ARTICLES REPORTS
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- ARTICLES REPORTS
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WIDENING HORIZONS - II
Dear Friends9
In this issue we introduce txo books
raise important issues about the crisis in
hospital based medical services and the increasing
problem of iatrogenicity or the disease producing
nature of medical care itself.
Illich is one of
the severest critics of the medical profession
and Horrobin attempts an answer to Illich *s
criticism on behalf of the medical profession.
These two books read together gives us a balanced
view of the crisis at hand.
The next two books are more personalised
approaches by two committed Christian doctors to
find answers to the problems of providing hospital
service and health care programmes to communities
where poverty is an increasing constraint.
How
do hospitals reach out to the community ?
How
do we reorder our priorities ?
Their experience
and suggestions will be most relevant and thought
provoking for all our CHA members
RAVI NARAYAN
LIMITS TO MEDICINE - MEDICAL NEMESIS .
THEgE^L&BATIQNJOF-KKALTH
Ivan Illich, Penguin Books (Pelican 1977)
The foremost critic of trends in modern
medical practice, Illich presents thought-provoking
evidence that *
the
medical establishment has
become a major threat to health and the disabling
impact of professional control over medicine has
reached the proportions of an epidemic?.
Discussing iatrogenesis in great detail,
Illich makes one of the most forthright pleas
for ’demystification of medical matters • and
exhorts lay people to reclaim greater autonomy
over health decision making.
He writes that
’A professional and physician-based health-care
system that has grown beyond critical bounds is
sickening for three reasons:
it must produce
clinical damage that outweighs its potential
benefits} it cannot but enhance even as it
obscures the political conditions that render
society unhealthy; and it tends to mystify and
expropriate the power of the individual to heal
himself and to shape his or her own environment.
2
The medical and para-medical monopoly over
hygienic methodology and technology is a glaring
example of the political misuse of scientific
achievement to strengthen industrial rather than
personal growth
.
*
The book is divided into four
parts and deals with Clinical Iatrogenesis in
Part I, Social Iatrogenesis (medicalisation of
life) in Part II, Cultural Iatrogenesis (disabling
impact of medical ideology on personal stamina)
in Part III and The Politics of Health in Part IV.
Interestingly Illich warns that *
if
contemporary
medicine aims at making it unnecessary for people
to feel or to heal, eco-medicine promises to meet
their alienated desire for a plastic womb'.
He
also warns that gullible patients should not be
relieved of the blame for their therapeutic greed
by making physicians scapegoats.
Health must be
seen as a virtue, as a right and people must be
involved in ‘political action reinforcing an
ethical awakening - that will limit medical
therapies because they want to conserve their
opportunities and powers to heal
3
MEDICAL HUBRIS - A REPLY TO IVAN ILLICH
David Horrobin, Churchill Livingstone, 1978
This book should be read after the earlier
one since it is the first serious critique cE Illich's
book.
Horrobin does not dispute the facts presented
by Illich, but disputes his interpretation.
Inspite
of all the inaccuracies and exaggerations in Illich's
books that he attempts to point out, he concedes that
Illich's first sentence *The
medical establishment has
become a major threat to health • is right and that
this book could prove to be • one of the key medical
documents of the second half
of the twentieth century ’.
In a very open and level headed assessment of the
criticisms of Modern Medical Practice the author gives
his own tentative suggestions to bring about a change
in this situation.
a)
More “*
Science
He makes a plea for
in medicine'to eliminate the errors
encouraged by warm emotiontthat 'to do something
must always be better than to do nothing '
b)
Less use of technology by subjecting them to
stricter control to determine whether they really
benefit the patient.
Attempts
c)
to be made to keep medical institutions
as small as possible and only for those who
strictly need them.
4
d)
Assess professional training and prescribe
levels of training actually required to enable
people to do jobs effectively and cut out un
justifiable part of courses.
e)
Challenge the discrepancy between the high
ideals which doctors often profess and their
personal life styles and ensure that the
profession should be acre humane and less a
•certain road to wealth and security * - so
that the rightly motivated people are attracted
to it.
These changes should be made at four main
levels ; of the individual doctor, of the
organisation of the profession , of the
relationship between government and medicine
and medicine related industries, and of the
medical school.
- A book which puts Illich’s criticism in proper
perspective•
5
MEDICAL CARE IN DI^Vi-.LOPING COUNTRIES
- a Primer on the Medicine of Poverty - Ed. Maurice King
Oxford University Press, 1966.
To many doctors who are working in small rural health
centres or hospitals, this book will provide interesting
and ingenious solutions to many of their questions on
the practice of medicine in conditions of poverty.
is not only the suggestions but
It
philosophy
underlying the approach to such problems in rural
health care - that the book is encouragingly different.
It starts with twelve axioms of medical care which
include that medical care of the common man is immensely
worthwhile; medical care must be approached with an
objective attitude of mind which is free as far as
possible from pre-conceived notions exported from
industrial countries; the maximum return in human
welfare must be obtained from the limited money and
skill available; all medical staff have a teaching
vocation in the community they serve; and medical
care must be carefully adopted to the opportunities
and limitations of the local culture.
It goes on to discuss the health centre, health
education, auxiliary, patient care, paediatrics, PCM,
diarrhoea, under-five clinics, immunizations, tuberculosis,
anaesthetics, blood transfusion, laboratory, X'ray department
6
medical records and so on in thirty practical chapters
which teesse based on ideas shared at a symposium organised
by Makerere University, Uganda on
Hospitals in Africa’.
’Health Centres and
It invites readers to feel free
to add or detract any idea and hopes that more of these
ideas will come from local doctors of developing
countries for whom this book was written.
PAEDIATRIC PRIORITIES IN THE DEVELOPING l;ORLD
David Morley, Butterworths, 1973.
This book is based mainly on the work of Dr. Morley
and his colleagues in Ilesha, Nigeria where among other
tilings over 400 children born into the village were
followed UP for over
5 years.
The ideas generated
from the Nigerian study were shared by Dr Morley with
colleagues in west and East Africa, Middle East,
India and south America and the discussions led to the
writing of this book.
the book is to
In the words of the author
’be of help to those planners who are
involved in discussion with the doctor-monopoly
may be at times conservative in its outlook’.
on from Maurice King *s
which
Taking
book, Dr. Morely defines his
own axioms of child care which include that an objective
and imaginative approach to child health is necessary
supported by a knowledge of loca 1 customs and practices;
HP G'33
7
a maximum return in terras of reduced child mortality
and healthier and happier children must bo obtained
from the limited funds available; do not separate
mother and child; child care must be the best that
circumstances allot; and so on.
In twenty two chapters
that include topics such as care of newborn, breast
feedingj at-risk child, road to health c ard, diarrhoea,
acute respiratory infection, measles, wikooping cough,
malaria, TB, skin diseases, anemia
family planning,
Dr Morley puts together an approach based on priorities,
practicality and common sense.
The book gives 228
references of work done on the problems covered in the
book especially in developing countries and makes an
impact because it comes from a committed clinician.
The book has an assessment questionnaire to be filled
up by every reader so that a constant feedbac k is
maintained.
_
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ST SOHN'S MEDICAL COLLEGE, BANGALORE 560034
Directorate of Rural Health Services and
Training Programmes
NEWSLETTER 4
JUNE
1982
Dear Friends,
With great sorrow we inform you of the passing
away of Major General B Mahadevan, Ex-Director
of Rural Health Services and Training Programmes
on 7th June 1982, after a heart attack. 'Papa'
as he was affectionately called by all of you,
was responsible for the development of the CHW
course and-we all remember with great gratitude
the interest and enthusiasm with which he planned
each course and guided each group of .participants.
Among the many contributions he made to the college
during the six years that he was associated with it,
as Professor of Community Medicine and Director,
he will be remembered particularly for his commitment
to re-orienting the college to Rural Health WorkMay his soul rest in peace!-
"Yes, all men are dust, but some are gold dust"
- John A. Shedd
For those of you, who would like to communicate with
his family, the address is;
MRS C. MAHADEVAN
187 Defence Colony
Indira Nagar, Bangalore 560038
(2) NEWS FROM THE COLLEGE
(a)
Affiliation :
The college has finally been granted
affiliation for two years by the Karnataka Government.
We thank you for your prayers!
We are continuing
the dialogue to get permission to start post-graduate
courses, which has still not been given.
(b)
Dr C M Francis, Dean left the college in May to take
up his new assignment as the Director of Salgaocar
Medical Research Centre in Goa.
(c)
Dr G M Mascarenhas, Professor of Cardio Thoracic
Surgery at St John's Medical College Hosoital has
taken over as the new Dean.
(3) NEWS FROM THE DEPARTMENT
(a)
Professor SV Rama Rao will complete his term as
Professor of Community Medicine on 30th June 1982
and will take over as the new Director of Rural
Health Services and Training Programmes from
1 July 1982. So please keep in touch with him
regarding your work.
... ...2
; 2s
(b)
The next Basic Course for Community Health
Workers (CHW BC9) will commence on 30 Aug 82.
The last date for applications is 30.7.82.
(c)
The next Refresher Course'for Community Health
Workers (tHW RC-4) will commence on 22 Nov 82.
The’ last date for receipt of applications is
10 Oct 82.
4. OUR PROJECT PLANS
As planned earlier, we shall be spending the summer
and monsoon months - MAY-JUL - writing out our experiences
of the CHW courses and analysing all the letters and questionnaires
that you have sent to us since 1979. We also hope to complete other
writing commitments.
Our extensive travel undertaken in January-April made us
realise that it would be unrealistic to try and cover the
whole country in a year. Many of our friends and CHWs are working
in interior areas and getting to each of them takes a lot of time
and travelling.
We feel that such a field contact can be undertaken by us
over a longer period of time ano need not be completed by December
1982.
Also other faculty could be involved as well. We also feel
that getting CHWs together at a central place for a one-day meeting
would not only cut down travel time but also give opportunities
for them to meet each other. The TNVHA meeting (NEWSLETTER 3)
was one such opportunity, places where this seems possible are
the Nilgiris, Mangalore region, Karwar region, Goa and Wynad.
We have decided now to give the Southern States lower priority
since we can continue to keep in touch with, them in later years
from St John's. The next trip will probably cover the Eastern region
■since this is a much neglected area. We are awaiting letters before
we finalise details.
With best wishes and regards,
RAVI i THELMA NARAYAN
"If everyone of us could drink pure clean water, keep our
surroundings free from flies and dirt, and make the best
use of the food we grow and buy, we could protect ourselves
against diseases and many of our health problems will
disappear. For pure water, good’ sanitation and adequate
nutrition are the world's best medicine"
\
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)t JOHN'S MEDICAL COLLEGE, BANGALORE 530034
Directorate of Rural Health Services and
Training Programmes
o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-e-o-o-o-o-o-o
NEWS
LETTER-1
JANUARY 1982
Dear
Greetings from Bangalore
Thanks for the lovely cards, interesting letters and
information that we hav( been receiving from you all in
response to our letter and Questionnaire sent in the second
week of December. The prompt response from about 90 CHWs
has been very encouraging. Not only has it given us great
confidence in the country's postal service but we have realised
that the CHW network is active and enthusiastic. Though not all
of you are doing village health work we were glad to hear that
the knowledge shared during the course is being put to good use
in a wide variety of situations which range from teaching in
schools; working in homes for aged, orphans, handicapped and
leprosy patients; infirmarians of communities; helping in
dispensaries; organising income generation schemes; running
community farms and estates and so on. A few have even become
superiors and we hope they will encourage others in the
congregation to get involved in rural work.
(1)
* The new Community Health Worker is not a paqshre provider of
*
*care who waits for patients to present themselves, but a
*
§dynamic promoter of self-help programmes leading to community *
^health. — Earthscan
g
*»
«****
*»»
*«»«•»»
***%
#
*
a###
******* ****** **********
(2) N>w for news about some of your colleagues.
(a) Location
The 155 CHWs arc spread out all over Indiaiin Andhra (17)
Assam (3), Bihar (12), Delhi (1), Goa (3), Gujarat (1),
Haryana (1), Karnataka (39), Kashmir (1), Kerala (7),
Maharashtra (7), Manipur (1), Mizoram (1), Madhya
Pradesh (11), Orissa (8), Tamil Nadu (12), West Bengal
(9) and Uttar Pradesh (18). Three are abroad - Ifepal (1),
Ghana (1) and USA (1) and one is just preparing to go
to Sudan.
(b) Health Work
The community health programmes being carried out include
Maternal & Child Health, CRS Nutrition programmes, School
Health, Balwadis, Health Insurance Schemes, training
local health workers and animators, NEP and Family Life
Promotion, Adult Education, organising youth and mothers,
and health education. We shall let you know details in
later newsletters, as we visit some of them.
p.t.o...2
contd..•from pre-page
(c)
- 2
Furthuring skills
Some CHWs have been adding further skills and knowledge
through other courses.
Nursing: Sr Tresa Jose (BC1), Sr Annakutty (BC4),
Sr Malathi Dophu (BC2) and.Sr KLsy (BC1).
Para-medical Course: Sr Juliana (BC4) and--Sr Lalitha (BC7).
Community Development and Social Work: SrElsy (BC5),
Sr Antonia/.Sr Bonitag"^BC2) has just completed a.specialcourse in the Care of Mentally Retarded Children.•
/BC2
(d)
Refresher Courses:
The following returned to St John's for a refresher course
in the last, two years - Sr Ann and Sr Trcsa Jose (all of
BC1); Sr Suma, Br Susantoy Sr Justina, Sr Martha Soreng,
Sr Vinaya, Sr< Theres Thomas, Sr Jovitta.(all of BC3)’, ■
Sr Mary Kurisscry and; Sr Mariamma Antony, (of BC4); and
Fr Joseph’ Furayidpm and Sr Pierlisa- (of: BG6). We hope many
more of you will get the opportunity in the future'.
(e) To the following who have been ill, W6 send our prayers
for a speedy recovery to an active'reaching out. Br Joseph
Jayaprakash (BC4), Sr Veronica (BOS') and Sr Immaculate Kisku(BC6).
(3)
St John's and Departmental News
(a)
We thank all- of you who sent messages, of support' and prayers
during the St John's crisis. You will be glad to know that
Bishop.Patrick of Varanasi told a CBCI Meeting in Tiruchi
on 12th January '82 that a happysolution of the problem
is expected by end of February. The discussions are taking
place' in a very friendly atmosphere (Indian Express—13.1.82^.
(b)
Maj Gen B Mahadevan (papa) retired from active service in
February 81, He was ill for.sometime and ’is . much better now..
:We thank all of you for keeping-him in your ..prayers,
The
following staff have left for higher studies:'
Dr Luis Barreto.to Canada; Dr K.’Nagaraj to Wardha; and
Dr SB Prakash to Hubli.
(d) The following have .joined the team in 1981. Dr Antony
Cblaco,' Dr G Gururaj, Dr & Nagaratna, Dr Kiriti Keshavan
■ and Dr K Malathi.
(e) Professor- SV Ra.ma, Rao-continues' as Professor & Head of
. the Department.
(f) The next CHW Basic Course (CHW BC9). commences on 30.8.82
and the next Refresher Course.(CHW RC4) commences on- 8.11.82.
(c)
With best wishes, and regards,
Yours sincerely,
Thelma and Ravi Narayan
** ********************************************************************
J"I seek not Kingdom nor Paradise nor even Salvation. I seek only
* the Deliverance from Affliction nf the Afflicted"
** ******* *************************************** »»******~if
*»***
*****
*
|^| )3 G-
SI No
House No
ST THOMAS MISSION SOCIETY, MANDYA
Town
Nagar
Socio-Economic Survey :
19
■_.Hobly
Village
1-
Name
2.
Address
5.
Members’ Name
Taluk-
_______________
Sex
Age
_
3-
Religion
4.
Caste/Comm
Rel to
Head
Educa
Occupa Remark
1)................. ....... ............. ....................
2)___ ____________________
3)____________ ____________________
4)..................... ............. .....................
5)___ -.......... ........................................
6).............. ............................................ .
7)..._____________________________ ...__
8)_____ _ ____ '...................................
9)____
10)...................... .....................................
11)_____________________ _ ._____
12)............ .............. ...............................
6.
7.
8.
.. .. —..
Disabled: ( ) Deformed
( ) Mentally retarded
( ) Dumb
( ) Deaf
( ) Blind
( ) Lame
( ) Old
( ) Orphan
House:
Own/Rent ( ) Single/Joint ( ) RCC/Tiled/Thatched ( ) Mud/
Brick I Stone
( ) Cement floor I Dung
•.( ,) Electr. I Not
( ) Own well / comm. Well / pipe
( ) Bath room
( ) Closet
( ) Phone ( ) Oven by Keros/wood / Dung cake /chaff/Gas/charcol
( ) News paper
( ) Magazine
(. ) Radio
Land
Acre | Cultivation. |~Production-1 ~ Water facility | Pump
Wet ■- ...................................................................................................... !...............
Dry:- ......... -...................................................... ................................... I................
9.
Live-stock ■- Bullock [ Cows | Buffalo | Sheep | Goat | Donkey | Pig | Others
Number|
|
|
1
J
I
|
10.
Industry
I No of employee i Profit
Name
Problems
Big
Sm. scale
11.
12.
13.
Cottage
Other
Industry
Name possible ones 1)
2)
Vehicle
( ) Bullock cart ( ) Horse cart ( ) Cycle ( ) Bike ( ) Auto
( ) car
Educational ( ) Nursery
( ) Primary Lower / Higher / English / Kannada
facility
( ) High School / Engl / Kannada ( ) College ( ) Adult ed. scheme
Distance to the nearest Higher Primary...
Distance to the nearest High school
The school your children go
.
14.
Medical
facility
(
) Hospital
( ) Homeo
(
.
( ) Health Centre
( ) Dispensary
) Clinic
( ) Ayurvedic
. 1.
Distance to the nearest Hosp/Clinic/Dispen/
__
Recurring diseases ?
Rural Health programmes ?
Preventive medicines ?
15.
16
Recreational ( ) Clubs
( ) Theatre
( ) Reading Room
facility
( ) Park
P and T
Post ( ) Office. Distance to the Post Office . . .
17.
Distance to the Telephone PCO
Marketing ( )Milk Society
( ) Co-operative Society
& Banking fund ( ) Small saving scheme.
Problem of marketing
18.
(
) Playground
.
..
.
............................
( ) Bank ( ) Chit
Nearest Bazaar ...- -----------------------
.......... —- ------------ ---------- ---- -
. .... -.......................................................................................................... ...
2)
Felt needs ■ The needs of the place are
1)............. ...........
19.
2)Assessment of the family^ economic position:( ) Upper
( ) Middle
( ) Lower
20.
Surveyed by
Date .....
( ) Lowest
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CATHOLIC RELIEF SERVICES - USSC MADRAS ZONE
NUTRITION EDUCATION PROJECT INDIA 76-45
MATERNAL CHILD HEALTH PROGRAM
MONTHLY
REPORT
FOR
1.
Name of the Centre
2.
Month of Reporting
3.
a. Number of anti-natal mothers participating
.................
in MCH Program
b.
Number of Post-natal mothers participating
in MOH Program
c.
Number of women delivered
d.
Common ailments among this group
iii
iv.
v.
vi.
e.
4.
Treatment given.
Pre-school children
a. Number of children treated for ;
1 Scabies
b.
2
3.
4.
5.
Other skin diseases
Worm infestation
A G. E. (Acute Gastro enteritis)
Respiratory Infections
6.
7.
Others
Deficiency Diseases Observed
1. Anaemia
2. Kwashiorkor
3
4.
5.
C. S. O. M.
Others
Marasmus
Vitamin Deficiencies (specify)
MEDICAL
AID
19
GIVEN
2
5. Treatment given
6
Causes
7.
Advice given
8.
Follow-up Action
9-
Other remarks
Date :
Seal :
Signature of Nurte
REPORT
FAMILY
OF
NUTRITION
COURSE
1. Name of the Centre :
2.
Name of Centre - in - Charge :
3.
Name of Local Aide :
4.
Reporting Month :
5.
Number of mothers Selected for FNC :
6.
Number of Absentees :
7.
Reasons for Absenteeism :
8.
Number of days FNC conducted
9.
Course content:
Date
Topic
198
Teaching
method
.
Visual Aid
used
Demonstration
conducted
Mother’s
response
10.
Problems Faced:
11.
Others :
Date :
Si gnature.
Signature of the Organiser
LW :
REPORT FOR CENTRE - IN - CHARGE
1.
Name and Location of the Centre.
2. Reporting Month
NEP
MCH
3.
Total number of Recipients :
a.
No of expectant Mothers
b.
No of nursing mothers
c.
No. of children 7 months
d.
No. of children 3 years
4.
Health and Nutrition Education
Centre
5.
Groups
— 3 years
— 5 years
Dates of
Clinics
Topic selected
for Nutrition
Health Education
Family Nutrition Course
a. No. of mothers participated regularly
b. No. of absentees
c
5.
Reasons for absenteeism
Problems faced by the Centre in organising classes
a.
Climate
b.
Mothers go out to work
o.
Others
7.
Follow-up visits
a, Number of families visited
be.
2
3.
4.
5.
Remarks
Food Demon
stration
conducted
Visual
Aid
Used
2
8.
Immunization
Name of the vaccine
and doses
Please write if there is any
reaction
dose
DPT
II
OPV
III
doses
II
III
SMALL POX
BCG
9-
Other Remarks
Date
Seal
Signature of Centre-in-charge
8
Finance:
°P6nillS
Balance
Particulars
Receipt
Closing
Balance
Expenses
Balance B.F.
Receipts
1. Collection from
Mothers
2.
Registration
Fee
3.
Sale of Empty
containers
4.
Others
Expenses
1
Freight &
Service Charges
1
2.
Sale of empty
containers
3.
Reg. fee to Diocesan
Director
4.
Salaries for full-time
workers
5-
Wages for Part-time
workers
6.
Transport expenses
to villages
-
7
T. A. & Supervision
8.
Stationery &
Postage
9.
Medicines
10.
Miscellaneous
TOTAL
Grand Total
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(D Project.-1982
We have been plan, ing out our travels
to your letters. We—shail let- you ]<
vhon" v.b' will
he pro. j ramme
ailNadu, a 35 km trek
in Aurarig^bad
a sojourn
of Ardhra
Bihar
Aace
days for our
1 places for a day eg
tions will be most
Icome. Do keep
in touch
be IJ-1C
ff Guari
St John ’s Medical College
Bangalore 56OO34
‘Many problems can be resolved when people work together
iard give each other help ard support
(&) Keeping contact with the Dept
While we are a ...ay on our travels, if you
are interested in the following:
a) List of latest addresses of CHVis of your batch
ard those working in your area; (b) letter to your
PHC doctor or DMO introducing you ard requesting
tnem to encourage you and include you in their
programmes (send name ard address of doctor/s);
(c) Details of next Basic Course or Refresher Course;
(d ) Any other inf ormatio^/please write to
Dept of Community Medicine, St Hohn's Medical College,
Bangalore 560034.
-2—
Element 5:
Humour
a.5
Ply humour is very often seen by others as irrelevant or pointless.
5
b.
Ply humour aims at maintaining friendly relations; or when strains
do arise, it shifts attention away from the serious side.
5
c.
My humour is very often hard-hitting, e.g. loud and pointed.
5
d.
My humour is putting me, or a position, in a favourable light.
5
e.
My humour fits the situation and always aims at giving pers
pective to the situation; even under pressure! retain my
sense of humour.
Element 6j
Effort
c-.B
I just put in enough effort to get by
6
b.
r rarely lead,
6
c.
I drive myself and others hard
but extend help
6
d.
I seek to maintain a good and steady, but not fast pace.
6
e.
I put in vigorous effort and others join in.
WORK SHEET
Pa RA GRAPHS
---------------------
a :
b #
'--------------------c :
(Enter the rank 1 or 2 or 3 or 4 or 5
against each paragraph (a, b, c, d, e) on
the dotted line)
e :
ELEMENTS
Copy the code letter (a or b or c or d or e) against each
Element(1 to 6) in the dotted space belows
Element 1 ; Decisions
Element 2 :
Convictions
Element 3:: conflict
Element 4
s Emotions
:
:
;
s
Element 5 :
Hunour
5
Element 6 :
Effect
:
5
(•<) Keeping.. taack..,-.
';t
’■ ' Jr‘
...
...------ -We-have -no-news- recently-from the following . If you
are in touch please ’ seifl us their latest addresses
.about .what .they are., .doing.,..._________
—.-------- .§rd_
- Sr-Michael'-'Tcrasu, BC6 -'Sr Paula, Sr; Stella
Mary ,. Sr- Betcy , . Sr -Celine Sa-ngma, .
Amutha,
BC5 - Sr Annette, Sr Genevieve.,..^Sr.-Kirmala^..Sr AnnieJose-j- Sr Elsie-, Sr Anna .Joseph, Br Sebastian Dung Dung,
Br Francis Tiru; Bc-4"- Sr Anasasia, Sr Egidia, Sr Evan gelir
Sr Servia ,.„,sr. jbsetta yBr George, i-k;' BC3 - Br G Victor,
BC2 - sr Shuba Minj."ard-.-.Br.,Nirmal.a.j-i .
•
News ofJ arty of your other- .colleague,s,- will also be
always welcome.
Hope you "Sre in touch with VHAI (Voluntary-Health
Association of Trdia, C-14 Community' Centre, -Safdarjung
Development"Area-,- New Delhi iicdl6)’ and CHA (Catholic
..Hospital Association of India, CBCI Centre, Goldakkhana,
.: New Delhi-.110001). ;They will keep you in touch .with
new concepts in health, audiovisual education materials
ard .contacts with others working, in the f ield in your
states.
*********
— 2—
Element 5;
Humour
a.5
My humour is very often seen by others as irrelevant or pointless.
5
b.
My humour aims at maintaining friendly relations; or when strains
do arise, it shifts attention away from the serious side.
5
c.
My humour is very often hard-hitting, e.g. loud and pointed.
5
d.
My humour is putting me, or a position, in a favourable light.
5
e.
My humour fits the situation and always aims at giving pers
pective to the situation; even under pressure I retain my
sense of humour.
Element 6s
c-.6
Effort
I just put in enough effort to get by
6
b.
I rarely lead,- but extend help
6
c.
I drive myself and others hard
6
d.
I seek to maintain a good and steady, but not fast pace.
6
e.
I put in vigorous effort and others join in.
WORK 'SHEET
PARAGRAPHS
---------------------
a :
b .
*--------------- ;----c :
:
:
'
(Enter the rank 1 or 2 or 3 or 4 or 5
against each paragraph (a,b,c,d,e)on
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■.
ELEMENTS
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Element 1 ; Decisions
Element 2 :
. :
Convictions
Element 3;; Conflict
•
Element 4 s
:
Emotions
Element 5 :
Humour
:
Element 6 :
Effect
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WIDENING HORIZONS - IX
Dear Friends9
In this issue we introduce two books >•
raise important issues about the crisis in
hospital based medical services and the increasing
problem of iatrogenicity or the disease producing
nature of medical care itself.
Illich is one of
the severest critics of the medical profession
and Horrobin attempts an answer to Illich's
criticism on behalf of the medical profession.
These tvjo books read together gives us a balanced
view of the crisis at hand
*
The next two books are more personalised
approaches by two committed Christian doctors to
find answers to the problems of providing hospital
service and health care programmes to communities
where poverty is an increasing constraint.
How
do hospitals reach out to the community ?
How
do we reorder our priorities ?
Their experience
and suggestions will be most relevant and thought
provoking for all our CHA members
RAVI NARAYAN
LIMITS TO MEDICINE - MEDICAL NEMESIS.
THE EXPLORATION OF HEALTH
Ivan Illich, Penguin Books (Pelican 1977)
The foremost critic of trends in modern
medical practice, Illich presents thought-provoking
evidence that ’the medical establishment has
become a major threat to health and the disabling
impact of professional control over medicine has
reached the proportions of an epidemic
Discussing iatrogenesis in great detail,
Illich makes one of the most forthright pleas
for ’demystification of medical matters ' and
exhorts lay people to reclaim greater autonomy
over health d ecision making •
He v.rites that
‘A professional and physician-based health-care
system that has grow beyond critical bounds is
sickening for three reasonss
It must produce
clinical damage that outweighs its potential
benefits; it cannot but enhance even as it
obscures the political conditions that render
society unhealthy; and it tends to mystify and
expropriate the potver of the individual to heal
himself and to shape his or her own environment.
2
The medical and para-medical monopoly over
hygienic methodology and technology is a glaring
example of the political misuse of scientific
achievement to strengthen industrial rather than
personal growth
.
*
The book is divided into four
parts and deals with Clinical Iatrogenesis in
Part Is Social Iatrogenesis (medicallsation of
life) in Part IIS Cultural Iatrogenesis (disabling
Impact of medical ideology on personal stamina)
in Part III and The Politics of Health in Part IV.
interestingly lllich warns that ‘if contemporary
medicine aims at making it unnecessary for people
to feel or to heal, eco-medicine promises to meet
their alienated desire for a plastic womb
.
*
He
also warns that gullible patients should not be
relieved of the blame for their therapeutic greed
by making physicians scapegoats.
Health must be
seen as a virtue, as a right and people must be
involved in
‘political action reinforcing an
ethical awakening - that will limit medical
therapies because they want to conserve their
opportunities and powers to heal
A thought provoking book to be read by all
CHA members.
3
MEDICAL HUBRIS - A REPLY TO IVAM rtjL:!i:CH
David Horrobin, Churchill Livingstone, 1978
This book should be read after the earlier
one since it is the first serious critique cf Illich 's
book.
Horrobin docs not dispute the facts presented
by Illich, but disputes his interpretation#
Inspite
of all the inaccuracies and exaggerations in Illich *s
books that he attempts to point out, he concedes that
Illich *s
first sentence *The
medical establishment has
become a major threat to health • is right and that
this took could prove to be • one of the key medical
documents of the second half
of the twentieth century '.
In a very open and level headed assessment of the
criticisms of Modern Medical Practice the author gives
his own tentative suggestions to bring about a change
in this situation.
a)
Moro *
"Science
He makes a plea for
in medicine'to eliminate the errors
encouraged by warm emotion 'that 'to do something
must always be better than to do nothing •
b)
Less use of technology by subjecting them to
stricter control to determine whether they really
benefit the patient.
Attempts
c)
to be made to keep medical institutions
as small as possible and only for those who
strictly need them.
4
d)
Assess professional training and prescribe
levels of training actually required to enable
people to do jobs effectively and cut out un
justifiable part of courses.
e)
Challenge the discrepancy between the high
ideals which doctors often profess and their
personal life styles and ensure that the
profession should be more humane and less a
'certain road to v.ealth and security • - so
that the rightly motivated people are attracted
to it
*
These changes should be made at four main
levels ; of the individual doctor, of the
organisation of the profession , of the
relationship between government and medicine
and medicine related industries, and of the
medical school.
A book which puts Illich's criticism in proper
perspective.
5
MEDICAL CARE IN ICVELOPINC COUNTRIES
- a Primer on the Medicine of Poverty - Ed. Maurice King
Oxford University Press, 1966.
To many doctors win are working in small rural health
centres or hospitals, this book will provide interesting
and ingenious solutions to many of their questions on
the practice of medicine in conditions of poverty.
It
is not only the suggestions but the philosophy
underlying the approach to such problems in rural
health care - that the book is encouragingly different.
It starts with twelve axioms of medical care which
include that medical care of the common man is immensely
worthwhileJ medical care must be approached with an
objective attitude of mind which is free as far as
possible from pre-conceived notions exported from
industrial countries} the maximum return in human
welfare must be obtained from the limitcd money and
skill available; all medical staff have a teaching
vocation in the community they serve; and medical
care must be carefully adopted to the opportunities
and limitations of the local culture.
It goes on to discuss the health centre, health
education, auxiliary, patient care, paediatrics, PCM,
diarrhoea, under-five clinics, immunizations, tuberculosis,
anaesthetics, blood transfusion, laboratory, X
ray
*
department
6
medical records and so on in thirty practical chapters
which were based on ideas shared at a symposium organised
by Makerere University, Uganda on
Hospitals in Africa
.
*
’Health Centres and
it invites re<iders to feel free
to add or detract any idea and topes that more of these
ideas will come from local doctors of developing
countries for whom this book was written.
PAEDIATRIC PRIORITIES IN THE DEVELOPING WORLD
David Morley, Butterworths, 1973.
This book is based mainly on the work of Dr. Morley
and his colleagues in Ileshu, Nigeria where among other
tilings over 400 children born into the village were
followed UP
over
5 years.
The ideas generated
from the Nigerian study were shared by Dr Morley with
colleagues in west and East Africa, Middle East,
India and touth America and the discussions led to the
writing of tills book.
the book is to
In the words of the author
’be of help to those planners who axe
involved in discussion with the doctor-monopoly
may be at times conservative in its outlook •.
on from Maurice King *s
which
Talcing
book, Dr. Merely defines his
own axioms of child care which include that an objective
and imaginative approach to child health is necessary
supported by a knowledge of loca 1 customs and practices;
7
a maximum return in terms of reduced child mortality
and healthier and happier children must be obtained
from the limited funds available: do not separate
mother and child; child care must be the best that
circumstances allow and so on.
In twenty two chapters
that include topics such as care of newborn, breast
feeding) at-risk child, road to health c ard, diarrhoea
acute respiratory infection, measles, whooping cough,
malaria, TH, skin diseases, anemia , family planning,
Dr Morley puts together an approach based on priorities
practicality and common sense.
The book gives 228
references of work done on the problems covered in the
book especially in developing countries and makes an
impact because it comes from a committed clinician •
The book has an assessment questionnaire to be filled
up by every reader so that a constant feedbac k is
maintained.
WIDENING HORIZONS-!
(CHA)
Dear Friends,
In the Eflitioftal of ’Medical service’ of January 1982,
our editor wrote "The catholic Hospital Association of
India, through its member institutions, need to realise
the seriousness of the present day challenge.
Option
for the poor is all the more important in the health care
field,
if our option is for the poor, then we need to
rethink about our health services,
we need to shift
our emphasis for curative aspect of health to health
promotion, and health maintenance by the people themselves.
This is a great challenge but worth taking•"
While considering this challenge medical teams in
all the member hospitals will have to get together to
reflect on this option, feel convinced of the alternative,
evaluate their own present-day efforts and mo¥e
gradually towards the new ideal.
The ’Medical Service’
through its new orientation will attempt to provide
articles and case studies to stimulate and encourage
this process of change.
There are no definite
directions or clear cut answers but it is most important
that we are open to dialogue with those who are raising
issues and spear-heading change.
In this column we
shall keep you in touch with t he c ontributions of
committed workers in this field .
You a re invited to
get hold of these books/reports (sources have been
mentioned) and initiate discussions on them to help
the process of change in your hospitals.
Any
suggestions for books to be included in this column
would be most welcome.
The extracts and notes on each
book are merely to help you understand the scope of
the book.
The selection is open-ended and do not
represent the thinking of CHA always.
We feel you must
-2-
read them yourselves and make your own decisions on
the perspectives shared by the authors.
All we know
is that these books have helped initiate dialogue
every where.
ravi n ar ay an
1 • The New 0rlentat.ioP o£ Health Services
Respect to
Primary Health Care work - The Pontifical Council
Cor Unum, Vatican City, 1978 (Available through CHAI
or CBCI in New Delhi)
This booklet contains the conclusions of an expert
group of Medical and Health Care Professionals invited
to examine the new orientations of health services to fit
in with the Primary Health Care Policy.
The booklet
starts on the premise that 'If we wish to be faithful
to Christ and take up his attitudes with regards to
our fellowmen, we must work for the overall development
of each man, and focus on the sick person more than on
his sickness,
since development also means solidarity,
we must necessarily turn our attention towards the human
community of the patient, his family first, but also his
neighbourhood or village.
community medicine'.
This means we must practice
It then reviews the WHO and
National Policies of Primary Health Care and the role
of the doctor, nursing staff, health auxiliaries and
community health workers.
It also suggests a new
orientation to the hospital, health care centre, and
government health organisations. Health services based
on hospitals only are 'leaven far removed from the loaf 1
and therefore it exhorts all of us to 'reach out towards
the masses by providi-g simple, accessible and promotional
health care according to our own possibilities, modest
as they are, or in conjunction with the public services,
where this is allowed t.
A must for all members
Rethinking the Healing Ministry of the Indian Church
2.
Jacob Chandy {Pamphlet on social Concern - Nev;
Series No. 2) Christian Literature society,
Madras (1970) - fc. 1.25/Professor Chandy starts by reviewing the studies
on Christian medical work in India, listing out problems
including their curative orientation, obsolescence in
building end equipment, underpaid staff, catering to
rich rather than the very poor, business orientation,
isolation from other mission or governmental work and
dependence on overseas donating agencies.
He questions
whether most of such hospitals are really symbols
of the healing ministry?
He goes on to warn that
•Christian Medical l.ork cannot afford to ignore its
theological basis - that total health or wholeness
is salvation • and the Indian Church must pioneer
once again to discover ’a new role within the context
of national development •.
The churches will have to
be responsive and take new directions within the
mandate of Christ which asks us to
*Go
and Heal
.
*
He outlines areas of change such as i) a new relation
ship between the church and medical teams
ii)
a new local leadership
integrated
iii)
health care programmes which emphasise
family care
iv)
greater utilization of governmental facilities and
programmes
v)
congregational and community participation in
recognition of needs and promotion of public health
measures
vi)
a
vii)
community orientation of existing mission hospitals
new financial outlook stressing local fund
generation
This little booklet raises many questions for
each of us to discuss with our colleagues.
-43)
An Alternative System of Health Service in India
some proposals - J P Naik, Indian Council of Social
Sciences Research, Alternatives in Development Series,
Allied Publishers, 1977 • Rs. 10/-
This booklet presents three articles by J P Naik,
D Banerji and. Jacob Chancy - three pioneers in India
who seriously question the philosophical framework and
organisation of the health care services in India and
suggest alternatives.
It also presents important extracts
from the significant report of the Group of Medical
Education and support Manpower set up by the Government
of India in 1976 (Srlvastava Report).
These four articles
put into proper perspective, the growing national debate
on alternative strategies in health care - alternative
to the 'over centralised, over expensive, over
professionalised, over urbanised and over mystified '
health service that we have at present.
Even though the
contributors are mainly concerned with the governmental
health care and planning, members of CHA will find this
booklet particularly useful since Catholic hospitals today
by and large are even more closely alligned to the
existing system, the lacunae and shortfalls of which are
described in this book,
while rethinking our own role
this booklet will help us to see it within the national
context.
4)
Health for All - An Alternative Strategy -
Report of a study group set up jointly by Indian
Council of Social science Research and Indian Council of
Medical Research (available at VHAI, C-14, Community
Centre, SIR, New Delhi 110016, &. 18/-)
This is latest in a series of efforts oficmr/icssr to
initiate a national debate on Health Care strategy and is
probably the most important of the four publications
mentioned in this note.
A must for every CHA member!
In the words of the authors “The objectives of the
National Health Policy should be to provide health
for -11 by 2000 AD.
These objectives and targets are
realistic and feasible.
But they cannot be achieved
by a linear expansion of the existing system and even
by tinkering with it through minor reforms.
short of a radical change is cailed for J
Nothing
Health is a
function not only of medicalc are, but of the overall
Integrated development of society - cultural, economic,
educational, Social and Political. Luring the next
two decades.... .integrated overall development,
improvement in nutrition, environment and health
education and provision of adequate health care services
for .11
should be pursued side by side within the
health sector.. ....... e
The existing, exotic, top-down
elite oriented, urban biased centralised and
bureaucratic system which over emphasises
large
urban hospitals doctors and drugs should be replaced
by the alternative model which is strongly rooted in the
community, provides adequate, efficient and equitable
referral services, integrates promotive, preventive and
curative aspects end combines the valuable elements
in our culture and tradition with the best elements
of the western system.
It is also more economic and
cost effective".
The why, what and tow of this alternative model
are discussed in fourteen chapters.
A report that
needs to b>: closely scrutinised and reviewed by all
of us interested in health Issues.
rif u
(mfc)
KEEPING TRACK - II
Dear friends,
The next three books in our column raise important
issues on the philosophy of Rodicinc and the increasing
problem of •latrogenicity ’ or the disease-producing nature
of medicine itself. The authors write mainly from their
experience of Medicine as practiced and developed in the
West, but in India, the same Western mocel in our urban
centres could well be facing the same crisis.
Interestingly ths ICMR/lCSSR Report (refer keeping
track I - No.4) already warns us that ’eternal vigilance’
is required to ensure that the health care system does
not get medicalised, that the doctor-drug producer axis
does not exploit the people and that the abundance of drugs
does not become a vested interest in ill health
.
*
For a
group like the mfc these are three books of utmost importance.
ravi narayan
»2t
5)
LIMITS TO MEDICINE - MEDICAL NEMESIS. THE EXPROPRIATION OF HEALTH
Ivan Illich, Penguin Rooks (Pelican 1977).
The foremost critic of trends in modern Medical Practice,
Illich presents thought-provoking evidence that "the medical
establishment has become a major threat to health and the
disabling impact of professional control over medicine has
reached the proportions of an epidemic”.
in great detail,
Discussing Iatrogenesis
Illich makes one of the most forthright pleas
for ’demystification of medical matters’ and exhorts lay people
to reclaim greater autonomy over health decision making. He
writes that "A professional and physician-based health care
system that has grown beyond critical bounds is sicktsning for
three reasonst
It must produce clinical damage that outweighs
its potential benefits, it cannot but enhance even as it obscures
the political conditions that render society unhealthy? and it
tends to mystify and expropriate the power of the individual to
heal himself and to shape his or her own environment.
The medical
and para-medical monopoly over hygienic methodology and technology
is a glaring example of the political misuse of scientific
achievement to strengthen industrial rather than personal growth”.
The book is divided into four parts and deals with Clinical
Iatrogenesis in Part I, Social Iatrogenesis (medicalisation of
life) in Part II, Cultural Iatrogenesis
(disabling impact of medical
ideology on personal stamina) in Part III and The Politics of
Health in Part IV.
Interestingly Illich warns that "if contemporary
medicine aims at making it unnecessary for people to feel or to heal
2
i3:
eco-medicino promises to meet their alienated desire for
a plastic womb".
He also warns that gullible patients
should not be relieved of the blame for their therapeutic
greed by making physicians scapegoats. Health must be seen
as a virtue, as a right and people must be involved in
"political action reinforcing an ethical awakening - that
will limit medical therapies because they?want to conserve
their opportunities and powers to heal".
A thought provoking
book to be read by all mfc/(?iffi. members.
.4
:4:
6)
MEDICAL HUBRIS - A REPLY TO IVAN ILLICH
David Horrobin, Churchill Livingstone, 1978.
This book should be read after the earlier one since it
is the first serious critique of Illich’s book.
Horrobin
does not dispute the facts presented by tllich, but disputes his
interpretation. In spite of all the inaccuracies and exaggerations
in Illich’s books that he attempts to point out, he concedes that
Illich’s first sentence "The medical establishment has become
a major threat to health
*
is right and that this book could prove
to be one of the key medical documents .of the second half
of the twentieth century".
In a very open and level headed assessment of the criticisms
of Modern Medical Practice the author gives his own tentative
suggestions to bring about a change in this situation. He makes
a plea for a)
More "Science" in medicine to eliminate the errors
encouraged by warm emotion that 'to do something must
always be better than to do nothing';
b)
Less use of technology by subjecting them to stricter
control to determine whether they really benefit the
patient;
c)
Attempts to be made to keep medical institutions as
small as possible and only for those who strictly need
them;
d)
Assess professional training and prescribe levels of
training actually required to enable people to do jobs
effectively and cut out unjustifiable part of courses;
e)
Challenge the discrepancy between the high ideals which
doctors often profess and their personal life styles and
ensure that the profession should be more humane and less
a 'certain road to wealth and security' so that the
rightly motivated people are attracted to it.
These changes should be made at four main levels:
of the individual doctor, of the organisation of the
profession, of the relationship betwen government and
medicine and medicine related industries, and of the
medical school.
A book which puts Illich's criticism in proper perspective.
«6s
7)
CONFESSIONS OF A MEDICAL HERETIC
Robert S Mendelsohn, Warner Books, New York - 1979
"If you’re ready to learn some of the shocking things your
doctor knows but won't tell you; if you're ready to find out
if your doctor is dangerous; if you’re ready to learn how to
protect yourself from your doctor; you should keep reading,
because that's what this books is about", so writes Dr Mendelsohn
in the introduction to a book which could quite well be the
fore-runner in a new people's health movement to gaurd themselves
against the harmful impact ipon their life of doctors, drugs and
hospitals. In a very sensational style of writing he presents
<7
facts to prova his convictions that in America today, annual
physical examinations are a health risk, hospitals are dangerous
places for the sick, most operations do little good and many do
harm, medical testing laboratories are scandalously inaccurate,
many drugs cause more problems than they cure and the X-ray machine
is the most pervasive and most dangerous tool in the doctors office.^
Incidentally he is Chairman of the Medical Licsnsing Committee of
the State of Illionois and Associate Professor of Preventive Medicine
and Community Health in the University of lllionis.
After eight chapters on his belief that "more than ninety
percent of Modern Medicine could disappear from the face of the
earth - doctors, hospitals, drugs and equipment and the effect on
our health would bs immediate and beneficial" he presents his blue
print for a new vision of medical care which includes, taking on
.7
:7t
the responsibility of onss own health and the health of ones
family; having faith in life and a system of ethical values^
eschewing any practice that promotes or condones violence
against lifej letting the doctors only be a life guard and so on.
He then discusses the profile of the ’New Doctor’, rhe new
doctor will be in the front line of people’s struggles. He will
be confortablc with people of all walks of life. He will be
conversant with the language of the people and willing to
place alternatives clearly to the patient. He will acknotuledge
nature as the prime healer and so regard natural supports of
health such as family as having supreme importance in the
healing process. Above all he will be a life guard motivating
people to avoid disease and have healthy habits. He also makes
suggestions for the new medical school to produce such doctors, He.
Jfe-S 1’The students of such a school will be easily identifiable
their first rule will be : First do no harm1'.
This book needs a careful perusal and probably will
be among the most important references for mfc/E38 members
as we define our own future perspectives.
Mp 6-S
2
(GHH]
IJITOTNG HORIZONS - II
Dear Friends,
In this issue we introduce two books raise important
issues about the cirisis in Hospital based Medical Services and the
increasing problem of latrogenicity or the disease producing nature
of medical care itself.
TlDich is one of the severest critics
of the Medical Profession and Horrobin attempts an answer to
Ulich's criticism on behalf of the Medical Profession.
These
two books read together gives us a balanced view of the crisis
at hand.
The next two books are more personalised approaches by two
committed Christian doctors to find answers to the nroblems of
providing hospital service and health care programmes to communities
where poverty is an increasing constraint.
out to the community ?
How do hospitals reach
How do we reorder our priorities?
Their
experience and suggestions rill be most relevant and thought
provoking for all our CHA members
RAVI NARAYAN
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