a tool
emerging frameworks of health action
for advocacy and a rallying point around
from the Movement and the Charter,
which the global health movement can
d. If the answer is a definite Yes - I
gather ..’
have been deeply and enthusiasti­
H()\y many of you, dear readers, have
cally involved, then too a time of
heard ;jbout the People’s Health Assem­
reflection is at hand!
bly? How many have seen the five little
It’s time to reflect whether in line
booklets? How many have read the
with the framework of action outlined
People’s Health Charter?
in the People’s Health Charter, your
a. If your answer is a definite No current medical/health initiative pro­
then h’s a time of reckoning!
motes health as a human rights con­
Haye you been so busy and occupied
cern; tries to tackle the broader de­
with your bio-medically oriented health
initiative that you missed
one of the largest health
II.
ibifeation of our times.
rerhaps as the ‘Cor Unum’
docuyient of 1976 re­
' ' A' fl
corded, ‘the leaven is still
I
far removed from the
bread ofhealth ’.
V
b. If the answer is a
qualified No - I have
o
been too busy working
£
with my sick and un­
Marching for a cause
healthy community or
terminants of the health problem my crowded OPD and wards - tack­
economic, social, political, cultural;
ling problems with my limited re­
tackles environmental challenges to
sources and my overstretched capac­
health including the viruses of con­
ity, then too a time of reckoning has
flict and violence; makes your health
come!
initiatives more people-oriented,
It’s time to take stock of your work,
more people-determined, more
share your innovative experiments at
people-accountable? Perhaps you are
microlevel with a larger network of
in the right direction but there are
□pig, learn from the experience and
‘miles to go before you sleep!’
enthusiasm of others and join the move­
As you read the Charter many may
ment bringing your zeal and local ex­
say, “Of course 1 believe in ‘Health
perience into it.
for All’ but isn’t the charter too po­
c. If the answer is a qualified Yes litical?" Others may say, "Of course 1
but I ^as only peripherally informed
believe in 'Health for All’ but why
and perhaps involved very little, then
be so against the new economic poli­
it’s a time of reckoning as well!
cies of globalisation, liberalisation
Pei haps you are still dazzled by the
and privatisation? Aren’t they im­
glamour of ‘technological prescrip­
proving outreach, quality and effi­
tions5 of health promoted by social
ciency?"
marketing strategies including our
The answer to both these questions
medical education that are driven by
are being reiterated all the time.
market forces rather than the basic

L!
I
nji. i

k

0 Prof Geoffery Rose, a famous
epidemiologist and a committed Chris­
tian, wrote this as his last testament a
decade ago after an illustrious career in
epidemiology of health:
"The primary determinants ofdis­
ease are mainly economic and social
and therefore, its remedies must also
be economic and social. Medicine
and politics cannot and should not
be kept apart."
0 Prof D Banerjee of the Jawaharlal
Nehru University has cautioned health
professionals for decades that 'health
service' is a socio-cultural process, a
political process; a technological and
managerial process with an epidemio­
logical and sociological perspective."
0 Dr Fidel Castro, well-known politi­
cal scientist and leader warned health
leaders in a WHO Assembly speech that:
"Never before did mankind have
such formidable scientific and techttologicalpotential, such extraordi­
nary capacity to produce.... Wellbeing
but never before were disparity and
inequity so profound in the world....
Another 'Nuremberg' is required to
put on trial the ecbjiomic order im­
posed upon us. The current global sys­
tem is killing by hunger and prevent­
able and curable diseases, more men,
women, children every three years
than all those killed by world war II
in six years...

“mZXTHEPE0PIJ5's
DOES THE PEOPLE’S HEALTH CHAR­
TER MEAN.
MEAN ANYTHING TO YOU?
ls the evidence available? The per­
spectives are emerging as we move into
the next millennium.

Dr Ravi Narayan
Community Health Adviser
CHCIPHM

32 • CMJI

. - W'upi-

■

I

HEALTH ADVOCATE

ShMr • 4 ■

r

War or Peace: What is Your
Commitment?
Dr Ravi Narayan

With the Middle East on the boil, do we as health professionals remain passive
and uninvolved, thereby supporting the war through our silence?

o February 15, 2003, over a
B million participated in the
largest rally London had seen
for decades. Hundreds of thousands
marched through Berlin; two lakhs
marched through Damascus; thou­
sands joined marches in Bulgaria,
Romania, Hungary, Brussels, South
Korea, Australia, Malaysia and Thai­
land; hundreds in Bosnia, Hong Kong
and Moscow; and thousands in Amster­
dam, Copenhagen, Johannesburg, To­
kyo, Dhaka. It was the largest anti-war
rally in recent decades.
Earlier many biaved the cold in
many American cities and many joined

f

No more war;
no more bombs;
no more war and bombs
for oil rhetoric
please!

30 • CM.II

similar protests
in Delhi and
Kolkata and
Kerala soon
after. The pro­
tests were a
significant
and inspiring
message by
peace loving
world citizens
all over the
globe. They
were
not
swayed by the
p ro - wa r
rhetoric of
Bush and Blair;
nor impressed by the machination of
the armament and nuclear trans­
national corporations all over the
world; nor provoked by the demonstra­
tion of some leaders or even stereotyp­
ing of one of the important religions
of the world. Men and women, young
and old, school children and college
students; farmers and teachers, artists
and musicians, disabled and. minori­
ties; people of all religions, class and
ethnicity joined the protest in an over­
whelming groundswell of public opin­
ion. No more war; no more bombs; no
more war and bombs for oil rhetoric
please!

f
1
I

I

Health Adv^ate

Sul
<?!

■

Ml

il

pS) '

\
Twenty five years ago in 1978, the Alma
Ata Declaration on Health for All had
clearly noted that

i

“An acceptable level of health for
all the people of the world by
the year 2000 can be attained
through a fuller and better use
of the world's resources, a
considerable part of which is
now spent on armaments and
military conflicts. A genuine
policy of independence, peace,
detente and disarmament
could and should release
additional resources that could
well be devoted to peaceful
aims and in particular to the
acceleration of social and
economic development of which
primary healthcare, as an
essential part should be allotted
its proper share. ”

In 1995, people from 92 countries
gathered at the People's Health Assem­
bly in GK Savar, Bangladesh and noted
in the People’s Charter for Health that:

“War, violence, conflict and
natural disaster devastate
communities and destroy
bumati dignity. They have a
severe impact on the physical
and mental health of their
members, especially women
and children. Increased arms
procurement and an aggressive
and corrupt international arms
trade undermine social,
political and economic stability
and the allocation of resources
to the social sector. ”

The Charter called on peoples of the
world to:

• supi^ort campaigns and movements for
peace and disarmament.
• support campaigns against aggression
and the research production, testing
and use of weapons of mass destruction
and other arms.
• support people’s initiatives to
achieve a just and lasting peace.
• demand that the United Nations and
individual states end all kinds of sanc­
tions used as an instrument of
aggression, which can damage the
health of civilian populations...
31 • CMJI
rgfaKiwwarjiwAattfs1 m

To live in peace takes a
lot of commitment.
To promote a world in
which Health for All Now
can be a reality, needs
all of us to be as
anti-war as we are
anti-disease
As members of a health network; as
members of an association and
ft )ll( nvers ofa ‘peace maker’; what was your
response?
Did you join the marches?
Did you e-mail your protest?
Did you talk to your family, your
friends, your colleagues, and your
associates against war and stimu­
late them to support jxjace?
Did you write against the war?
Did you pray for the peace?
Or
Did you remain passive, unlhvolved,
disinterested, confused and Suppon*'-’
the imminent war through your
silence?
lb live in peace takes a lot of com­
mitment. lb promote a.world in which
Health for All Now can be a reality,
needs all of us to be as anti-war as we
are anti disease; as pro-peace we are
pro-health.
Are you going to respond?
Are you going to make your small voice
part of a big bang against war?
What is your commitment?
War or peace?
Peace needs You!! k.

Dr Ravi Narayan
Co-ordinator
RUM Secretariat
CHC- Bangalore

H V2. 2_G
"

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HEALTH ADVOCATE

Remembering Alma Ata
♦

Dr Ravi Narayan

The 25th anniversary of the Alma Ata gives us an opportunity to ponder over the
realities and the options available to us

Have we got enmeshed in
the demands of an
increasingly costly health
system
------ c-»4.rs

Tpn September 1978, an International
I Conference on Primary' Health Care
JLmeeting in Alma Ata (then USSR),
pressed the need for urgent action by7 all
governments, all health and develop­
ment workers and the world community7
to protect and promote the Health of
all the people of the world through the
famous ‘Declaration of Alma Ata’. This
was affirmed by a large number of coun­
try7 delegations from all over the world
and became the blueprint of a new
Health and Development Philosophy
around the world.
The declaration strongly reaffirmed that
• “Health is a state of complete physi­
cal, mental and social well-being and not
merely the absence of disease or infir­
mity.”
• “Health is a fundamental human
right.”
• “The attainment of the highest pos­
sible level of health is the most impor­
tant worldwide social goal whose
realisation requires the action of many7
other social and economic sectors in ad­
dition to the health sector”.
In September 2003, as we reach the
twenty-fifth anniversary' of this famous
Declaration, it is important to reflect on
some of its key recommendations and
sec whether the health professionals and
healthcare institutions who are members
of our CM\I network have been true to
these exhortations.
i
• Have we focused our clTorts on the
‘gross inequality in the health status of

our people which is politically, socially
and economically unacceptable’ and
tried to reach more and more of the poor
and marginalised sections of our society
in our work?
Or have we allowed the ‘market of
health’ to change our strategies, to fo­
cus not on ‘Health for All’ but only on
‘Health for those who can pay’ leading
to more and more poor being left out of
our institutions?
• Have we focused our efforts on ‘the
promotion and protection of the health
of the people’ as our sustained ‘contri­
bution to the economic and social devel­
opment’ and ‘contribution to better qual­
ity of life’ and ‘to ‘world peace’?
Or have we got enmeshed in the de­
mands of an increasingly, costly, second­
ary' and tertiary^ care oriented health sys­
tem, which is pricing itself out of the poor
person’s options and sometime the mar­
ket itself? Have we contributed to the
worsening of their quality of life and to
the inevitable social tensions leading to
conflict and war?
• Have we recognised that ‘people
have the right and duty to participate in­
dividually and collectively in the planning
and implementation of their healthcare’?
Or have we continued to view them
as patients and potential beneficiaries of
our systems and prevented a real, in­
formed and active lay participation in
hospital / healthcare planning and man­
agement’?
• Have we recognised that ‘govern-

19 • CM.II

2'00-5
tik i; iLHui..

E

Health Advocate

J-

I •

• Has this socio-cultural gap manifested
particularly in our continued negligence
and disregard of traditional systems of
healing and the folk health traditions of
our people?

"•
<
o

±-...

•

.

. ■

ments have a responsibility for the health
of their people which can be fulfilled only
by the provision of adequate health and
social measures’?
Or have we watched passively as un­
interested citizens in spite of ‘our so
called preferential option for the poor’,
as governments at national and state le\'cl
have reduced health budgets, cut back
support to rural healthcare and allowed
‘privatisation’ and ‘corruption’ to ravage
the health systems, which are supposed
to be accessible to the poor?
• Have we built our community out­
reach and community-based healthcare
programmes on the “Principles of Pri­
mary Health Care - recognising it as
essential healthcare based on practical,
scientifically sound and socially accept­
ably methods and technology made
universally accessible to individuals

and families in the community through
theji lull participation and at a cost that

community and country can afford?’’
Or have we let our hospitals and
health systems become the means to in­
troduce glorified, high technology; fancy
brapd medicine and promoted hospital
pra< lice that has a vested interest in the
abundance of ill health’? Have we simul­
taneously also become at communilv

technological systems and thereby dis­
tanced ourselves from the people?
• Have our healthcare and hospital sys­
tems evolved from the economic con­
ditions and socio-cultural and political
characteristics of our country and its
communities?
Or have we continued to transplant
westernised, imported systems and ideas
and a medical culture that has evolved in
a different socio-economic, cultural and
political milieu?

.
level, subcontractors ol g( nernment and
internationally inspired and supported
health programmes ‘socially marketing’,
’magic bullets’ for verticalised diseaseoriented interventions, thereby destroy­
ing the spirit of Alma Ata?
• Have we encouraged our ‘health­
care initiatives to move closer and
closer to, where the people live and
work’ - focusing on first level contact
that individuals, families and communilies make with < )ur health systems.Or have
we
built
buildings and
more build­
ings, ivory
towered and
cut off from
our people
by larger and
l?* *ry
larger walls of
con c r etc,
worr\ ing
G
I
more
and
more about
our own se­
curity and the
security of
our machines
and costlv

7^

20 • ( \111

• Have we ‘promoted maximum com­
munity and individual self-reliance and
participation in the planning, organisation,
operation and control of healthcare,
making fullest use of local resources
and developed through a appropriate
education, the ability of communities
to participate?
Or have we continued to build ‘char­
ity and dependence creating’ systems
funded by exterrtyl resources or deter­
mined by the temptations and the mar­
keting strategies of the growing medical
industry?

■

•y

A
A

I

; WW til I

l^heakh'Advocate

collective solidarity'
of institutions with
a mission to reach
the poor and
marginalised, shar­
ing our human re­
sources, our facili­
$1 ties and our expe­
rience?
•
Have we
relied at ‘local and
Pl
referral levels, on
health
workers in­
fJO
cluding general
physicians, auxil­
iaries, community
'-WvW->'workers and tradi­
tional practitio­
ners, suitably
trained, socially
and technically to
work as a health
team and to re­
Kv^
spond to the ex­
pressed health
< needs of the comh munity?
gill
o
Or have we be­
gun to focus on
• Have we integrated our mission hos­
more and more sophisticated health
pital and dispensary network with other
workers and technicians, and begun to
like-minded institutions including gov­
compete with each other to participate
ernment institutions in ‘functional and
in the increasing commercialisation and
mutually supportive referral system,
specialisation of medical and health pro­
leading to progressive improvement of
fessional education, even lending our in­
comprehensive healthcare for all and
stitutions as partners to more and more
giving priority to those most in need’?
of these capitation fee initiatives?
Or have we continued to grow in
• Have we promoted through our
splendid isolation, relating to other mis­
church and lay leadership and educa­
sion institutions and government insti­
tional resources, greater encouragement
tutions, only through cut-throat compe­
‘to genuine policies of independence,
tition or ‘holier than thou’ or ‘cleaner
peace, detente and disarmament’ and
than thou’ attitudes that have kept us all
encouraged our governments to move
apart rather than helped us to build a
their resources from ‘spending on ar-

4

i

!,<

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■;

i

•

■' 1

It

/

maments and military conflicts to
reaching an acceptable level of health
for all (he people of our country'?
Or have we in our eagerness to align
with the powers to be or to maintahi sta­
tus quo, or promote social acceptance ,
among the elite, or even through a
‘Pharisaical’ disregard of the increasing
poverty in the lives of our people ~ al­
lowed conflict - both religious, ethnic
and language based, to devastate the
lives of our people and destroy the
bonds of communities that have ke^f our
multi-religion and multi-cultural coiihtty
together all these years?
As we ponder over the realities df our
own options - and the trends in onr in­
stitutions over the last twenty-five j^ars
since the call of Alma Ata, it would be
important to keep in mind some reflec­
tions of health professionals, with the
same motivation and inspirational history'
as ours:
• In 1976, the pre-Alma Ata Cor Utium
document (1976) on the ‘New Orienta­
tion of Health services-with respect to
Primary' Health Care work’ observed:
“The mission that we have been give
is a call fora true conversion of our hearts
and also of our methods..
“We must work for the overall devel­
opment of each man, and focus on the
sick person more than on his sickness.
Since development also means solidar­
ity, we must necessarily turn our atten­
tion towards the human community of
the patient, his family first, but also his
neighbourhood or village. This means
we must practise community medi­
cine...’’

“Since Christians are the leaven, we
must reach out towards the masses by
providing simple, accessible and promo­
tional healthcare according to our own

% access the Atma Ma Anniversary Tacl^of materiafs from Teople 5 9-feahth Movement, visit
http:/TVivw.phmovement.oyj/pubsinde\.html ^AhmaAtaAnniversarypacI^
21 • CM||

as
JOIN THE MILLION SIGNATURE
CAMPAIGN
DO YOU BELIEVE IN ‘HEALTH FOR
AU. NOW’? THEN JOIN THE MIUION
SIGNATURES FOR ‘HEALTH FOR AU
NO^’ CAMPAIGN LAUNCHED BY
TH^ PEOPLE’S HEALTH MOVEMENT
(GLOBAL) AT THE ASIA SOCIAL FO­
RUM, IN HYDERABAD IN JANUARY
200$
JOIN A MILLION OTHER SIGNA­
TORIES TO AFFIRM THE PRINCIPLES
OF TOE ALMA ATA DECLARATION
WHICH WERE REAFFIRMED IN THE
PEOPLE’S HEALTH CHARTER - DE­
CEMBER 2000, THE LARGEST CON­
SENSUS DOCMENT IN HEALTH
SINCE TOE ALMA ATA DECLARATION.
IN THE ALMA ATA ANNIVERSARY
YEAR, JOIN US AU TO SPREAD THE
MESSAGE OF ‘HEALTH FOR ALL,
NOW
VISIT THE WEBSITE
wvsWIheMilliorLSienatureCamDaign.org.
AND SIGN INTO THE CAMPAIGN.
GET AU YOUR COLLEAGUES AND
STAFF MEMBERS OF YOUR HOSPI­
TAL / INSTITUTION TO DO THE
SAME.
WELCOME TO THE PEOPLE’S
HEALTH MOVEMENT. HELP US IN
THE STRUGGLE FOR HEALTH FOR
AIT NOW
For more information contact:

Ctpnmunicalion Officer,
Pl IM Secretariat (Global),
Community Health Cell,
367, Srinivasa Nilaya,
Jak-kosandra 1st Main, 1st Block,
Koramangala,
Bangalore - 560 034
Tel; 080-51280009
Faye: 080-5525372
Email:
coinm.pl)nisec(^toud)telitidianet
Website: www.phmovement.otg

possibilities, modest as they are, or in
conjunction with the public services,
where this is allowed...”
“It sometimes happens that as a re­
sult of changes which not everyone is
necessarily aware of, too many of them
work in hospitals and health centres that
have become too expensive for the ma­
jority of the population, and are only
within reach of the pockets of certain
‘elite’ who can afford them. In this case,
the leaven is too far removed from the
loaf...”
• Twenty years later in 1996, as we
were reaching the Health For All- 2000
milestone and Health for All was no­
where in sight, a group of health pro­
fessionals invited by CMAI for a consul­
tation on primary Health Care - A Chris­
tian Mandate had this to say:
“A church has a mandate to work to­
wards a just and health society. We be­
lieve that Primary 1 lealth Care in its wid­
est sense would be instrumental in this
work. We are conscious that as of now,
the poor remain marginalised and ex­
ploited, and that we as a church have a
clear bias or preferential option for
them. We realise that with
the change of direction in
India’s economic develop­
ment policies with
globalisation, structural re­
forms and marketisation of
society, the poor are being
- sidelined and jeopardised
even more. We are commit­
ted to increasing the un­
derstanding of the contex­
tual realities of the country,
within the church, its insti­
tutions-, amongst health
professionals and the pub­
lic at large and of the ur­
gent roles we need to take
on, especially on the side
of the poor." (2)
• It is time to move be­
yond prophecy anil polk s
rhetoric to concrete insti22 • CM.II

•. .Mm

KW1 • • '

tutional and professional change. The
twenty-fifth anniversary of the Alma Ata
Declaration is a time of reckoning.
• What will be our individual option?
• What will be our institutional op­
tion?
• What will be our collective option?
• On which side do we stand? ‘Health
for All Now’ or ‘Health for those who
can pay’?

Dr Ravi Narayan
(Co-ordinator)
People's Health Movement
(Global),
CHC, Bangalore

[Note: The quoted extracts in bold in this re­
flection are taken from the following source:
The Alma Ata 1978, Primary Health Care,
WIIO/UN1CEF, 1978.
The quote-marked (2) is from the handout
conclusions of the Consultation on primary
I lealth Care - A Christian Mandate, CMA1, New
Delhi, February 1996, put together by Dr
Thelma Narayan and Dr John Oommen].
'

■*

I
I

H
,

■

-

Making a Difference
♦

Dr Ravi Narayan

Are you a floor mopper or tap turner-off?

8

I
■

■

Dr Ravi Narayan

This question
has been a great
stimulus to me
for the last
30 years,
helping me
explore
a new meaning
for the role
of the doctor
and a new
vision for the
healing
ministry

■ ’"’thirty years ago, as a young post| graduate student of public health
JL in 1973,1 had the opportunity to
listen to a lecture on ‘Future directions
and challenges in research’, by late Dr
Denis Burkitt. He was a famous mis­
sion hospital doctor and medical re­
searcher from Africa, who for many
years, directed the Medical Research
Council of the UK and promoted a re­
thinking in the focus of medical re­
search - from a preoccupation with; in­
tracellular research’ to a new commit­
ment to ‘behavioural and societal re­
search’. The core of this lecture was an
important question he presented to all
of us youngsters, as a challenge in our
future vocation. This question has been
a great stimulus to me for the last 30
years, helping me explore a new mean­
ing for the role of the doctor and a new
vision for the healing ministry. In
• memory of this late medical prophet, 1
share this question with the readers of
CMJI.
Imagine a room with a wash basin.
On entering the room, you find that wa­
ter is pouring out of the tap, the sink is
overflowing and (here is a mess on the
floor. What would your first response
be to tackle the situation? Will you be a
floor-mopper or a tap turner-off?
The medical and nursing profession
have long been floor-moppers, using
drugs and technology to floor-mop the
overflow of illnesses and disabilities in "'
the community. With the knowledge
of preventive medicine being limited,

20 • CMJI

this seemed the most logical response
and therefore, the clinically-oriented
drug-technology-dispensary-hospitaloriented healing ministry developed.
As we reach the end of the millen­
nium, medical knowledge has grown
and our knowledge of diseases has also
improved greatly. Many more of the pre­
ventable causes of illness are known and
the deeper social determinants are bet­
ter understood. Also newer tap-turningoff skills have been developed to vary­
ing levels of competence.
Are the healers in the ministry ready
to become tap turners-off or are they go­
ing to continue t& ‘floor-mop’ in the old
tradition, getting distracted and carried
away by the glistening versions of floor
mops being produced by the multina­
tional medical industry today?
For many in the ministry, this ques­
tion will be a very disturbing one as it
was for me 30 years ago. Brought up on
the white coat, stethoscope and
Pavlonian prescribing reflexology of or­
thodox medicine, I failed to understand
what tap turning-off meant and its rel­
evance to the medical vocation, when I
first heard about this ideas. Today, three
decades later, I have become a little wiser.
• The ‘floor-mopper in me had stressed
the relevance of coronary care units and
promoted coronary bypass surgery, till
the ‘tap turner-off’ in me took over to
promote exercise, cycling, diet modifica­
tion, reduction in smoking and various
other lifestyle changes and social controls
over advertising.

1

I

• The ‘floor-mopper in me had stressed
trauma surgery and neurosurgical care
as a response to the increasing epidemic
of accidents and violence till the ‘tap
turner-off’ in me took over to
promote road safety, occupa­
tional hygiene, helmets and belts,
gender sensitivity and communal
harmony.
• The ‘floor-mopper’ in me had
promoted vitamins - pills, tonics,
enriched and fortified foods in re­
sponse to the continuing prob­
lem of malnutrition - till the ‘tap
turner-off’ in me took over to pro­
mote low-cost, local food mixes,
vegetable gardens and efforts to
make our institutions more baby­
friendly and our society more nu­
trition security conscious.
• The ‘floor mopper’ in me had
stressed intravenous fluids and
antidiarrhoeals for the treatment of child­
hood diarrhea till the ‘tap turner-off’ in
me took over to promote home-based
ORT, access to clean water, and environ­
mental sanitation and land reform.
As a medical college teacher for a de­
cade (1973-83), and as a community
health trainer in the next two-decades
(1984-2003), I discovered an additional
challenge in Prof. Burkitt’s question.
Could education of the health team
geared to the floor-mopping tradition
of orthodox medicine be reoriented to
the tap turning-off challenges arising
out of the new medical knowledge of
today? Is socially relevant and commu­
nity-oriented education of such a health
team possible? Could health team mem­
bers be sensitised to the deeper socialeconomic -political-cultural determi­
nants of health? *
Today, three decades after hearing
that disturbing question, I can unrepentantly affirm that floor-moppers
among us can become tap turners-off.
But floor-moppers need a new under­
standing of medicine - a ‘conversion’
if you please.

'

1

...... ..Jjyu.

■ -IJ

What type iof Healthworker are you?
A “Tap Turner-Off”

OR

A “Floor Mopper”

I
I

This new vision calls for a paradigm
shift in our thinking - a shift to a new
people and community-centred, holis­
tic health paradigm promoting people’s
empowerment, educational and soci­
etal processes, and creating autonomy
and awareness-building.
The Christian Medical Commission
study on ‘Health and wholeness: the
Christian role in health’ some empha­
sizes the same need for conversion in a
different way. Its study recognises a
simple fact:
“From around the globe, the 10 re­
gional grassroot consultations on
‘Health, Healing and Wholeness’ wove
a tapest^ depicting their understand­
ing of health. The major recurrent
thread throughout that fabric is the fact
that health is not primarily medical. Al­
though the ‘health industry’ is produc­
ing and using progressively sophisti­
cated and expensive technology, the in­
creasingly obvious fact is that more of
the world’s health problems cannot be
best addressed in this way”.
Thirty years ago, I was asked the
question: Are you a ‘floor-mopper’ or a
‘tap turner-off’? Today, the question 1
21 • CMJI

W.::S ■

would like to put to you for serious re­
flection is: Can the healing ministers
continue to be floor-moppers when
they are being challenged to become
tap turners-off? If so, join the People’s
Health Movement - a global network of
‘tap turner-offs’. The People’s Charter
is a global consensus of around 1500
‘tap turners off’.
Are we ready for this conversion?

Dr Ravi Narayan, Coordinator
People’s Health Movement (Global)
(A revised and updated version df an ear­
lier Health Advocate column that teas fea­
tured in CMJI nearly a decade apo.)

I.

Ch -2-S
health

Bharat has spoken. ‘Is India Listening’?
Dr Ravi Narayan

Change is a way of life... but some changes herald a new epoch;
and then it is time for us to take stock

Dr Rain Narayan

^Tplhe results of the not-so-recent
| Indian elections, ‘Verdict 20Of’ JL the largest democratic exercise in
the whole w’orld. had been a joy and ju­
bilation for some and a crushing disap­
pointment for some others. As social sci­
entists and social analysts identify the
trends, the contradictions and the quan­
titative and qualitative realities of the
electorates’ behaviour patterns, the wis­
dom of Bharat becomes established.
RIGHT ACROSS THE VARIED ANALYSIS,
SOME FACTS ARE CLEAR AND HARD­
HITTING:

They have waited
over fifty years
for the country to make
a reality of the
constitutional
mandate

♦ The politics of hate has been re­
jected.
♦ Governments, who have promoted
development through economic re­
forms that ignore or exclude the poor
and the disadvantaged regions of the
state have been rejected.
♦ Those who claim to feel good’ when
so many around us are not feeling good'
and many decidedly feeling bad have
been rejected.
♦ ‘Origins of birth politics have been
voted out. Social sensitivicy and empathv have been voted in.
AS USUAL

♦ The poor have voted more than rich
♦ The rural have voted more than the
urban
♦ The illiterate, but wise villagers have
voted more than the ‘all knowing’
middle class and elite.
Bharat - (whom the poor represent)
has re-established again their local
wisdom.

38 • CMJI

The peoples wisdom has re-estab­
lished through ‘electronic voting ma­
chines’ that India is a secular, plural, di­
verse. but united country which has no
place for exclusionary models of eco­
nomic reform or the homogenising poli­
tics of communal polarisation'.
Bharat has spoken dramatically, em­
phatically and with unexpected passion!
IS INDIA LISTENING?

Are the elite planners and decision mak­
ers of India, who have in recent years been
pondering to the created needs and ‘fan­
cies' of the middle class in India, rather
than the development, health and welfare
needs of all. including Bharat. listening?
PEOPLE ARE SAYING LOUD AND CLEAR

♦ We want acknowledgment of our ba­
sic rights to food, water, shelter and emploxment!
♦ We want basic education and access
to Primary health and social services,
schools and the market place!
♦ We want freedom from hunger and
disease.
♦ We want a state government that de­
livers not only promises!
♦ We are happy with our pluralistic so­
ciety - and our multi-cultural and multi­
religions ethos. We reject chauvinistic
projects that destroy this ethos!
What does all this mean to us - doc­
tors and nurses, health professionals
caught up in our mission hospital, world
of diseases, drugs, technology and medi­
cal care pre-occupations?
It means different things to us depend­
ing on how w'e voted. If you voted for a

I
i

J

1

India that was shining with:
* The quest for education and social
• Information technology and ‘Golden
processes including universal literacy;
Highways'
women’s empowerment and life skill
• Foreign drugs and high tech hospi­
education for youth.
tals
k*
You will understand the
• Latest shining medical technology”
ver^ct -004 and discover
and medical tourism
that you are listening.
• Fast foods and multi-cultural cui­
Whatever your
sine
• The quest for technological so- \ J I
*c *
lutions to our basic social and soU'
cietal problems.
Sr ,
You may be disappointed with
vote,
the result and discover that you are
C
the message
not listening.
V
of verdict 2004 was
If you voted for a ‘India that could
clear. The people, es­
shine some day but not without:
pecially the poor and the
• Food, water shelter and employment
marginalised wished to par­
for all strategies
ticipate in the fruits of devel• Essential drugs which can be accessed
Xi/ opment.
by all people
They have no time for our pre­
• ‘Health for .Ml’ strategies that respond
occupation with computers; flyovers;
to the basic needs of people wherever
processed foods; television channels;
they are based
new temples: and fashion designs or our
• The quest for low cost effective alter­
shiny hospitals with sophisticated gad­
natives rooted in local tradition
getry. They have waited over fifty years

for the country’ to make a reality of the
constitutional mandate to the basic rights
of food, water, shelter, education health
and employment. Do they want it? Will
they make it happen?
ARE YOU LISTENING?
Did you vote for Bharat’ or for India? Did
you vote for ‘.Medical Tourism or ’Priman*
Health Care ?
Did you vote for Health for ^1’ or only
for ‘Health for Those who can pav ?

Dr Ravi Narayan
Coordinator, People 's Health
Movement Secretariat (global)
CHC-Bangalore
"Srinivasa Nilaya "
Jakkasandra 1st Main. I Block
Koramangala
Bangalore - 560034
E-mail:
secretariat (d pbmovement. or^

The Global Health Watch
The Global Health Watch is a new
stitutions and corporations to account
.........
We are still
looking for paniciparion
project led by the People’s Health
♦ Strengthen the links between civil so- from interested individuals > and
Movement which articulates civil
ciety organisations around the world
organisations.
society’s vision for global health. It is a
♦ Provide a forum for magnifying the
You can help us by:
platform for strengthening ofadvocacy
voice of the poor and vulnerable.
* Endorsing the Watch
and campaigns to prpmp^
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,iequ‘table
? Crea^g demand for the Global
f^diforall
ft B The Global t feahh Wch Reportfor2005 > Health W&tch in your region
The Wch will.
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♦ Promote human rights as the basis
'will be written by NGOs, academicians
and campaigners from around the world.
* Initiating local national and regional
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The first report will be launched at the
health watches
♦ Shift the health policy agenda to
rn .' time oftheWbrid Health Assembly in May '* Submitting testimonies and case
recognise the political, social and eco­
2005 and at the People’s Health Assem- .-stores
nomic barriers to better health
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39 • CMJI

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HEALTH ADVOCATE ARTICLES BY RAVI NARAYAN, CMJI , 1992-JUNE 2004.pdf

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