Report on the Training Fellowship at Community Helath Cell
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- Report on the Training Fellowship at Community Helath Cell
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CPHE
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Report on the Training
Fellowship
at
Community Health Cell
October 1, 2002 to April 21, 2003
By
Dr. Anant Bhan,
Community Health Cell,
367, Jakkasandra,
I Main, I Block,
Koramangala,
Bangalore - 560 034.
Phone Nos. 55 31 518 / 55 25 372
Email: sochara@vsnl.com
Website : www.sochara.org
Dr. Anant Bhan: anantbhan@sify.com
I
-
Background
I was born in Srinagar (J&K) and raised up in Madhya Pradesh where both ol my parents
were working. It was a very sheltered middle class upbringing. I completed my schooling
in 1996 by which time I was interested in joining medicine and got through the All India
Entrance Exam that brought me to BMC. 1 had not been to Bangalore before and was
looking forward to college life as well as the city. The location of BMC was the first
grounding factor- located in the midst of the bustling City Market area that has a mass of
humanity at all times of the day, we were daily exposed to the vagaries of everyday life
for the masses running around for daily survival. I also found the first year course
outdated in many instances wherein we were made to pith frogs to tear them apart on the
pretext of physiology practicals (interestingly, the instruments and the practices had not
changed in many years). The dissection hall with its omnipresent formalin smell was also
used by more of us as a discussion board than to study or learn.
It was during the early part of my second year that through some friends who were in the
field of social work, I got in touch with some voluntary organizations on an informal
basis. I would volunteer with them whenever possible- help the patients referred by them,
collect drug samples for their clinics; visit their outreach areas etc. 1 was also on good
terms with the community medicine dept, of my college, which ordinarily my classmates
despised. I would participate in the programs that they conducted and interact with the
faculty and postgraduates wherever possible.
By the time I started my internship, I had developed a liking for the field of community
health and wanted to explore it. I had heard of Community Health Cell on a regular basis,
it being one of the foremost health NGOs in the country and had interacted with the
various team members at events like the JAA mobilization in 2000 and the World No
Tobacco Day related activities.
At the end of the internship, I decided to spend six months with a voluntary organization
to expand my knowledge and gain valuable hands on field experience. CHC was my first
choice and Dr. Thelma, Coordinator, CHC was very supportive of my foray and agreed to
let me work in CHC to help in this process. 1 joined CHC on October 1st 2002 as a result
of this meeting.
Month 1: October 2002
The first day of work at CHC- I reported to the AO Mr. Gopinathan and met Dr. C.M.
Francis who gave me an overview of the work that CHC was doing. I also met the
various team members and discussed their areas of interest with them. I had a brief
meeting with Dr. Ravi - I was already feeling at home with the warmth that everybody
was exhibiting.
1 started reading the journals ‘Community Health: the search for an alternative process'
and ‘Health Action: the search for a new paradigm’ that gave me an idea about the
journey that had resulted in the birth of CHC. The process was quiet interesting though 1
could see that the academic world of Community Medicine had lost two good teachers
when Drs. Ravi and Thelma had decided to leave SJMCH to start CHC. This was
especially so because there was dearth of good teachers in the subject who could instill
interest about community health in the minds of the medical students.
Dr. Ravi presented his experience at the 1NCLEN meeting at Trivandrum: that there was
now an effort to network by the clinicians actively involved in epidemiology was
interesting - hopefully they would not be exclusive towards research into clinical subjects
and would collaborate with non-clinical specialists also to further the field of
epidemiology; Dr. Ravi had come with an impression that the group was trying to some
extent to do this.
I attended a workshop on ‘The Joy of Parenting’ conducted by Ms. Hema Srinivasan
from the Kamaraj Balamandir Foundation at the St. Joseph’s convent al Doddaballapur;
the ease with which Ms. Hema mingled with the groups, which consisted of sangha
women from the surrounding villages, was a pleasure to watch and the way she explained
the concept using the local language and involving all the participants was interesting.
Parenting was a skill that would benefit all members of society, as all of us needed care al
some point of time or the other. (Appendix 1)
In the following week, Chander and I conducted a Tobacco Awareness session for about
250 students of the Catholic Pre-University College, Richmond Road. While speaking to
large audiences was not new to me in any way, but the chance of using a session to
impart health education, that too about a topic that affected these students directly was a
challenge. We got a positive feedback form the students about the session and many of
them explained that this had been an eye opener to them on the issue.
CHC had conducted a LSE training program for the students of Seva Sadan IT1 College
in the previous session. LSE was an area that I did not have much knowledge in. The
opportunity to assist Dr. Mani Kalliath in conducting an evaluation in the subject helped
me in getting an introduction to the subject and also in picking up valuable tips on the
process involved in evaluation. I could also spend some time interacting with Dr. Mani
and discuss about the field of public health. (Appendix 2)
A panel discussion had been organized on ‘Pesticides and Health' at IS I in Benson Town.
The panel discussed the disadvantages of the indiscriminate usage of pesticides that was
prevailing and the deleterious health effects of the same. I found the heartfelt testimony
of a farmer who had stopped using pesticides and was also trying to get the neighboring
farmers to do the same the most important in the process because that was what the whole
program needed to be geared towards - change at the level of the farmer through
awareness to prevent further harm. As an old Indian proverb so succinctly puts it, "The
environment is not a gift from our parents but a loan from our children'.
Dr. Romy Quijano, a toxicologist from the Philippines who was part of the panel visited
CHC the next day and shared his experiences including the hardships he had faced in
advocating reduction in pesticide usage and the studies he had undertaken to link heath
disorders with the pesticide usage in certain areas. His commitment to the cause was an
inspiration and the knowledge gained valuable.
The beginning of the next week was also holiday season because of Ayudh Pooja and
Vijayadashmi. Prof. Mark Nichter, a medical anthropologist -ftfom the University of
Arizona had come down to Bangalore. He has had a lot of experience working in India
especially in the coastal areas of Karnataka. Rajan and I visited him in his lodge in
Majestic (he was staying in a simple room on the top floor which helped him, as he
explained it, to keep a watch on the terraces of the neighboring buildings that were
potential mosquito breeding sites). We spent almost a day with him as he shared his
experience with us especially in the field of Malaria and Tobacco- it was food for thought
and very interesting. We related the work of CHC in these fields and he expressed
interest in collaborating with CHC. (Appendix 3)
At CHC, we were trying to for a network of NGOs working in the field of imparting
education especially to the disadvantaged children so that we could work together for
evolving Educational Strategies for Tobacco Control. As a part of this, we organized a
meeting at INSA where the various related issues were discussed after presentations. All
the organizations present expressed their interest in the area and committed to include the
subject of awareness about Tobacco in their educational programs. (Appendix 4)
After the assessment of the previous batch had been completed, the CHC including Dr.
Mani and me visited Seva Sadan to do a pre-course assessment of the new batch of
students using a questionnaire method. After this, a meeting was held in CHC where the
report of the previous program and the expectations in the upcoming course were
discussed, a part of team building and sharing of strategies for the future sessions.
Ms. Shireen Haq from Nari Pokho, Bangladesh visited CHC in this period. Her account
of the women’s movement in Bangladesh and their struggle for getting rights of the
women was moving. The indomitable courage exhibited by her and her colleagues in
fighting the establishment and decadent social practices was also an inspiration.
I did some research for Drs. Ravi and Thelma’s visit to Africa and this gave me the
opportunity (with Dr. Ravi’s guidance) to get an idea about international health, about
the various indices used and about correlation of the health indicators of African
countries with those of Indian states- a sort of homogeneity in the health status of
populations across the Arabian Sea.
I attended a symposium on Leprosy Prevention, Control and Rehabilitation on 28,h
October 2002 organized at IMA where the importance of continued work in the field of
Leprosy was brought out.
I also attended a 1 day national workshop on Medical, Legal & Economic Aspects of
Road Traffic Accidents; the concerned experts spoke about the issues involved and the
rising number of accidents; the workshop gave me a fresh perspective about the problem
and the need for an all round effort to decrease the number of accidents which were
causing deaths and disability on a large scale especially in the productive age group.
As a part of our networking in the field of Tobacco, I also attended a meeting at
NIMHANS where the tobacco deaddiction program which had started there was
explained and also an attempt was made to get the groups present to work together for
tobacco supply and demand reduction.
Month 2: November
The time at home had offered me a well deserved break after a long time and also the
opportunity to meet relatives that I had not been able to do while I was in medical college
with the ill planned schedule.
I met the CHC staff after coming back and got updated on the plans for the month. I also
met the SPANDANA group from Shimoga, which along with Naveen Thomas had done
an interesting study in the tobacco growing areas of their district, and was in the process
of dissemination of the same. Later I attended a meeting at Equations where the
implication of GATS on the various sectors was discussed - this was an area which I was
not much aware of and this gave me an opportunity to get some introduction to the same.
Vinay Baindur form CIVIC shared about their work on the 74th amendment. (Appendix
17) '
Medical Law and Ethics, a field in which I was undergoing a course was the subject of
my discussion with Dr. C.M. Francis- his vast experience in the field and expertise
helped me in clarifying a lot of my doubts and he also gave me an insight about the work
that had been done by the Community Based Rehabilitation Forum. I also went with
Chander and conducted a Tobacco Awareness course for a batch of students of Christ
College who are always an interesting bunch to deals with because some of them look
upon these so called 'moral values’ sessions with disdain and so that extra effort has to be
made to involve them in the process- a challenge every time.
The whole of 14lh November was spent in attending the various functions associated with
World Diabetes Day- here was a disease that had been blown out of proportions by the
medical community and the press and the pharmaceutical companies were having a field
day with the ‘bazaar’ drugs available for the same. The Chief Minister and the Health
Minister made the usual perfunctory speeches and there was a rally to mark the occasion
wherein the students from the various nursing colleges who had been herded and brought
were made to walk with banners and the other paraphernalia. Health education in the real
sense seemed to be the last thing on the agenda.
I had by now also begun to take sessions for the Hindi/English/Konkani speaking boys in
the fresh Seva Sadan batch and this offered me the weekly opportunity to interact with
these adolescents who were full of questions and did not mind asking questions as they
occurred to them, thus making the whole process very informal, which was the way I
liked it. Adolescent education had been an area of interest for me, and talking to these
boys about health and life skills on a regular basis also helped me gain valuable
experience in dealing with people their age. (Appendix 5)
Drs. Ravi and Thelma had by now returned fcfom their trip to Africa and it was interesting
to listen to their varied experiences in that diverse continent and the health situation
prevalent there. Dr. Thelma also spoke about her contribution in changes in the health
policy of Orissa where the govt was being supportive and many initiatives were taking
place.
Dr. Srikala Bharat visited CHC to give an overview of the LSE program- needs and
objectives and also the pilot program that the GoK was starting in some schools across
the state to implement the LSE program. While I had already taken some sessiomin Life
Skills, I had not been exposed to the history of Life Skills and hence this session was of
interest for me too. The same day, we also had a meeting where Naveen presented his
analysis of the pharma policy and there was a discussion on the same.
We had been trying to get a tobacco network going for some time and we finally arranged
a meeting at CMA1 where many voluntary organizations and a few medical institutions
came together and realized the need to work together in the field as there was a lot which
needed to be done especially in Karnataka which was in a way the hub of the tobacco
production and consumption in the country.
On the 23rd November, VIMOCHANA had organized a meeting to discuss Dr. Satish
Agnihotri’s exploration of the declining Sex ratio in the Indian population. A former
bureaucrat, Dr. Agnihotri’s analysis looked at the issue in a broad manner and had
brought in interesting facets and aspects.
The following day, the DAF-JSA meeting took place at St. Martha’s hospital where the
National Pharma Policy/Essential Drugs were discussed. It was disappointing for us that
in spite of enough advance information and personal communication also, not many were
attending these meetings. However, for all of us present it was an opportunity to analyze
and try to identify what could be done about the loopholes in the existing policy.
The Health Informatics Project had come to CHC by this time and we decided that we
would as a team go and visit the project areas so as to get first hand info and to interact
with the medical practitioners, Anganwaadi staff and Panchayat institution members etc.
and give them an insight about what we proposed to do in the project. We managed to get
a fair idea about the local healthcare system and the dynamics that were prevalent in the
local conditions and made some inroads in what in many ways was a new area for all of
us. We also attempted to network with local organizations to make the project feasible
and successful.
The following day Dr. Ravi share about the Mallur experiment and it was in many ways
inspirational the way the project had been run Ibringing in the components of community
participation and self sustenance- I could see: how many of the ideas and experiences
from that experiment had stayed and had now percolated into the functioning of CHC.
1I along with Prahlad was visiting the Hakki Pikki colony in Bannerghatta and we were
trying to devise and health intervention for the members of the hamlet there with the help
of VIMOCHANA team that had been working there for quite some time. While
accessible health care was available nearby in the form of a well-equipped charity
hospital, the people in these hamlets were not taking benefit of the same. Their nomadic
habits and also the rampant alcoholism in both the sexes was also a problem, as we could
not follow up regularly. Prahlad and I spent some time trying to understand this
community and this led to some interesting findings. Unfortunately, our visits were
ending up becoming treatment camps when we wanted it to be a program, which would
train local volunteers to become health workers and help their own community. This
process would obviously take more time.
I attended the Dr. Jaishree Thomas memorial oration at SJMCH on 29th Nov along with
Drs. Ravi and Thelma - I found that a lot of alumni had come together to remember an
old friend - these kind of meetings were rare in BMC where the alumni association was
sort of defunct and only occasional met for ‘banquets’ at the Bangalore Golf Club.
CHC was by this time was going into the preparation mode for ASF/WSF by this time
and there was a sense of expectancy in a lot of us about the upcoming event at
Hyderabad. I was closely following the web based activities in the ASF website for CHC
and I could see that this was going to be a meeting point of a lot of issues.
December: Month 3
The whole of December had all of us in CHC busy with the ASF preparations as CHC
had also taken the onus of facilitating the registration and stay of a lot of associates and
friends of CHC.
Prahlad and I visited the Hakki Pikki colony again and tried to ascertain the social,
economic, cultural and health dimensions of the colony so as to help us in devising any
intervention. (Appendix 16)
MMB in Bangalore was organizing a festival on making Water Everybody's Business in
Bangalore around this time and I had the opportunity to listen to Sunita Narain who heads
the Center for Science and Environment at New Delhi - an organization that has done
yeoman service for the cause of environment in India and brings out the respected journal
‘Down To Earth’ on a regular basis. The importance of Rain Water Harvesting and the
immense benefits that the technology had to a nation like ours where many parts
remained water starved for most of the year was imprinted on me.
Late in the month, I went with Dr. Ravi when he went to conduct session related to the
Peoples Health Movement at INSA for their workshop participants. We also met a
number of community health practitioners form around the country and this gave me an
opportunity to gain insights into their work and what was the kind of work they were
involved in. Il was heartening to see such a committed group of people who enjoyed
doing their work. I also attended the 20th anniversary celebrations of INSA and learnt
about its inception and the way the organization had grown.
We conducted a one-day workshop at Kanakapura on HIN, Tobacco and TB. The
workshop for the paramedical staff was fairly attended but the attendance in the evening
session, which was for doctors, was not satisfactory. We gave an introduction to the
issues; the local milieu with regards to the relevant topics was analyzed which would
form the background for the future HIN activities.
Shobha John from PATH-CANADA visited Bangalore and we organized a meeting at the
deaddiction center, NIMHANS where she spoke about the deliberations at the FCTC
meetings at Geneva which was aiming to build upon the first Public Health Treaty to be
drafted by the WHO - the networking idea and the formalization of CFTFK was also
discussed here.
We also conduced a full day ASF preparatory meeting at Ashirvad which offered the
space to various organizations conducting events in ASF to give a brief introduction
about the same to other organizations - the aim was an united Karnataka contingent
which would have solidarity with each other in the myriad issues being raised. After all.
the whole process was to be a coming together and a support structure to refresh us in our
areas of work.
The following day Anthony shared his experiences at Vimukti where there had been an
incident of atrocities against Dalits, which he had investigated with Eddie from Vimukti.
It was sad the way that the caste system after all this years was still a feature in our social
fabric that was tearing us apart and that the Dalits were still living in oppression.
ASF preparations kept going on at a pace. I had the opportunity to attend a session on the
alternative systems of medicine, which Dr. Tekur took. Himself a practitioner of various
systems of medicine, it was an enriching experience to get to know about the systems of
medicine in existence and how they looked at the concept of disease, patient and the
treatment process.
The HP visits continued but they were becoming too treatment oriented which I was
afraid of and I narrated this to Dr. Thelma - we decided to have a discussion with
Vimochana about the way the intervention should be conducted.
We also had a meeting about the HIN workshop and put our thoughts down in the report
about the workshop.
I had the opportunity with CHC’s support to attend the annual meet of the Medico
Friends Circle in Baroda. Dr. Ravi and Thelma had told me about the MFC in my
discussions with them and I was looking for meeting the group. Also in the background
of the communal outrage in Gujarat and the fact that my own family had suffered the
same in Kashmir, it was also in a lot of ways a voyage of discovery into how religion was
dividing and not uniting humanity in so many places. I liked the format of the meeting
itself a lot because it was informal and there was an open discussion after every
presentation allowing for clarifications and arguments. Also, the courage shown by a lot
of those present in the face of rioters and their work in providing relief and succor gave
us all hope while we tried to express our solidarity and unity with them. 1 also met a lot of
interesting people who had different thinking streams; their openness to discuss with a
much younger and inexperienced person like me endeared them all to me- I was already
feeling like a MFCite.
I returned on 31st Dec as the final preparations for the departure to Hyderabad were
underway and did a brief presentation about the MFC meet to the CHC team.
Month 4: January 2003
The beginning of a new year and after a day’s break we all met in the evening as we
prepared to go to Hyderabad for what was going to be a grueling but exhilarating week at
the Asian Social Forum. (Appendix 6,7)
All of us who went to ASF returned with a lot of material and information and also the
associated administrative issues that took us the whole day to deal with before we could
even launch ourselves into a normal routine. There were also the accounts to settle, the
reports to write which took another couple of days. I attended the CAMHADD meeting
in .layadeva Institute of Cardiology - I found their approach of trying to evolve a
partnership between civil society, the public sector and the private providers in the field
of health care for the urban poor interesting, but it was a process that would take lime and
was going to only benefit the small area in Yeshwanthpur that they were planning to
concentrate on and develop into a model area while not dealing with the problems of the
urban poor in a more comprehensive manner given the amount of effort already put in
and the expertise that was being utilized.
The following week I helped Rajendran and Chander I conducting a LSE program at the
Redemptorist congregation- these young men and women were very inquisitive and
enjoyed the course and extracted the maximum information possible from the resource
persons.
Immediately following this was a LSE course for the Jyoti Sadan scholasticates and this
was an older all male group that was expecting help in developing their skills, which
would help them when they went out to work in the community in their capacity as
religious leaders. They were also very forthcoming with their appreciation & criticism
(the bouquets and the brickbats) about the course and hence helped all of us who took
various sessions to do a critical analysis about the way we conducted the sessions. I was
personally not satisfied with the way that I had conducted the session- the topic being
’Self Awareness’ there was a lack of background information on the topic, and also 1
had not spent enough time in preparing for the session. The session hence turned out to
be a bit vague and technical, which I could gauge, from the response of those present.
Nevertheless, a learning experience in the art of presentation.
Dr. Paresh Kumar also took a session on societal analysis and it interested me the way 1
he made all of those present think about their views on their role in society- as liberators,
benefactors or as contributors which was I guess, a question all of us in community health
have to keep asking ourselves when we deal with the population in our projects or field
areas. Dr. Paresh was in the transition period before he joined CHC and I was looking
forward to benefiting from his experience and insight.
Dr. Ravi took a session on male sexuality for all of us in the technical team after a couple
of days so that we clari fied our stand on a whole range of issues when we dealt with the
subject and also for us to look into our own understanding and the biases that we still had
which were preventing us from being objective in the programs we conducted. Male
sexuality was an issue that was not much discussed in the Indian society and this could
arguably be one of the reasons for the ever-increasing sexual crimes against women in
our country.
Prasanna had joined on a trial basis by this time and he was trying to put the informatics
and the documentation into a systematic classification- I tried to help him with this; this
was a good exercise because it also gave all of us the opportunity to review what all of us
done in the past and had documented. I also helped Dr. Rajkumar with the finalization of
the first HIN newsletter and Maggesh with the content of the CHC website. All of these
were opportunities for me to learn as I contributed- what could be better than this!
Month 5: February 2003
The month began with an interesting workshop conducted at NIMHANS where the whole
range of issues related to the media coverage of the suicides in Bangalore was discussedthis also brought out the question of sensationalization of certain news stories in the
media. (Appendix 8)
The following week I and Chander traveled to Doddabelavangala where we conducted a
workshop for the health animators - it was a two way process to elicit the health
problems of the villages in which they worked and also relate them to the various issues
such as environment, hygiene etc. They had a good number of songs already in place for
health education and it was a pleasure to listen to them especially the lead singer who in
spite of being physically disabled and blind was the spirit of the whole troupe.
Drs. Praveen and Krishnamutry from BMC who had gone to Baran to investigate the
hunger deaths there had returned by now and they shared their experiences with us. The
fact that the situation was improving and that malnutrition was being addressed slowly
was heartening, but the summer was coming up and that would be a real test for the
whole support structure that had to be put in place. Hopefully the local groups assisted by
others like OXFAM (Naveen was also part of this initiative by now) would be able to
prevent the tragedy of human lives being lost again when our PM proudly was giving full
pages ads that our grain godowns were full!- after all, it was going to be election year.
Prahlad was conducting a session for the EWRs of many parts of Karnataka on their
responsibilities related to health and to see the huge group of 300 women, some
interested, some not but all there as a proof of the vibrant democracy that our country still
is. The explosive situation of HIV/AIDS and the stigma that it entailed in Northern
Karnataka was apparent in the experiences that these women shared. I could vividly
remember the fact that the greatest risk factor for women to acquire HIV was to get
married and I was wondering if women’s empowerment alone would be the answer if the
long run- we also needed to encourage the activities that worked for behavioral change in
the sexual behavior of men, who were predominantly spreading the infection.
I had attended the HIV/AIDS care group meeting organized by SAMRAKSHA on a
couple of occasions and I found these to be quiet educative and a meeting point for the
many groups working on the various aspects of HIV/AIDS.
1 look a session for the students of the state govt, high school in Jeevan Bima Nagarmany of them already addicts of cigarettes and gutkha- as 1 tried to tell them the various
health problems that tobacco usage could lead to, I was also realizing that they needed
constant encouragement to quit and to stay away. That the percentage of people who
could quit tobacco usage was very low was something we had to realize and, hence the
need to work as hard as possible to stop these students from falling into the habit.
Mr. Meindert Schaap presented his study on the sexuality of street boys in Bangalore
which was still going on- this was a group all of us encountered everyday and did not pay
attention to unless we had newspaper reports of some of them being abused in the railway
carriages; there would be a hue and cry for a couple of days and then the situation would
come back to stage one; Meindert’s concern for them and his extensive research that
could help devise a program to help these young citizens of India in leading more
comfortable lives, away from the fear of exploitation and violence was apparent.
I attended a few sessions of the Health and Hospital services Management course that
CM Al was conducting at Ashirvad and found a lot of middle level managerial staff form
various hospitals present; the sessions on medical ethics, CPA and insurance were helpful
in updating my knowledge.
On the 15th and 16th, Prahlad and I visited the projects of India Every Child at Korategere
(Tumkur) and Hassan and conducted session for the staff members of these projects on
Primary Health Care and the role of functionaries in Pry. Health Care. We had the
opportunity to do field visits in these areas; in Tumkur, the doctor in charge of the local
health center was very forthcoming and told us about the problems in that area; we could
also pick up a lol of fluorosis in some areas and saw many children with dental
symptoms. The project staff was trying to bring this to the attention ol senior health
officials and we were hoping that would bear fruit.
The PHM office had by now been opened across the road from CHC and Dr. Qasem
Chowdhury who had come down with a Bangladesh medical delegation came to the
office to share the story of the GK project that had been painstakingly been built up and
was testament to the fact that the Primary Health Care approach could work.
Dr. Olle Nordberg from the DHF also visited during this time and we shared the work of
CHC with him as he told us about the work of the DHF.
We also conducted a session for the voluntary organization in the Bangalore rural district
at Nelamangala organized by the Sandeep Seva Nilayam, a group that was among the
first with which I had worked during my graduation. This was part of our commitment to
keep the Janaarogya Andolana alive and kicking in Karnataka and spread the word
around so more grassroots initiatives could take place.
Towards the end of the month, I and AP visited the GHE project of Mahila Samakhya at
Koppal - AP was taking sessions for the staff members of the project in PRA methods
but we also were doing field visits to the clusters and talking to communities at times
which were convenient to them (early morning or late evenings) and trying to get the
local populace to identify the health problems, the causes of these and fix up time frame
for working on solutions for the same. The ground work done in facilitating the formation
of womens’ sangha, Kishori sanghas and the village health committees in may places
made it easier for us to do this work.
Month 6: March 2003
The beginning of March 2003 was spent in preparing for the oral and poster presentation
at the SDTC symposium on Acute Respiratory Infections, a national level meeting of
researchers. Thanks to Dr. Ravi’s encouragement and the willingness of^Lt.Gen.
Raghunath to accommodate a youngster like me, it was almost a dream corneal or me. I
had attended the previous symposium and had enjoyed the discussions thoroughly.
Slightly skeptical if I would be able to do well in the midst of presenters with a whale of
experience, I launched myself into the background research of the public health aspects.
That the whole team of CHC stood by me and helped me in this endeavor assisted me in
doing a presentation that was well appreciated. It was something to remember because it
was my first formal scientific presentation. ( AFPEHMX 21^
1 had earlier attended a seminar on the PNDT act organized by various groups in
Bangalore and it seemed that the act was good enough only on paper as the conviction
rate in this rampant practice of sex determination was very low. Hopefully, as the
Governor put it, if such meetings would be organized in all the parts of the state and raise
awareness about this practice which I sincerely believed was barbaric as it was like a
death sentence on an unborn human being (without any valid indication). (Appendix 9)
I was helping in the training of the HIN volunteers - two bright young graduates who
were my age and so easy to relate to - I tried to give them an insight into the world of the
WWW which they could use for answering the health related queries of the people they
met as part of the project.
With the upcoming tobacco legislations around the world, we decided to take the
initiative of organizing workshops to raise awareness about the related issues in the
heartland of tobacco agriculture in Karnataka, Shimoga and Dharwad. We also brought in
the component of Primary Health Care into these. We had long sessions at both the
districts and there was a positive response for our call for local action to reduce tobacco
cultivation in the area.
A LSE program for training the trainers was organized by CHC at I YD and 1 attended the
same; the sessions were very interesting, especially the way the facilitators like Dr.
Sekhar Seshadri and Mr. Prakasam conducted theirs, making the audience comfortable. I
also helped Chander in his session. The concepts of Life Skills and their necessity were
clearer to me after this workshop. (Appendix 10)
Drs. Ravi and Thelma who had returned from their lecture tour of USA by now gave us
an insight into the health problems that were prevalent in the Country which was now
wanting to be the only superpower (and was inching towards it!). That there were so
many citizens of the Big Sam not covered by medical insurance as the govt, spent more
money on guns and weapons (media for destruction!!) was news that we knew of, but
were not aware of the extent of. Also, as they so concisely put it, the anti-war sentiment
demonstrated by many of the Americans showed that all the thinking did not emerge in
America from Washington and the Pentagon but the citizens did differ with their govt, on
many important issues.
I had the oppurtunity of visiting the AMCHSS at the SCTIMST. Trivandrum and
interacting with the students and faculty about the course as I scouted for future academic
pursuits. Thanks to the hospitality of Dr. Amar Jesani and Dr. Sukanya, I got a fair bit of
an idea about the center and also traveled around Trivandrum. My discussions with Amar
and Sukanya helped me a lot in my personal understanding of a wide range of issues.
The end of the month was spent in report writing and also in participating in the team
meeting regarding the upcoming SEPC analysis of the Malaria prevalence in
Chikmagalur, a process that interested me because of the way it was planned under the
guidance of Dr. Paresh - a different approach.
Month 7: April 2003
After finishing six months with CHC, after a discussion with Dr. Ravi, I decided to spend
some time as a technical volunteer with the Peoples Health Movement Secretariat, which
had shifted to CHC from the beginning of the year.
1 worked on collating all the ideas/suggestions from the ‘Taking the PHM Forward'
seminar at the Asian Social Forum; this was also partly to feed into the thinking that
would go into the JSA-National Working Meet, to be held at New Delhi on 1 l,h and 12'1'
April 2003. After this, I worked on putting the content of the seminars and workshops
that CHC facilitated at the ASF into order- this involved searching the old emails,
requesting people, writing to some and was like the game of ‘Beg. Borrow or Steal' that
we used to play as kids.
On the 14, 15 and 16 April 203, 1 attended a Trainers Training program on
Documentation and Rapid Assessment of Local Health Traditions conducted by FRLHT,
Bangalore. This program helped me get an insight into the rich cultural heritage of health
traditions that the local communities had been using for thousands of years and the need
to work for preservation of these. It was also important to keep the rights of these
communities over their traditional knowledge in mind before contemplating any
commercial or widespread use of their traditions. (Appendix 11)
After this program, I spent a couple of days finishing the reports and the paper for
submission to the SDTC center based on my oral presentation.
My stint with CHC/PHM formally came to an end with the presentation on ‘Public
Health Aspects of Acute Respiratory Infections’ that I did on the 21st April 2003 at a
team meeting.
A brief analysis of the time spent in CHC
Strengths
Helped me move from a biomedical understanding of disease and health to
also a social awareness of the issues involved.
I feel that I have now deeper understanding of movements/ ideology and the
role that major events play; I probably was much more superficially
involved in these earlier as is the case with most middle class Indians today.
I got a lot of chances to spend time in field projects with CHC team
members and with the local staff and the communities' involved- 1 feel that
this was very essential for me to experience community health.
I could spend some time away from clinical medicine and concentrate on
my other interests.
All of the senior staff members were always very approachable and
everybody gave me help, support and guidance as and when I wanted it.
I learnt about the working of an organization on a day-to-day basis.
I could understand that there was a great thirst for knowledge out there
among the community health workers (at least the doctors have the chance
to attend the regular CMEs) and organizations like CHC were helping them
by orienting them at regular intervals.
Suggestions for improving the fellowship scheme
A senior person should be asked to mentor the candidate on a regular basis;
this would probably involve weekly discussions and feedback sessions from
both sides.
The candidate should be given material to read and discuss with the
mentor/team to help in clarification regarding the various aspects of
community health.
The candidate should be especially given an insight into the broader issues
involved like policy matters, LPG (Liberalization, Privatization and
Globalization).
The candidate can have one or two focus issues that s/he tries to understand
inside out and also contributes in terms of viable alternatives, if required.
The candidates can be asked to come out with a regular newsletter
highlighting their work and learning experiences.
Accommodation near to CHC would be a very helpful to candidates,
especially the outstation ones.
S/he should be asked to do regular presentations on topics that are selected
in discussion with the mentor; this can be done in regular team meetings
arranged for the same purpose.
The amount of time spent with other partner organizations should at least be
a quarter of the duration of the fellowship.
Post Script
I look back with great fondness at the time spent in CHC. I have found a sea of
knowledge, good friends and inspiring mentors and guides.
I have undergone a paradigm shift in my understanding of health and its various
components. From an initial biomedical understanding of disease that was taught
and ingrained into me at the tertiary medical teaching facility where 1 studied in, 1
have slowly graduated to a deeper awareness of the social, economic and political
mechanisms. The acute need for bringing about changes in the healthcare system
through encouraging communities to get aware about their own health problems
and devise solutions for it as well as demand action on the same from the
responsible government bodies is very evident to me now. The lopsided
distribution of medical services and the dwindling government support to health
administratively and financially in the budget is a field of concern. The toeing of
selective health care as advocated by the international Tending' (they should not
be termed funding) organizations like the World Bank and the IMF has had
negative implications already. There is definitely a need for concerted social
collective action to work for Health for All- it should no longer be a forgotten
goal but a contemporary reality.
I hope to be able to be in touch, whatever may be my future endeavors and
hopefully again be a part of the team someday and contribute to the committed
work being carried out by CHC.
Anant Bhan
Bangalore. April 2003
Glossary
AMCHSS - Achutha Menon Centre for Health Sciences
AO - Administrative Officer
ASF- Asian Social Forum
BMC - Bangalore Medical College
CFTFK - Consortium for Tobacco Free Karnataka
CHC - Community Health Cell
CMAI - Christian Medical Association of India
CPA - Consumer Protection Act
DAF - Drug Action Forum
DHF - Dag Hammerschultz Foundation
EWRs - Elected Women Representatives
FCTC - Framework Convention for Tobacco control
FRLHT - Foundation for Revitalization of Local Health Traditions
GATS - General Agreement on Trade Services
GHE - Gender Health Equity
GK - Gonoswashtya Kendra
GoK - Government of Karnataka
HIN - Health Information Network
HP - Hakki Pikki
IMA - Indian Medical Association
INCLEN - Indian Clinical Epidemiologists Network
INSA - International Services Association
I YD - Institute of Youth & Development
JSA - Jan Swashtya Abhiyan
LSE - Life Skills Education
MFC - Medico Friends Circle
MMB - Max Mueller Bhavan
NGO - Non-Governmental Organization
NIMHANS - National Institute of Mental Health and Neuro Sciences
PHM - Peoples Health Movement
PNDT - Pre Natal Diagnosis Techniques
SCTIMST - Sri Chitra Institute of Medical Sciences & Technology
SDTC - Sir Dorabji Tata Center
SEPC - Social, Economic, Political & Cultural
SJMCH - St. John’s Medical College
WSF - World Social Forum
WWW - World Wide Web
9
Appendix 1
Workshop on Joy of Parenting
Pindakurthimanahalli (Jayanagar), Dodaballapur
Date: 4th October, 2002
A workshop on ‘The Joy of Parenting’ was conducted on 4/10/2002 at St. Joseph’s
Convent, Jayanagar, Doddaballapur.lt was targeted at representatives of self help groups
and women’s sanghas from the surrounding 20 villages. The number of participants was
around 40 (including the staff of the convent). Mrs. Hema Srinivasan, a volunteer with
the Kamaraj Balmandir Foundation, Chennai conducted it. Mr. Rajendran,
Mr. Antony and Dr. Anant Bhan from CHC attended as observers.
Mrs. Srinivasan first gave a brief history about the topic - how it had originated in
Canada and how it had been then modified for Indian conditions. She then asked the
participants to introduce themselves using the opportunity to gauge their understanding of
parenting roles. This served as an ice- breaker and some interesting viewpoints were put
forward. The importance of a conducive atmosphere in the household right from the time
of conception through the child’s formative years was stressed as it led to the child being
healthy- physically, mentally, socially and spiritually. The participants were explained
the fact that stimulation plays a very important role in the child’s growth and also how to
foster a creative environment to allow the child to realize its full genetic potential. The
importance of emotions, the need of proper communication and the use of proper
language were emphasized. Furthermore the stages in the growth of a child were
explained using charts and by learning through games.
A short lunch break was then taken which allowed the CHC team and Mrs. Srinivasan to
interact with the staff of the convent and learn about their activities.
In the afternoon, innovative learning tools such as diagrams, use of folk songs and games
was used to reinforce the morning lessons. An innovative game of‘Find The Partner’
started the session. Another activity involved dividing the participants into groups of 5-6
women who were then asked to discuss the topics in the charts given to them and
comment. There was an active participation in this from the Sangha group(s) women who
ranged in age from teenage to grandmothers. At the end of the workshop, the participants
were asked to clarify any doubts. Some of them gave their feedback. They then thanked
Mrs. Srinivasan for enlightening them about Parenting Skills.
The CHC team and Mrs. Srinivasan then thanked the staff at St. Joseph’s convent for
their hospitality and left for Bangalore.
It was a pleasure to watch Mrs. Srinivasan ‘s skills at building up a rapport with her
audience and using her experience as a child counselor in trying to encourage the target
group to learn new skills, which they could share in their individual communities.
A few areas where improvements could be made for future sessions would be the usage
of better audio-visual aids (like Color Xeroxes, OHP sheets etc). Also the husbands
should be encouraged to attend such programs as the ‘Joy of Parenting’ is best explained
to the couple as a unit
1
Appendix 2
A 2-day evaluation of the health awareness program conducted by the Community
Health Cell at Sevasadan technical training institute was carried out on the mornings of
9th and 10th October, 2002 by Dr. Mani Kalhath, consultant with CHC assisted by Dr.
Anant Bhan.
On the 9th October, 2002,2 batches of students from Seva Sadan were approached to
give their feedback about the health programs that had taken place about a year ago for 3
months in 2001.
The first batch of students was from the carpentry division. This was a group of about 15
students. The first few minutes spent in familiarizing with the students The students
remembered about most of the topics that had been covered in the program. The students
especially liked and recollected the topics of cancer, malaria, cleanliness and personal
hygiene, sexuality and condom usage. The students were of the opinion that the
knowledge that smoking and oral usage of tobacco was harmful and could cause cancers
had helped them; some of them divulged that they had stopped smoking as a result also
and were trying to influence others to stop too. However, they did not remember about
the other types of cancer besides the tobacco related ones. While a student said that he
had dealt with his pimples by avoiding oily soap and using ‘CinthoT, when asked what
caused them, he said ‘heat in the body’. The students were also concerned about
cleanliness and personal hygiene and said they endeavored to keep themselves and their
surroundings clean. The knowledge about HTV/ AIDS in terms of mode of spread,
symptoms and window period was good. However, they did not know the difference
between HTV and AIDS. They had fairly good knowledge about family planning
methods- temporary and permanent. Also they said that they had realized the importance
of discipline, friendship and helping others and how to deal with their emotional
problems. This batch of students wanted the frequency of classes to be increased from
once a week to twice a week and also the duration of course to be longer than 3 months.
Also they felt the need for training on how to deal with their family backgrounds, which
were traumatic in some cases. They also said that they preferred more audio- visual aids
as that helped them to retain more information. They felt that they could not approach
any of their teachers for personal problems but said that they trusted Brother Prabhudas
and Bro. Paulus, for the same.
The 2nd session was with the welders and turners batch. This group was less forthcoming
and very few students actually spoke. The topics that liked included sexuality, malaria,
HTV, tobacco awareness. One of the students said that he believed that sex in young age
group could cause birth defects in the child. However the students had very limited
information about family planning methods and the concept of safe period. The students
had lesser information about HTV/ AIDS compared to the first group and still had some
doubts in the topic. A group of students said that they wanted more Kannada to be used in
the teaching. They said that there was nobody among the staff or faculty whom they
could approach for problems.
The next groups that we met were the teachers on the 10th of October 2002. They came
across as a disinterested lot. They spoke about the adjustment problems that the students
had when they joined the institution because of their diverse backgrounds. They felt that
since 75% of the students came from a rural background, it would be better more time
given for orientation and to overcome the language barrier as it would help the students
to retain more. Also, one of them said that his students had told him that they found the
health education classes boring! Most of the teachers seemed reluctant to take up
additional responsibilities in guiding the students about the health issues. Some of them
were however ready to volunteer to be trained in the program themselves to help the
students as well as themselves and their families. Later on, we met the principal of the
institution with whom we shared about our observations. He said that he was satisfied
with the program but expressed his inability in making this a continuous process, as it
would require permission from the higher ups in the organization.
We also later met the group of trainers and interacted with them. They said that they
needed more support in terms of materials including audio-visual media as they felt that
lecturing alone was not enough to sustain the interest of young boys. We also asked them
about the topics that they liked teaching. They said that the students had given them good
feedback.
ObservationsWhile the first group was quiet forthcoming and shared their opinions about the program
quiet readily, the 2nd group seemed to be governed by the politics of language based
formations where there was a leader whose opinion was paramount and hence prevented
others from sharing their thoughts. Also there was a lot of negativity in the group.
Most of the students seemed to retain only a few topics well, which would ordinarily be
of curiosity to them such as sexuality etc. also there were lacunae- e.g. while the students
knew about HIV/AIDS, they had no knowledge about STDs. Also there opinion of
sexuality seemed to revolve around it being as a tool for reproduction rather than
something that two consenting adults could enjoy provided if it was practiced safely.
Similarly while the students seemed to remember the other topics, they did not seem to
retain the important content of the topics. The teachers seemed to not be much interested
in the health awareness program and were not very forthcoming about being a part of any
initiative to try to improve the program, there being only a few exceptions. Also, the
management seemed to put the onus of conducting the program entirely on CHC not
wanting to involve much in either conduction or long-term commitment.
Suggestionssessions to be shorter - 90 minutes, maybe twice a week with more audio
1) The
r
visual aids and also constant reinforcement of past topics to ensure more
retention.
2) The interested teachers to be trained themselves so that they could help the
students with their doubts when the CHC team is not around.
3) To take up the program as a continuous initiative with Seva Sadan rather than a
yearly contract.
4) To ensure that there is mixing of various groups of students and the problems
related to language are addressed.
5) To try to ensure structured learning- the program could run longer than 3 months.
6) The retention of the content of the topics and not just the topics alone to be more
important.
7) To maybe expose the students to> some community health initiatives.
8) To try to train some peer educators from among the younger teachers and staff to
address the doubts and problems of the students.
9) To organize a health check-up for all the students on a regular basis.
10) To arrange for some type of counseling for the students to address their
individual needs.
11) The trainers to be fixed according to their topics of interest.
Appendix 3
Rendezvous with Prof. Mark Nichter, Medical Anthropologist,
University of Arizona on 14th October 2002 at Bangalore
Dr.Ravi had met Prof. Mark Nichter at the Indian Clinical Epidemiologists’
Conference2002 held at Trivandrum. Since Mark had extensive experience in the field of
medical anthropology especially in relation to India, Dr. Ravi invited Mark to Bangalore
to interact with the CHC team and share his experience especially in the field of Malaria
and Tobacco.
Unfortunately due to death of a friend, Mark was delayed in coming to Bangalore and
visited on 14lh October 2002, which fell between a series of holidays. Since most of the
team members of CHC were either not in town or were not available, Dr. Rajan Patil and
Dr. Anant Bhan went to meet Mark when he visited Bangalore and spent almost 7 hours
interacting with him at his lodge in Majestic.
Initially after the introductions, Mark spoke about his active work in the field of medical
anthropology, he being one of the pioneers in the field. He said he had 17 PhD. students
working and researching in various parts of the world, few of them in India. He also said
that he had a deep affection for India and he always looked forward to returning to visit
India.
He spoke about the possibility of Urban Malaria and Dengue that was a outbreak waiting
to happen in Bangalore and that this was the reason he preferred to stay on the top floor
of a lodge / hotel so as to have a panoramic view of the roofs in the city which could be
possible breeding grounds for mosquitoes.
While discussing institutional work, Mark said that while he respected CMC, Vellore as
an institution, he did not like to work with them as he had differences with them about
their work policy; he felt the grass root workers there were grossly under-paid and
exploited.
Mark then explained about he became interested in the field of Tobacco after tobacco
companies had rubbed him the wrong way during a televised debate on Tobacco and
made him resolved to fight them back. He spoke briefly about the planned study that he
and his colleagues (Harry Landow, Association for Nicotine Control, Dorothy,
Pharmacologist, Myra who trains Community Health Workers and Keith, Methodologist
and Mark’s wife) were planning to start in Kerala shortly to address various issues related
to Tobacco addiction especially cessation. However, he said that their scientific interest
was wavering as ICMR clearance was still being awaited and precious time and money
was being lost.
Mark said that in India, the concept of‘Toilet Cigarette’ is unique wherein certain people
do not get any bowel motions in the morning unless they have a smoke in the toilet. The
age of onset of Tobacco usage in India is also quiet low. The usage of Gutkha and other
oral forms of Tobacco is increasing and is in the range of 15% in South Canara.
Mark stressed the importance of media in addressing the issue and he said that articles
with catchy headlines like ‘ Saving the children for the tobacco industry’ had been very
effective in the U.S. He said that ‘INFECTIOUS IDEAS’ were needed to give any
program a boost and said that there was a need to practise science for activism .
Prevention in the field of Tobacco was difficult; an effective way to prevent new starters
was to show people they could relate to giving up tobacco.
There was a need to respect the tobacco industry for its effective marketing strategies. In
Indonesia, there had been an economic recession and most of the industries had collapsed
but the tobacco industry was going strong (60-80% of Indonesian men were chain
smokers).
There was an inherent similarity in Tobacco and Malaria in the fact that in both there was
a need to ‘control the breeding sites’.
Mark drew a parallel with work in the field of STDs where it was important to target the
environment and not the groups ‘at risk’ (similarly with alcoholism too), as environment
was the chief influencing factor.
Mark said that while working with kids and adolescents and trying to educate them about
Tobacco, it was important not to resort to the gimmicks that tobacco companies employ
by using glamour/models/actors as they feel that then the educator is also manipulating
them the same way that tobacco companies are; however, EMOTIONAL
TESTIMONIALS from those adversely affected by tobacco are very effective as
youngsters like them the most.
There was a need to reach out and talk to more people and anticipate the questions and
the doubts the target audience might to have and be ready to address them. There was an
urgent need to develop a package for schools and to make it specific to the environmentsocially, economically, regionally etc. Also the quality of the program offered to rural
Karnataka should be as good as that offered to urban areas. It was important to invest in
the process and document the steps. Messages that cater to the people s imagination
should be used. If other organizations want to take the program up for implementation,
then they should be offered a list of options; they should be given choices so that they can
evolve their own program.
Mark said that Tobacco is emerging as the second fastest game in public health after
Antibiotic Resistance. Tobacco should be looked upon as a nicotine delivery device. To
evolve a successful program, it is important to invest in the process and then make the
product. We should talk openly about the mistakes you made (maintain a book); also its
necessary to make tobacco an occupational health issue. There is a need for a good
cessation program for any intervention in the field of tobacco to be successful.
Mark cited the example of T.B. saying that there is no good educational program for
tuberculosis in India. He also said that there was a need to try to get the academic
institution and NGOs to work together. When told that CHC was working towards this,
he lauded the efforts and was impressed by the Fellowship Program being envisaged.
Mark had an extensive discussion with Rajan about the field of Malaria. He said that
local panchayats needed to be involved in the process of malaria control so as to bring
about input of new ideas. It is a good idea to encourage young kids as elements of change
and to act as Mosquito Busters.
He stressed that SWAT (Strength, Weakness, Analysis, Target) analysis was an effective
way to judge a program and the only way to defeat a paradigm is an alternate paradigm
that is better.
There was also a need to increase community participation in health programs, which is
now limited to ‘they should listen to us’ or ‘they should pay for it’.
Mark said he would want to interact with Dr. Thelma and Chander especially regarding
their work the field of Tuberculosis and Tobacco.
He expressed his interest in remaining in touch with CHC and helping CHC network with
various organizations working in related fields at a global level.
Appendix 4
SEMINAR ON EVOLVING EDUCATIONAL STRATEGIES FOR TOBACCO
CONTROL
A Report by Naveen Thomas & Dr. Anant Bhan
Date: 18th October 2002
Venue: International Services Association, Benson Town Bangalore
It is generally observed that while the use of tobacco is declining in developed nations, it is
still quite high in India. A Global Status Report of the World Health Organisation (WHO)
estimates that 65% of men in India use some form of tobacco, (about 35% smoking, 22%
smokeless tobacco, 8% both). Prevalence rates for women differed widely, from 15% in
Bhavnagar to 67% in Andhra Pradesh. However, overall prevalence of bidi and cigarette
smoking among women is about 3%. The use of smokeless tobacco is similar among women
and men. About one-third of women use at least one form of tobacco. Differences in tobacco
use also vary among other groups; Sikhs do not use tobacco at all, and Parsis use very little,
while tobacco use is permissible among Hindus, Moslems and Christians. Smoking rates tend
to be higher in rural areas than urban areas. Smoking is a status symbol among urban
educated youths, but most appear to be unaware of the hazards of smoking (Tobacco or
Health: A Global Status Report, Country Profiles by Region, 1997).
With tobacco use so widely prevalent, can diseases be far behind? The estimated number of
new cancer cases in India per year is about 7 lakhs and over 3.5 lakh people die of cancer
each year. Out of these 7 lakh cancer cases, about 2.3 lakhs (33%) cancers are tobacco
related. Tobacco related cancers accounts for about 52% of all cancers in males and 25% of
all cancers in females. There would be about 1.5 lakhs cancer cases at any given time in
Karnataka and about 35,000 new cancer cases are added to this pool each year. (Source:
Kidwai Memorial Institute of Oncology, Bangalore)
It is estimated that Karnataka has about 8 million tobacco addicts including more than 60,000
children below 15 years of age and about the same number of youth aged between 15 and 25
years enter the pool of tobacco users in the state every year. Data from Karnataka shows that
91% of young individuals below 40 years who develop Acute Myocardial Infraction will
have one or other risk factors including tobacco usage especially smoking. (“Prevention is
better than cure”, S.T. Yavagal. http://www.csiblr.com/index.html). At Sri Jayadeva Institute
of Cardiology, Bangalore, a premier institute run by the Government, 3883 acute myocardial
Infraction patients were admitted in 1997 alone. This reflects the gigantic problem of
coronary artery disease in Karnataka.
Background
Community Health Cell (CHC) has been working in the field of tobacco control and
awareness for the past few years. This includes conducting sessions on tobacco awareness for
schools, colleges and corporate institutions. CHC is also involved in tobacco control activities
at the policy level by playing an active role in organising rallies, protest marches, mobilising
students and concerned citizens to create awareness throughout the year and especially on
World No Tobacco days. CHC is involved in the functioning of the Consortium for Tobacco
Free Karnataka, which involves more than twelve institutions,
associations, hospitals, student bodies and voluntary organisations.
including medical
CHC has brought out a memorandum on tobacco control, which has been endorsed by more
than 5000 school and college students and is to be presented to the Government soon. The
memorandum calls for ban on sale of tobacco products to minors and implementation of the
govt. Order prohibiting smoking in public places.
During the course of the above activities, CHC realised the importance of networking with
other organisations working with children, adolescents and vulnerable sections of society to
sensitise them about the extent of the problem, and to work together towards preventing the
further spread of tobacco usage by evolving common educational strategies which are
culturally specific and relevant to children, adolescents and vulnerable sections of society. A
meeting was organised on 18th October 2002 at International Services Association (INSA) for
which more than 25 organisations working with the above groups were invited to be a part of
the deliberations.
Proceedings of the Seminar
The meeting was delayed for around half an hour as we were waiting for participants. Finally,
the seminar started at around 10:00 A.M. with around 15 participants from a few
organisations (see appendix for list of participants/ organisations). After a round of
introductions, Ms. Edwina Pereira, Programme Director, IN SA formally welcomed all the
participants and wished the programme all success. Chander gave an introduction about the
purpose of the meeting and began by conducting a quiz about various issues related to
tobacco. He presented the global pattern of tobacco usage and its various implication (health,
environment, economic, etc.). He highlighted the fact that tobacco was an addictive substance
and gave figures to show that lesser the age of onset of tobacco usage, the harder it was to
quit the habit. He also quoted industry sources that clearly were attempting to influence the
younger people into taking up the habit by using the “catch ‘em young concept. This set the
ground for focussing on children and adolescents as a potential group who needed to be
educated and supported to prevent them from falling prey to the unethical practices of the
local and global tobacco industry.
This session was followed by a session on Health Implications of tobacco usage by Dr.
Rajkumar and Dr. Anant. They highlighted the scientifically proven association of tobacco
with a range of health problems including lung cancers, heart disease, sub-mucosal fibrosis,
oral cancer, sterility, and a range of problems associated with tobacco smoke (active and
passive). The harmful effects of second-hand tobacco smoke/ environmental tobacco smoke
(ETS) were explained. The fact that only 15% of the smoke was actually consumed by the
smoker while the remaining 85% was ETS shocked the audience. This session was conducted
using visual aids like OHPs and Slides.
After tea break, a session on economic implications of tobacco was held. Chander began by
introducing the global economics and the unviability of tobacco trade (in terms of foreign
exchange), while Naveen concentrated on the economic aspects at the local level. He spoke
of the health costs, occupational risks, environmental costs, balance of trade costs and the
costs of substituting essential crops/ nutrients at three levels (Government, Tobacco
producers and Consumers). He illustrated these with information from the latest study he
jointly conducted in Karnataka and from studies on street children in Mumbai.
This was followed by a session on environmental implications, where the huge deforestation
due t to production and curing was discussed. Naveen presented the findings of his study
from Shimoga district in Karnataka including the occupational hazards the tobacco
cultivators and beedi rollers undergo. The other aspect that was covered was the use of paper
for rolling cigarettes, packing, etc. The aspect of ETS was reiterated here, which sparked off
a discussion on how to work towards demand and supply reduction. The participants
suggested various means like increasing taxes on tobacco products, decreasing accessibility,
etc.
The group then decided to list down reasons for increasing tobacco usage among children and
adolescents. Various reasons like peer pressure, rebellion, imitation, identity, symbol of
adulthood, stress buster, to relax, to concentrate, feel the taste and to have something to do
with their fingers were listed.
The last session then focussed on evolving strategies for tobacco control through an
interactive session. The important strategies suggested by the group includes:
•
•
•
•
•
•
•
Influencing parents, teachers and doctors to understand the issues involved in tobacco
usage and the need to engage them in addressing the problem and supporting
youngsters.
To influence the media to avoid glorification of tobacco usage (especially in TV
serials movies and advertisements)
To ensure that tobacco products were not available near hospitals and educational
institutions.
The importance of life skill education so that youngsters could withstand peer
pressure and say NO to tobacco.
Scouts & Guides, NSS / NCC cadets to be enlisted as support groups in this campaign
and peer educators/ influencers
Use of testimonies (through direct interaction/ multi media, etc.) of tobacco users who
had quit or people suffering due to tobacco related illnesses as powerful
communication tools.
To develop a module using locally applicable themes, which could be used to educate
youngsters about harmful effects of tobacco.
22nd November was fixed as the date for the next meeting. CMAI tentatively agreed to host
the next meeting, subject to availability of their hall. All the participants agreed to make
presentations on “Tobacco use in their work areas and strategies to overcome them . It was
also suggested that a meeting of the Consortium be convened on the same to discuss further
strategies.
Dr. Rajkumar thanked all the participants on behalf of CHC and INSA for attending the
meeting and taking a first step towards establishing a network of organizations working with
young people to educate them about the ill effects of tobacco.
As an afterthought, since a meeting is being held in NIMHANS on the 31st October 2002
with the same objective (to establish a network), it might be a good idea to club resources and
try to work with them and develop a module with their help.
Appendix 5
Seva Sadan Boys LSE Program
Session in Nov.
As a part of the Seva Sadan LSE program, AB took a session for the Hindi/
English/ Konkani speaking boys group numbering around 10. This was the
fourth session being taken for this group.
The students initially recollected the last session wherein they were given an
introduction to sexuality and the previous speaker cleared their doubts.
Objective
1) To assist the students to clarify doubts related to lust, fantasies, sex
and to develop healthy opinions and attitudes to wards sex
2) To discuss the abilities related to decisions on sexual experience based
on sexual needs and following the societal norms.
3) To make the students recognize in themselves emotions, which are
sexual, identify sexual needs and accept them as healthy.
4) To help them decide to postpone sexual experience till marriage/
development of a stable relationship.
Techniques Used
Group Discussion,
Attitudes
Brainstorming,
Sharing
ideas,
Opinions
and
• Initially the boys were given a brief introduction about the sexual
organs in males and females
• Some of the boys wanted to know why girls use sanitary pads so the
menstrual cycle was given to them; it was also reiterated here that
menstrual blood is not bad or dirty blood and also that ladies during
their periods are not dirty or unclean. Rather it’s a normal
physiological change in a woman’s body.
• When to have sex?
The boys after discussion agreed that sexual activity with a
person should take place only after they develop feelings of love, care
and concern for the partner.
• The various ways though which couples demonstrate their sexual
feelings including kissing, hugging, touching each other’s bodies were
II
•
•
•
•
•
•
explained to the group. This was followed by a description of the act
of intercourse.
It was explained that sexual feelings are normal and all humans-male
or female have these.
The process of conception and the changes in a woman’s body after
pregnancy including the signs of pregnancy were then dealt with.
The care of a pregnant woman during pregnancy was discussed.
The boys were then asked about the methods of contraception they
knew of and then all the methods available were explained.
Myths and misconceptions related to sexuality were discussed; most
of the boys still had a lot of doubts, which were cleared.
Homosexuality was explained to the boys and they were told the need
for developing tolerant attitudes and respecting the choices that other
people make.
The session then concluded with a brief revision of the key points.
Appendix 6
.Asia Social Forum- a Reflection - By Dr. Anant Bhan, CHC
The recently concluded Asian Social Forum held from January 2-7,
2003 was the first attempt at the Asian regional level at unifying all
forces that have faith in the surmise that Another world is possibleanother world that need not necessarily be dominated by imperialists
& where the third world be continuously subjugated in the name of
globalization.
To be able to work to bring together different organizations, networks,
issues, people of diverse nationalities, cultures and give them an
opportunity to be able to an exchange of ideas through conferences,
seminars, workshops, open houses, cultural performances, movies and
plays was always going to be difficult but ASF managed to pull it off.
More than 14,000 delegates and a floating population of at least 6,000
more people had ample opportunity to unite and find common ground
even within the diverse fields and issues that they were advocating. So
there were burqa clad women from Hyderabad attending the dalit
events and relating to the feelings of suppression; there was the
mother( Nora Cortinas) from a Latin country(Argentina) whose son
had been taken into custody and than never seen again who saw the
hands that wield power in Burma use rape as a means of suppression
on the hapless citizens; there were the health-wallas from the Peoples
Health Movement trying to remind everybody that this was the 25th
anniversary of the Health For All call of WHO which has been
conveniently forgotten by the governments in favor of the selective
health care that the World Bank and the International Monetary Fund
advocates, hence it was time to demand healthcare as a fundamental
right; there were those who could still not understand why Gujarat
could have exploded the way that it did; there were those who were
dedicated to the cause of protecting our indigenous plant varieties and
traditional folk-systems; there were also those who felt that they
needed to attend because they wanted to prove that they had done
their quota of social work for the year & happily went back home in
their latest imported cars with soft drink cans in one hand and sleek
mobile phones in the other.
Was there something achieved at the end of such a mammoth
gathering- or was it a huge loss of resources? I have now come to
realize after talking to my senior colleagues that the whole purpose of
the meeting was just to be a platform- for everybody to be able to
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stand up and have their say; there was no hierarchy and negligible
security (though I guess the organizers lament that after the Hussain
outburst) and so you had the activist celebrities mingling with the
grassroots workers who were the real strength of the organizations. It
was a great opportunity for people to meet old friends and make new
ones.
The outlets serving Hyderabadi food, the dances, the continuos roll of
drums in some part of the sprawling Nizam College grounds, the
jostling around at the stalls that sold all kind of stuff from books, bags,
handicrafts to short eats and ASF memorabilia just added to the 'mela'
feeling and believe me at the end of each day, if you had not managed
to gather enough dust to have to necessarily drag your tired body to
have a pre-snooze bath, you had not entered into the true spirit of the
ASF.
The mass of volunteers from all over Andhra who ran the whole show
guiding delegates, making sure that you did not get fleeced by the
autos and stayed on the grounds in the shamianas need to be
appreciated. The efforts of NAZ foundation to provide safe drinking
water to the thirsty masses went along way in ensuring that ASF did
not become a public health nightmare that it so easily could have
turned into.
From the opening plenary, when we began to the calls of the Telugu
theme song 'AASIA SOCEL PHORUM'to the closing plenary when many
joined in the chorus of the song, it was an experience that left of us
enriched and convinced that Another World is Possible, Another Asia is
Possible.
For a young medical graduate like me who had come from a
biomedical background and had only attended medical conferences
that were less of academic updates and more of marketing
juggernauts of 'pharma' companies who sponsor everything from the
delegate registration and travel to toilet paper in the rest rooms, ASF
was a refreshing change. It offered a chance to remember a plethora
of lost issues that the govt, and the media has conveniently forgotten.
There was at the end of the event a deeper understanding in all of us
of how the macroeconomic policies affect each and every corner of our
country and continent. The interaction and time spent with people
from diverse nationalities learning about their lives and the reasons for
their convictions are memories that will last a lifetime. The discovery
that arises from almost all the events at ASF is that health is
inextricably linked to all the topics that were being debated whether it
H
be poverty, women's issues, malnutrition and the right to food, dalit
marginalization or the problems of the landless, the agony of those
affected by torture and communal disharmony. This is a learning
process that cannot be conveyed through textbooks, lectures or
seminars in our ivory towers of medical education but has to be
explored through the sharing of experiences that ASF provided space
for.
Sometimes, there was the feeling that the most of local populace of
Hyderabad were not aware of the ASF and hence were conspicuously
absent; also the fact that most events spent too much time on
analysis and discussing much less of action was disappointing. There
was also a feeling of mistrust in some sections about the funding and
the involvement of the World Bank indirectly in the organization of
ASF, which was unfortunately not clarified. This led to some groups
deciding to organize an 'Alternative ASF' in Hyderabad which was
purportedly free of the machinations of multinational funding agencies
while others decided to protest- one of the most visible being the one
led but Gadar, the revolutionary poet form Andhra. Their views have to
be respected and thought upon, as there has to be room for dissent in
the 'another world' that we are seeking. But these were minor hurdles
which I guess, are to be expected in an event of the magnitude of
ASF.
ASF as a meeting point was a success- a success that need not be
quantified and critically reviewed too much in detail. It has been an
experience that has left its mark on all those who participated in it. In
this time of turmoil that the country is going through, I am sure we
need more social forums to experience the feeling of togetherness
which all of us felt during the ASF and while traveling to & fro to the
events in trains and buses, singing, raising slogans and exploring new
ideologies, new languages and new cultures etc.
I am sure we'll successfully organize World Social Forum in India next
year as we have all learnt in ASF that national boundaries are not
barriers to the basic problems that all of us face and the indomitable
courage that some of us exhibit in the face of these problems to be an
inspiration to mankind.
This reflection was published in the March 2003 issue of Health Action
Appendix 7
Action Towards a Tobacco Free World
A workshop at Asia Social Forum, Hyderabad
Date: 3rd January 2003
Time: 2:15 to 6:30 P.M.
Venue: Taj Mahal Hotel, Abids Road, Hyderabad
Facilitated by:
Community Health Cell, Bangalore on behalf of Jan Swasthya Abhiyan / People’s Health
Movement)
Partner Organizations
Consortium For Tobacco Free Karnataka
PATH-Canada, LIFE
A Report by Dr. Anant Bhan, Community Health Cell
The workshop began with registration of all participants. They were given files with
background material about the purpose of the workshop. Around 40 people participated in the
workshop.
The workshop began with an introduction to the purpose of conducting the workshop by Mr.
S.J. Chander from the Community Health Cell who spoke about the global problem that
Tobacco had become and the targeting of Asia and developing countries by Tobacco MNCs
and hence the importance of a concerted effort to network for freedom from tobacco.
Dr. Ramesh S. Bilimagga, Radiation Oncologist and member, CFTFK (Consortium For
Tobacco Free Karnataka, Bangalore, chaired the first session. He welcomed all the
participants to the workshop and reiterated that tobacco was a major problem not just in India
but also across the world. He stressed that a small step by everybody in the direction of a
tobacco free world would make a big difference. He then invited Dr. Thelma Narayan from
CHC to give an overview of the problem.
Dr. Thelma explained that the workshop was being held under the platform of Jan Swasthya
Abhiyan (PHM) which was active in more than 92 countries ands was working towards
making the govts, and WHO and international bodies accountable to their commitment for
Health For All. She stressed that many coordinating and facilitating agencies had helped in
organizing the workshop and also enumerated the other events at ASF being facilitated by
CHC/JSA/PHM. She said that the workshop would help us understand the tobacco issue
especially in regards to dealing with the tobacco industry. It was needed to share our
solidarity in the ASF platform and to strategize and reflect. The effect of globalization on
public health needed to be studied in depth. Opium had been used in the past by Britain to
subjugate China and now the western powers through the tobacco MNCs were using tobacco
to subjugate the Asian countries. The US was promoting the global consumption of tobacco
and there had been a sharp increase in tobacco usage in many areas; the issue of tobacco
advertising was also an important issue. While tobacco use was reducing in the North
America and Western Europe, the tobacco market was being relocated with increasing use in
Asia and developing countries. Data from different Asian Countries was presented. The
dynamics and intricacies influencing the negotiations of the Frame Work Convention For
Tobacco Control (FCTC) led by the WHO (World Health Organization) needs to be more
transparent in order to evolve a useful instrument.
A Magic Show and a talking doll show followed this. The magician stressed on the ill effects
of tobacco and requested people to not let their lives go up in smoke and to avoid the bad
habits. It was well appreciated by the audience. He also wished everybody present a very
happy and tobacco free New Year.
Dr.Ramesh then invited Dr. Prakash C. Gupta, an epidemiologist and a public health
consultant from Mumbai having 36 years of research experience in the field of tobacco.
Dr.Prakash began by saying that tobacco is a public health problem even at the grassroots
level. Understanding the problem was not enough and something needed to be done about the
problem. There were various organizations working in the field of tobacco control in India-a
loose coalition of which was the ICTC (the Indian Coalition for Tobacco Control). Each of
the organizations was free to pursue their own agenda but it was an interactive forum for all
participating organizations to pool their resources. He expressed hope that more organizations
would join the fold. He also mentioned that a death clock had been installed in Delhi that
would register the deaths being caused by tobacco usage in India.
After thanking Dr. Prakash, Dr. Ramesh introduced Mr. Sonam, a bureaucrat form the
Ministry of Health and Education in Bhutan. Mr. Sonam said that Bhutan had initiated
tobacco control regulations as early as 1729; the state religion (Buddhism) did not permit the
usage of tobacco. He cautioned that in their experience regulation alone was not enough and
there was he need to take undertake aggressive information dissemination and work for anti
tobacco legislation. The Hon’ble Minister of Health had ensured that the sale and
consumption of tobacco had been banned in public places. The effort had come through a
decentralized approach wherein 18 out of the 20 districts in the country had themselves taken
up the initiative to work for local tobacco control. He said that a dilemma that faced the govt,
was the continuing sale of tobacco in the duty free shops in the capital city, which could not
be stopped because of diplomatic problems- he invited suggestions from the participants on
how to deal with the problem. He said that one of the queens in Bhutan was committed to the
cause of tobacco control and had been appointed as a goodwill ambassador by the UNFPA
and she advocated the tobacco and health issues in various districts that she regularly visited.
Appreciating the people of Bhutan, Dr. Ramesh said that it was important to remember that
perseverance was the key.
Dr. Ramesh then called upon two members of the Bangladesh Anti Tobacco Alliance to
speak about efforts at tobacco control in their country. One of them Mr. Ratan Deb said that
sometime ago though there were many groups working in the field not many were working
together ;only school level programs were being organized to raise awareness about the
harmful effects of tobacco and these also not very effective as they were leading to rebellion
in many cases. He felt that what would work is strict enforcement, high taxes, controlling of
advertising, more elaborate warning in the packs. He said that BATA has little resources
compared to other groups and tobacco companies. BATA had filed a case in the Bangladeshi
courts and had managed to achieve a significant legal victory which led to decrease in the
rampant advertisement of tobacco companies and had also proved that British American
Tobacco Company’s antismoking campaign was a sham. BATA has been closely working
with the Bangladeshi govt, and have been attempting to spread the message of harmful
effects of tobacco even in the regional languages. A law for stricter tobacco control is now
pending in the parliament. A second writ petition is now pending in the courts under the
Right to Life campaign against the Imperial Tobacco company; the court has given a stay
order on all relevant advertisements for two months. Many organizations and facilities in
Bangladesh are now tobacco free due to the efforts of BATA. He ended stressing that
working together was very important for tobacco control. Mr. Naveen Thomas expressed the
view here that one major factor for the success of the campaign in Bhutan was the fact that
the political, religious and local leadership had come together to fight the problem and were
very much involved.
Dr. Ramesh appreciated the efforts of BATA and raised the fact that the various govts, had a
dichotomous attitude towards tobacco wherein e.g. the Karnataka govt, had an anti tobacco
cell in the Kidwai Memorial Institute of Oncology, it also had a research wing in the Tobacco
Board to try to improve productivity and quality of tobacco crops. He said that in K’taka
• There were 8 million tobacco addicts.
• 6000 children under the age of 15 yrs of age and as many between the ages of 1524 enter the pool of tobacco users.
There was a need to publicize the tobacco issue among the lay public as they had the right to
information.
Mr. Jaggaiah, a security guard from Hyderabad who used to smoke around 48-50 beedis a
day for over 40 years presented his medical problems directly related to his tobacco
addiction. He used to get cough, dyspnoea and chest pain; he had to undergo surgery
(pneumonectomy) for pathology arising from his tobacco usage; he said that he had now
stopped smoking and was proud to be free from tobacco.
Ms. Lalitamma from Karnataka, an ex-cultivator then shared her experience .She said that she
had been working in the tobacco fields for over 15 years; most of the workers used to be
employed as daily wage workers by the rich cultivators and had work for only 3-4 months/yr.
The workers had very hectic work in the fields everyday and at the end of each day they were
so tired that they could not adopt any hygienic methods before consuming food or have a bath
before sleeping. They also used to use a lot of pesticides in the tobacco nurseries in their
homes and because of all this problems she felt that they used to inadvertently consume a lot
of pesticides. During the course of her work, she developed health problems and approached
a medical practitioner who advised admission - her treatment bills were in the range of about
Rs 30,000. She said that she had resolved to never do that kind of work again and was hoping
that other people also left that hazardous work.
Dr, Ramesh thanked all the speakers for giving an insight into the various issues related to
tobacco that were affecting their lives and work. He then thanked the organizers for having
given him the opportunity to chair the session and handed over the stage to the next
chairperson, Ms. Devaki Jain.
Ms. Devaki then chaired the next session, which was distribution of certificates and
mementoes of appreciation to
•
•
•
The people of Bhutan for having shown great collective resolve for the fight against
tobacco. This was received by Mr.Sonam Thunsho, secretary, government of Bhutan
in charge of health education.
The members of BATA for their work for tobacco control in their country and for
dragging the guilty tobacco companies to court and make them accountable for their
unlawful practices. This was received by Mr.Ratan and Mr. Biplob
Dr. Prakash C. Gupta for his extensive work in research in the field of tobacco.
A short tea break was then announced which gave the opportunity for the audience to interact
with the speakers and also for them to view the exhibition of anti tobacco posters that had
been put up by Community Health Cell in the hall.
The tea break was followed by a panel discussion on various facets of the tobacco issue. The
discussion was chaired by Ms. Devaki Jain. She said that the amount of money the govt,
spent on treating diseases arising from the usage of tobacco was more than the money it
received through excise. Tobacco related deaths were more than the number of deaths caused
due to HIV, Malaria, and T.B. combined. There was a need for campaign mode activists, as
knowledge about the ill effects of tobacco did not deter people from harmful habits. Death
was a close phenomenon in India especially among the poor and hence morbidity and
mortality due to tobacco could not be used as an effective deterrent in that sector. There was a
need to work to change attitudes; also important was to fight the tobacco industry, which was
targeting the young by using unfair advertising means. There was a need to talk about it in the
background of globalization and macro-economic program. The relation between poverty in
India and the addiction to tobacco, alcohol and the susceptibility to HIV in poor communities
was well known and proven in studies such as one done by NIMHANS. Also, interestingly,
the govt, had included Tobacco in the Foods and Beverages list.
Dr. Devaki then invited Dr. Prakash Gupta to give his presentation. Dr. Prakash’s
presentation had the following salient points:1. There were only two causes of death that were increasing worldwide- HIV and
Tobacco.
2. Death was an objectively measured event; Tobacco usage was the single most
preventable cause of death in the world.
3. Current WHO estimates of tobacco attributable premature deaths are in the range
of4.9 million/yr. This is expected to rise to 10 million / yr by the year 2030; already
in the 20th century approx. 100 million people had died due to health problems related
to tobacco usage.
4.
India was the second largest producer and consumer of tobacco in the world; ICMR
estimate for the annual attributable mortality from tobacco was 8,00,000.
5. Tobacco causes a lot of medical problems and addiction is a key issue because of the
nicotine content
6. Children are the mot severely affected and unfortunately they are powerless to fight
against this evil.
7. There were many misconceptions related to tobacco e.g. that it was not a high-risk
product and that tobacco users do not have any choice, once addicted.
8. The truth was that more than half of chronic tobacco users would die of health
problems arising from that habit.
9. Tobacco smoke had a lot of toxic chemicals and carcinogens and had an effect even
on passive smokers; hence there was a need for concerned people to fight for their
right for clean air.
10. Tobacco and social justice was also an important issue- as its usage was more among
the lower SE strata and the relative risks were also higher in this group; beedis,
commonly used by this group were more harmful than cigarettes; also unfortunately,
most of the interventions were aimed at the higher SE strata.
11. The rising usage of tobacco among the women was alarming- one study had shown
that as many as 10% of college going women in Mumbai were using tobacco.
Dr. Devaki then invited Dr. Srinath Reddy to present his views and experience as the
Indian govt, nominee and as a NGO health activist at the FCTC deliberations. FCTC was
an attempt by WHO to exercise its treaty making power for tobacco control. The critical
issues included stronger action required on the demand and supply sides. There were the
issues of trade and public health involved; most country representatives participating in
the deliberations were advocating a total ban on all forms of advtg.- direct and indirect.
But there had been pressures from some quarters and in the ongoing round the talk was
around restriction of advtg; unfortunately the issue of surrogate advtg had not been
addressed. The WB and developed countries were of the view that there was a continued
increasing demand for tobacco irrespective of control measures (more in the developing
countries and lesser in the developed ones). Global resources were lacking for
implementation unless a global fund was set up. Also, cross border advertising continued
to be an issue and trade v/s public health was a battle that was still being fought out in the
FCTC. The recent draft of the FCTC was disappointing. It has been prepared for the
next round of negotiation in February 2003.
Ms. Devaki thanked Dr. Reddy and mentioned that the UN precincts and most eateries in
the developed countries are smoke free. She then invited Ms. Shobha John of PATH
Canada (Programme For Appropriate Technology for Health) based at Mumbai to make
a presentation. Shobha spoke about the poor being affected the most by tobacco usage
and she presented some data from her PATH studies which showed that the tobacco
consumption among the pavement dwellers was 82% and among the street children was
76% - these people were spending less amount of money on food than tobacco. She also
raised the issue of misplaced targeting by activists who were not addressing the tobacco
problem that was afflicting the poor SE strata and the need to reach out to that group. In
Bangladesh, a study had proven that many households were spending 18 times more on
tobacco than health. The tobacco issue was causing a loss to the country as the estimated
health costs were in the range of Rs 6.5 billion while the excise returns were only Rs.4.5
billion; hence the economic loss to the nation was immense. Also the tobacco industries
were themselves promoting smuggling of their products and were using a lot of front
groups for surrogate advertisements. The industry’s argument that a lot of workers would
lose their job had to be viewed with scepticism because the companies as they were
getting mechanized were laying off a lot of workers; also experience had shown that the
industry was actually quite exploitative; Ms. Devaki mentioned that some traders in
B’lore had been subletting the space outside their shops which was actually govt,
property to vendors; she then invited Ms. Suvarna to share the findings of her study in
Shimoga in Karnataka.
Suvarna mentioned that she had been working in the area for the last 12 yeras and she had
noticed that tobacco cultivation had decreased by more than 50% - this had sparked an
interest to initiate the study. They had discovered that the cultivators were actually the
large farmers as the govt. Tobacco board regulations were that all tobacco cultivators
should a possess a minimum of at least 3-4 acres of land .Tobacco cultivation was labour
intensive. It also required a lot of wood for curing which had led the farmers to steal wood
from the forests. Almost 80% of the forests had been depleted and now the local populace
had sometimes to walk a distance of 10 kms to collect firewood. Good quality wood was
required for curing wherein temperatures were maintained at 90-120 degrees Fahrenheit
for 4 days. The alternative crops that some families had shifted to in the state were maize
etc.; they had noticed that the land became more fertile if tobacco cultivation was
decreased. As tobacco was a very labour intensive work, the people used to be busy from
morning to evening in their work, which had affected families, as there was nobody to
look after children and the elderly. This has been shown in falling attendance in school for
the children of cultivators and agricultural laborers. The Sanghas and self-help groups
discussed this and decided to utilize the govt, programs. Supporting each other, they
started animal husbandry and were managing to get continuos money inflow. In tobacco
cultivation, women were the most affected - they had occupational problems, were made
to work hard and do menial jobs; there was gender insensitivity and the women were made
to do the most difficult and strenuous work. This had affected the lives of many women
and children adversely. Ms. Devaki appreciated the presentation and mentioned the need
for linked narratives to help with advocacy issues.
This was followed by a group discussion involving all participants that was chaired by
Dr. Srinath Reddy. The main points that were highlighted in the discussion by various
participants were: -
•
Coronary Artery Disease (CAD) caused by tobacco usage needs to be studied and
publicized.
•
FCTC needs to advocate strong regulations- local and national.
•
Need to sensitize the politicians about the issue.
•
Need for effective political lobbying and policy level interventions.
•
Need to safeguard the interests of the involved people and to try to bring the larger
forces to come together.
•
Lesser emphasis to be laid on health and more on the fiscal and the environmental
aspects.
•
To try to attempt a linkage with the right to food campaign and the environmental
issues.
•
Promote the usage of the 73 rd and the 74th amendments that promote local
governance.
•
Need for economists to study the long term effects of tobacco usage.
•
Promote the ban of tobacco consumption in public places as it gives the right to
people to protest tobacco usage.
•
Alternate employment strategies to be promoted.
•
Need to understand that there was no direct subsidy by the Govt, of India to the
tobacco industry but indirect subsidy.
•
Legislation against tobacco would be ineffective if people were not informed and
convinced about the reasons for legislation.
•
Need to approach and convince even the local and vernacular media to cover tobacco
related issues.
•
Need to convince the film producers and artists to not promote the usage of tobacco
in the movies/serials; this was especially relevant as the theme of the World No
Tobacco Day this year was ‘Free Films from the influence of Tobacco \
•
The information about tobacco to be integrated into existing health programs and
through the educational system in school and colleges.
Mr. Niranjan from the People’s Health Movement in Sri Lanka shared that the cost of
one cigarette in Sri Lanka was 7-8 rupees and that was an effective deterrent also; it was
discussed that Prof. Panchamukhi’s study on Karnataka had proven that tobacco farmers
were ready to diversify into vegetable cultivation but the market support was not in
place. Whereas the tobacco industry was picking up its produce and taking it to the
market, this support was not available for the farmers involved in vegetable farming to
transport their produce to the distant markets.
The group then discussed the statement to be issued by the workshop participants- certain
changes were suggested for incorporation in the statement before finalization and
distribution to the ASF organizers and the media. The modified statement and the press
release are attached.
Dr. Srinath thanked the participants for their active participation in the group discussion.
A formal vote of thanks was proposed and the workshop ended.
Appendix 8
NIMHANS- WHO Workshop on ‘Suicide Prevention: Capacity Building Strategies’
for Media Professionals
Venue:- NIMHANS Convention Centre, Bangalore
Date:- 1st February 2003
The Departments of Epidemiology and Psychiatry, NIMHANS have been organizing a
series of workshops on the topic ‘ Suicide Prevention: Capacity Building Strategies’
involving professionals such as doctors, teachers, police staff etc. to try to address the
issue of increasing suicide rates in Bangalore. As a part of this series, a workshop was
organized for media professionals to examine the role of media in the glamorization of
suicide and to evolve parameters for ethical reporting of suicides.
As a part of this exercise, representatives from the various sections of media like radio,
print, journalists, serial actors and directors along with a few NGOs and psychiatrists
were invited to debate on this issue.
Prof. Mohan Issac, NIMHANS in his introduction said that suicide is becoming a public
health problem throughout the country. Bangalore has the highest rate of suicide in the
country and thus has got the dubious distinction of being called the Suicide Capital of the
country. He explained that the suicide statistics in India, unlike other countries are
sourced from the police and home departments using data of the National Crime
Research Bureau. In the west, some studies had suggested that media portrayal of
suicides did have an effect on the increasing suicide rates in the country but this effect
needed to be studied in India. He said that the aim of the workshop series was to evolve a
National Suicide Prevention Strategy.
Dr. Gururaj from the Dept, of Epidemiology spoke about the increasing reporting of
suicides in the media. He said that the work on the present project had started with a seed
grant from the Dept, of Science & Technology, GoK for work with the police in 12-15
hospitals. The Dept, had come out with two epidemiological reports regarding the same.
There was a need to develop on the research as well as the intervention front and to
translate research into practice. The current workshop was the seventh in a series of
capacity building workshops to try to evolve culturally specific sustainable prevention
programs. NIMHANS had begun a helpline in Bangalore along with the Medico-Pastoral
Association and the Rotary Bangalore East. Suicide, which was a type of deliberate self
harm, was becoming a global problem. The WHO was trying to study violence as a
public health problem. Violence linked to mental health was capable of leaving scars that
would last for a long time.
Mr Ramesh Kumar, Former Speaker, Legislative Assembly, Karnataka who inaugurated
the workshop said it would be better to revise the theme of the workshop to ‘ Has the
media a role to play in the controlling of suicide rates’. Was suicide an act of bravery or
one of cowardice? Age/Sex/Class was no bar to this problem and the factors that could be
blamed would include discrimination, social/economic order, tension, anger, stigma,
political system etc. Suicide attempts not only affected the individual but also the family
& community and the media needed to step in and try to address the general trends that
were promoting suicides. A major reason could be the break up of the institution of
marriage and evils accompanying marriage, which were leading to several suicides. A lot
of vested interests were working to hush up theses issues- the media needed to realize
that there was no need for sensationalizing but sensitive and courageous reporting was
required to try to address the issue. Education of parents was also needed to make sure
that they did not put unnecessary pressure on their children to perform in their exams.
The race to be number one in all fields in Bangalore was perhaps by itself a mental health
problem! The people who attempted suicide did not need compassion but support. The
impact of cinema was significant and was working against the intentions of the seminar
in this context, the work of the people at the helm of affairs and the censor board had lost
credibility. Suicide was an ailment and not a crime (which is how it is looked upon in the
IPC) and directly or indirectly, we were all responsible for the suicides. Another
important point was the role of teachers- parents left their wards in the care of teachers
but some of them were behaving not as guides but as policemen without uniform. There
was also a need for a commitment to tackle this problem by the medical profession.
Prof. D. Nagaraj, V-C and Director of NIMHANS in his presidential speech said that the
suicide rate in Bangalore was three times more than the national average. Only 10% of
the attempted suicides got reported to the police. In a way, suicide was a social (mis)
behavior and society could promote a particular behavior. Frustration was common to
everybody and there was a need to work to decrease it. He felt the best step for the media
was to ignore the reporting of suicides. Sometimes the excessive glorification of toppers
in various exams also caused a lot of depression in the not so successful candidates. The
commonest association with suicide was family structure especially in relation to
disturbed families - alcoholism/marital disharmony/mental health problems; media could
help in promoting the strengthening of our family system.
Session 1
The First session dealt with an overview of the problem by Dr. Gururaj. He said that the
global suicide rate had increased. The highest prevalence was in the states of Karnataka,
Tamil Nadu , Kerala and West Bengal all of which had suicide rates in excess of 15/ lakh
population. In Bangalore, the rate was the highest in the country (around 35/lakh
population in 1999) followed by Indore. This increase had been marked in Bangalore
which had seen the figure rise form 20/lakh in 1989 to 35/lakh population in 2000. The
maximum numbers of suicides were reported in the age group of 15 to 34. 75% of the
attempted suicides in the city involved usage of OP or carbamate compounds. Alcohol
played a major role in suicides- directly or indirectly. The issues in causation were
combined, cumulative, progressive, repetitive, unresolving in nature and inter-related to
each other. The media sometimes indulged in irresponsible reporting and did not follow
up the causes of suicides. There was also the sensationalizing of celebrity suicides on the
front page of newspapers while the other stories usually appeared in small print in the
innards of the paper. There was a need for a humane approach utilising our strengths.
Session 2
Prof. Mohan Issac in the next session examined the topic of whether media portrayal &
reporting of suicidal behaviors influenced the society.
He raised two main queries
• Did media have the power to trigger suicides in some people?
• Did it also have the power to prevent suicide?
There was a variety of media including literature, press, music, broadcasting, theatre,
films, television, electronic and internet (there were even a few sites that even helped in
the planning of suicides).The person who was attempting to commit suicide could have
displayed behavioral changes in the form of suicidal ideas/ gestures / threats
/communications. The effect of the media portrayal could involve the following
components:• Invitation- learning by modeling.
• Contagion effect- copycat suicides in the younger age group- teens/adolescents/
early 20s
The media effects could be examined with regards to the following issues:1. age and gender specific.
2. size of coverage.
3. audience/readership.
4. frequency and manner of presentation.
5. characteristics of the model of presentation.
6. personality of the viewer/reader-suggestibility of the individual and
vulnerability.
Most of the research in the field of effect of media was from the developed
countries and it would not be necessarily be applicable in the Indian context.
Within the universality of rising suicides throughout the world, there were certain
variables:> Suicides increased with age in the west while they decreased in
India
> Suicides were more among the males in the west (global male:
female ratio was 3.5: 1) while in India the ratio was in the range of
1.4 - 1.5: 1. In some age groups, the ratios was reversed (this
phenomenon was also seen in China)
> The causation of suicides was multi factorial with a predominance
of socio-cultural factors in India while in the west the developed
countries, more than 90% of suicides were due to psychiatric
disorders like depression
> The methodology in the west was suicide by firearms/motor
exhaust/domestic gas/ CO poisoning while in India, it was OP and
other insecticide poisoning, drowning and burning.
> It was important to not blindly ape the western findings but to do
our own research.
Session 3
Mr. Prakash Belavadi, Kannada Serial & Movie Director did an analysis of the
topic ‘Suicide on the silver screen- Is there any silver lining’.
The main factors according to him were:Morality and values
♦> Milieu
❖ Motivation.
♦♦♦ Methods and treatment (depiction in the media).
<♦ Media- Cinema and television.
He also tried to analyze the treatment of the subject in various religions :□ Islam- Suicide was forbidden by the Koran but there was a feeling
that certain sections had been misconstrued and so there were the
jehadis who were glorifying suicide attacks.
□ Hinduism- it was rarely allowed but the practice of sati had been
accorded social recognition.
□ Christianity- it was tolerated in the early ear but had been declared
a sin in the post 6th century.
Some authors had also dealt with suicide in their treatises like Shakespeare in
Antony & Cleopatra- Act IV
Three main categories for the depiction of suicides in the media would include:Martyrdom & Sacrifice- For God/community/country/cause/love e.g. the
death of Jack in ‘Titanic’ movie.
S Honour & Dignity- Family/Gender/ Social Status/ Community Values.
S Expiation & Redemption- Sacrifice, Demonstration and Isolation.
The milieu exhibited in contemporary mainstream cinema predominantly had
a feudal setting with the rich upper class where it was fine to have a
glamorous lifestyle and divorces took place routinely while the lower classes
were condemned to their lives. There was thus a lack of adequate
representation of the middle class urban families.
The plot & setting of the suicides in movies/serials waso Family: monetary, premarital or marital discord.
o Community: Feudal setting in village, criminal mafia don in the city,
political.
o Motivation: Lover, friend, poor father.
o Women: Bride or mother.
o Repentant Villain /Parent or mislead vamp.
o Suicide because of dishonor or for gallantry.
o Suicide out of shame.
o Suicide by the villain out of disillusionment or vengefully.
As the final aim was commercial success, the theme had to be visual & action
oriented and had to be filmed in locations such as railway lines, cliffs, waterfall,
factory godowns, home. The suicide was always of an identifiable character as it
would be emotive. It was also assisted with special musical effects to reinforce the
melodrama.
Television serials tended to be more realistic rather than movies unlike cinema
that was intense. There was also more social censorship on TV than in films
because of the advertising restrictions. Also, TV serials were primarily geared
towards the middle class viewers.
Session 4
Mr. T.S. Nagabharana , Director, Films & TV in the next session said that there
was a certain percentage of audience that received entertainment exclusively
through the cinema. The main purpose of cinema was entertainment and very few
ventures were meant for social reform. Violence, sex and thrill garnered the
maximum amount of revenues for the producer and hence dominated the
storyline.
Session 5
Ms. Aparna, film and serial artist and anchorperson spoke about the glorification
of suicides in the media. Media could be used to prevent suicides and it could also
work as an interventional tool. She recollected about the depiction of suicide in
one of the famous Kannada movies that had stayed fresh in her memory because
of the way it was conceptualized and shot. There were also increasing suicide
rates related to job stress and the decline in the software sector. The ethos of the
struggling city dwellers were such that they had all become apologetic about their
lives and the belief that only if one could be a software professional working in
the states was a person successful was causing a lot of depression. City life was
impersonal and there was nobody to talk to (Gossip as a stress buster!). There was
a need for an active outlook and to encourage everybody to respect their lives and
the way they lead it (self esteem).
Session 6
Mr. Nagesh Hegde, Scientific writer, Deccan Herald explained that there were
severe limitations in the way the media could deal with suicides; there was the
necessity to stick to the truth. The print media depended on the police records and
version and could not have a roaming reporter searching for suicides; also they
could not have emotional coverage but had to strive for unbiased reporting. There
was a lack of print space to reflect on causes and also the press could just be a
mirror of the society. He also invited the health professionals to stop pointing
fingers at the media but to start informing the media about how to intervene and
howto teach parents/family members to pick up pre-suicidal hints in children.
Session 7
Mr. Krishnamurthy, Station Director, IGNOU Cyan Vani FM channel spoke
about his three decade long association with AIR that included a stint as director.
The policy was to seldom report suicides in the news along with murders and
sexual assaults. The primary focus of AIR was education, information and
entertainment and in its 75 yrs of broadcasting it had tried to convey news without
sensation or speculation. Accurate and confirmed news were only broadcast
According to him, mass media could only act as a catalyst but it was for the
society to change.
The media could not be blamed for the increase in anti social activities when the
society itself was denigrated
Session 8
The next session was a panel discussion that was moderated by Ms. Shailaja
Santosh and involved artists, journalists and medical professionals. The main
points that emerged included: ■ The public tended to remember those things that glorified
violence/sex/problems rather than other parts of the movie.
■ The increased expectations in the society - educational, financial etc.
might be a root cause.
■ There was also the issue of depiction of the women in media vis-a-vis
helplessness, violence, gender disparity and sexual oppression.
■ Emotional fulfillment was possible only in a relationship - this myth had
been spread around in young women and so failure in relationships/love
lead to devastating results.
■ The print media usually buried the news relating to suicides in the middle
pages in small font.
■ The material aspects of life were being given prominence.
■ Non-participation was the problem in our country and this was also
reflected in the lack of concern in civil society to respond to the rising
suicides.
■ There was probably some indirect suggestibility of the suicide stories - it
could mirror the fact that repeated viewership of advertisements could
influence some viewers to buy that product.
■ Genetic epidemiological studies had also shown some familiar
predisposition towards attempting suicides.
Session 9
Dr. C.J. John, a leading psychiatrist then presented the experiment in Cochin that
was among the very few cities that was witnessing a falling trend of suicides. A
voluntary organization called Mythri had trained 42 volunteers to listen to the
problems of those at risk of suicide. The organization had done a content analysis
of the reporting of suicides - the unusual methods got prominence e g. suicide
pacts, celebrity suicides. However, there was under reporting of the preventable
health problems such as depression and about people who had managed to deal
positively with their suicidal thoughts and about early identification and
prevention in those at risk. A suicide affected the family members as well with
stigma/discrimination/grief.
The issue of suicide was multifactorial and the media did definitely contribute.
The same stimulus had different effect on different people and on the same person
in different situations.
The media suicide stories with the potential of contagion effect were those
that paid undue emphasis on the method, had repetition with prominence,
involved celebrity status and had over simplified causes highlighted, those that
were done with a touch of glorification.
The disinvestments in human values and relationships caused increased
vulnerability and many ended up being emotionally isolated and depressed in
economic hardships.
In Kerala, it was not poverty but the misconceptions about prosperity that were
leading to the phenomenon of neo-poverty in the middle class families with the
associated stress. State wise, Kerala had a higher suicide rate than Karnataka.
The decision to change the media coverage would have to address the need to
attract and hold the audience, the freedom of expression and the desire to serve
the public interest. Achieving a balance was difficult yet possible. Society also
needed to debate whether the media was being provided with stories giving the
message that living worked.
Mythri had especially tried to work on the Sorrow ofMay when the public exam
results of X standard were declared. The stress here was the perception of failure
- even 85% and not 90% and above marks in the exams was looked upon as
failure. The interventions dealt with the facts that students in distress needed
somebody to listen and to care and the understanding that they were not alone in
that feeling because many were going through the same state. The Kerala govt,
inspired by this initiative has decided to open intervention centers in all the
districts of the state. There was now a
movement ‘Life calling: Suicide
Prevention is Everybody’s duty’ which wanted to make the community aware that
there would be feelings of depression in the midst of jubilation and celebration.
The health professionals need to consider meeting journalists as an opportunity
and not a threat. Suicides were preventable in many cases if some simple things
were remembered:♦♦♦ Learn to listen to the cry for help.
Learn to share when depressed.
❖ When encountering severe depression, consult experts.
Some Suggestions that Dr. John gave form his experience included: -
> Suicide stories could be perhaps published with the obituary
columns.
> Counseling training could be given to the teachers ofschools so
that they could help during exams.
> Reorientation ofGPs so that they could identify the depressed and
counsel them at the earliest.
> Need to work at different levels with formal and informal leaders
of the communities.
> Pre exam counseling in two batches for the students and
anotherfor the teachers/parents.
The media was playing a role in the moulding of unrealistic expectations in life.
Session 10
This involved an open house discussion in which the audience interacted with the
speakers and gave their inputs about the topic.
Session 11
The final session was the framing of guidelines for the media, which was
facilitated by Dr. Mohan Issac.
There was a need to strike a balance between freedom of expression, freedom of
the media, the public health interest (minimizing the risks) and the commercial
interests that influence media reporting and policy. The proceedings of the
workshop would be framed into guidelines for the media and it would be a first
step for a long term association with the media . There could be a dialogue with
specific people in charge of sections in the media with innovative ways of
reporting soliciting the help of NGOs. Work with the media required in depth
investigation into the types of the media and how to address them. The media
needed to desensitize help seeking when in distress and highlight the succour
centers and helplines for those depressed. The media could also portray
suicides differently, highlight the alternatives, focus on the positive roles and
work for follow up.
The workshop ended on this note after a day of deliberations and discussions.
Dr. Anant Bhan
CHC
IS01 Feb 2003
(a synopsis of this report yvas published in the Issues in Medical Ethics Apr-Jun
2003)
Appendix 9
One-Day Seminar on the ‘Pre Natal Diagnostic Techniques
(Regulation and Prevention of Misuse Act)
Wednesday, 5th March 2003
Venue:- Institution of Engineers, Ambedkar Veedhi, Bangalore
Organized by
The Directorate of Health & Family Welfare Services, Govt, of Karnataka
Voluntary Health Association of Karnataka
Family Planning Association of India, Bangalore
Background:- In India, the female child population in the age group of 0-6 years has
fallen from 945 per thousand males in the 1991 census to 927 in the 2001 census. In
certain cases the fall is alarming with Punjab, which had a 0-6 yrs. female population of
875 per thousand males in the 1991 census having presently 793 per thousand male
children. In the present scenario, female foeticide has become common while it was
female infanticide earlier. The misuse of technological innovations like the ultrasound
machine, Amniocentesis and Chorionic Villus Sampling (CVS) for the Sex
Determination Tests has been a crucial factor in the rising number of abortions of female
fetuses.
The PNDT Act was enacted in 1994 after a prolonged struggle by concerned members of
society and various women’s organizations. Despite this act having been in force for 9
years now, there has been not even a single conviction for female foeticide countrywide.
With these facts in mind, this seminar was organized to raise awareness about the act not
just among the doctors but also the members of the public especially the women.
Proceedings of the Seminar:
The seminar began with a Sharing of Experience by Dr. B.S. Ramamamurthy, renowned
sonologist form Bangalore. Dr. Ramamurthy spoke about the pressures through which
doctors are put through by the parents and the family to reveal the sex of the child. But
the doctor has to be steadfast in refusing to divulge any such information especially now
with the strict provisions of the Act. He revealed that many doctors while doing a
chromosomal analysis also do not report on the types of sex chromosome but only
whether they are normal or not.
The formal inauguration of the program followed this frank talk by the doctor. The key
note address was delivered by Dr. Manorama Thomas, Emeritus Professor, St. John’s
Medical College. She said that the aim of the seminar was to raise awareness about the
declining sex ratio and about the act. The purpose of the act was to prevent misuse of
genetic techniques for the identification of the sex of a child for foeticide.
The problem was very acute in the states of Punjab, Haryana and Punjab and also in some
parts of southern India like Salem district in Tamil Nadu. There had been some cases in
families wherein ‘draupadi’ system was being followed with one bride for 2-3 brothers
because of the lack of women in the community. Interestingly, the ‘Charakha Samhita’,
the ancient Indian treatise on medicine also mentions technique for sex determination
using the pregnant women’s urine. The PNDT act was passed in 1994 and published in
the Karnataka gazette in January 1996; the advisory committee was established in
February 1996. The committee started registration of the ‘antenatal genetic counseling &
techniques’ clinics. However it was soon realized that the advances in ultrasound made it
possible for the sonologist to be able to predict the sex of the baby by scan after the 12th
week of gestation and hence an amendment was brought in the Act to bring in ultrasound
scan centers under the ambit of the Act- this move had met a lot of protest and in
Karnataka, the professionals in Bangalore and Mangalore were very vociferous in their
opposition to this amendment.
This was important as the sex ratio had fallen in the various districts in Karnataka except
Hassan , Udupi and DK districts. Some of the doctors were not directly mentioning the
sex of the baby but rather using terms like ‘jalebi’ for the female foetus and Taddu’ for
the male foetus. As this was not a part of the records maintained at the centre, the
committee could not do anything about it.
The need of the hour was to change the mentality of preference for males, but it had to be
accepted that this was rather difficult.
Dr. Thimmaiah, Project Director, RCH, Karnataka then mentioned the responbilities of
the state appropriate authority ( Project Director, RCH). He said that each of the 27
districts of the state had a district appropriate authority. More than 1300 organizations
had been registered, but only 31 implicated for practices against the provisions of the law.
Mr. Kogadu Thimappa, the Hon'ble Minister for H &FW and Information then formally
inaugurated the seminar. He spoke about the dual personality that was persisting in the
Indian psyche wherein we try to be scientific in our outlook but at the same time we are
bound by our social beliefs. We cannot claim to have social and gender equality until we
look upon a lady and a gent coming out of a room together in the same light as two men
coming out together. There is a need for a consistent movement, campaign and debate.
The practice of sex determination is more among the educated class who are aware about
the relevant technology and in many cases also know the doctors who will oblige them unfortunately, this seems to be catching up even among the rural folk with the
mushrooming of mobile clinics. He said that the information dept, of the state govt, was
very good at making posters and other educational material but a token 5000 posters
would not change the mindset of a population in the state running into several lakhs. He
expressed happiness that there were several young college girls in the audience who were
the future mothers and would benefit the most from the seminar.
Mrs. Subhadra Venkatappa from the Family Planning Association of India (Bangalore
branch) delivered the presidential address in which she highlighted the fact that as a
2
society, we need to be able to say an emphatic no to these abominable practices. She
reiterated the fact that the misuse of the available technology was most by the educated
class. Both women and men need to work together to address this social problem. Female
or male, the child still belonged to the parents. Perhaps, a partnership between the civic
society and the government would help.
Dr. S.V. Joga Rao, a famous health law consultant gave a detailed explanation of the Act.
He began by saying that we were in the midst of pervasive technology, be it IT or BT.
Any technology has a positive side and a negative side and this holds true for the medical
technology also. At this point of time, the actual birth of the baby is not required to be
able to know the sex of the baby but technology can do the same during the period of
gestation only. The main aim of the technology was to diagnose and treat but the
incidental finding was the sex of the fetus, a fact that could be misused. There was an
ardent need for regulation of the technology. In India, the medical termination of
pregnancy had been allowed in special conditions under law by the MTP act of 1972 and
these provisions had been misused rampantly for female foeticide. All of society and not
just the population in the reproductive age group is instrumental in the problem. By law,
the Sex Determination Tests (SDTs) like amniocentesis can be used for the diagnosis in
certain conditions like the woman’s age being above 35 years, history of previous
abortions, and family history of chromosomal disorders but adequate records mentioning
the reasons need to be maintained. At present, the law is there, the structures are there,
but the practices continue unabated. When the Supreme Court enquired about the fact that
how many clinics had been registered across the country, 15 states feigned ignorance
about the existence of the Act! SDTs were the cause of the victimization of the voiceless
by a network, which could include the mother, father, in laws, the doctor and the
brokers/touts. Already there were ads which proclaimed ‘If you want a boy, contact Dr. X
between 10 & 11’ - maybe the day was not far when we would get promos saying ‘If you
want your child to be the next Sachin Tendulkar, contact at this time’. The need for
regulation of the centers and proper documentation was needed but it was to be
remembered that it was still possible to communicate the sex of the foetus in indirect
ways. In India, we were experts in passing the buck. A few cardiologists, nephrologists
using ultrasound machines had questioned their inclusion in the act but the court had
clarified that any machine that is capable of picking up the sex of the foetus has to be
registered. Three registerations have to be done- that of the place, the machine and the
centre; this was to make sure that the relevant authorities knew who was doing the tests
and where to address the issue of mobile clinics. At the end of the day, the PNDT Act
was a simple Act but it had a lot of social ramifications. Records in all registered centers
had to be kept for a period of two years unless a criminal case was ongoing wherein they
had to be maintained beyond two years. Sometimes it was not the doctor conducting the
test who was disclosing the sex of the foetus but some other accomplice and the new
amendment in the Act had made this also illegal. The new amendments made it also
illegal to indulge in techniques of pre conceptional sex determination (the infamous ad
controversy regarding the ad of GenSelect in leading daily in Bangalore was mentioned)
and the new title of the act was now the Pre natal/Pre conception Sex Determination
Regulation and Prevention of Misuse Act.
3
Dr. Kamini Rao from the Bangalore Assisted Conception Centre spoke about the medical
professionals and highlighted that it was for the health professionals and the activists to
not be on opposite sides but to join hands to address the menace. The blacklisting of the
medical profession due to the practices of a few was unjustified and unwarranted ‘doctor
bashing’ needed to be stopped. The doctors could not go to the streets and do dharnas and
morchas to present their case. The Dept, of Health & Family Welfare, which Dr. Kamini
Rao had voluntarily approached for registration of her centre did not have any idea about
the procedure involved for six years. Unfortunately, there was a lot of mistrust about
doctors developing in the masses. FOGSI, which was the national body for Obstetricians
and Gynecologists and consisted of 18000 professional members and more than 150
branches across the country had opposed the female foeticide and supported the
empowerment of women. Education was not just teaching of the alphabet but the change
needed to be in the heart of the person which would stop mothers from allowing their
own daughters to be killed. Unless a multi pronged strategy was adopted to target the
women who asked for the test, the family who was pressurizing her to do that and the
doctor who agrees to do the test, it was difficult to make much progress. She stresses that
doctors were ready to pledge at any forum their support for this campaign as they stood
for the health of humanity -it was unfair to look upon them with jaundiced eyes.
Ms. Shantala, a senior correspondent with a local daily presented her thoughts about the
role of the media, which comprised the fields of advertising, films, radio, television and
newspapers. She reminded the audience about the controversy that had erupted when the
soap ‘Kyunki Saas Bhi Kabhi Bahu Thi’ had shown pre natal sex determination in one of
the episodes. While Article 19(1 )a of the Constitution gave the freedom of speech. Art
19(2) also imposed reasonable restrictions and this was a clear violation of those. She had
been offered a fellowship to study the PNDT act implementation in one district of
Karnataka. Ms. Shantala had chosen Mandya as it happened to be the constituency of the
Chief Minister. Mandya was a predominantly agricultural area and the feudal system still
persisted. The first child in a family was expected to be a boy and there were cases
wherein women who had two daughters had subsequently undergone five consecutive
abortions (after SDTs) in the ‘quest’ of a son. The sex ratio in these areas was among the
lowest in the state with Maddur registering 910 and Srirangapatna 890 in the age group 06 years. In a small locality called Ashoknagar in Mandya, there were around 15 nursing
homes; most with scan centers attached, which were involved in the practice. Theses
places preferred the uneducated who would have no knowledge of the law. The bait was
the slogan ‘5000 spent now will save you 5 lacs later’. It was package deal wherein a
middleman/ANM would help the patient get through the entire process of a SDT and an
abortion, if needed for Rs. 5000 in a couple of days; the doctor would send the patient to
a scan centre which would not give any report but only a chit of paper with + or - written
on it which the referring doctor would interpret and act accordingly. The process was
supposed to save the patient and her family the sum of Rs 5 lacs that they would have to
spend on their daughter’s marriage in the future should she be allowed to be bom and
raised up.
Dr. H. V. Ramprakash, a radiologist elaborated on the role of the voluntary organizations.
He explained that a major reason for the increasing scan centers were because of
4
increased role of ultrasound in the fields of medicine- only 10/100 patients approaching
sonologists were pregnant antenatal women. He hastened to add that however there were
122 female children dying for every 100 male children dying in the 0-4 years age group.
The number of dowry deaths had also been showing an upward trend. The NGOs had an
important role to play. Female literacy and health awareness was a major component and
the high literacy levels in Kerala and the healthy sex ratio there was an indicator of the
importance of this step. Some TBAs had a belief that they needed to kill the 3rd born girl
child as it was supposed to bring harm to the attendant. There was also the problem of
neglect of the girl child and the battered baby syndrome- in these cases the mid day meal
schemes like the Akshayapatra service of ISKCON could help. We as a nation had quite a
high MMR ( 490 per 1 lakh live births which was the highest in the world ); only 30% of
the deliveries taking place were being handled by the trained staff. In the productive age
group of 15-48 years, there were only 906 women per thousand males. There were more
than 7 lakh abortions a year in the country while the govt, claimed that it was only around
60,000(because only these many got registered). Identification of mobile clinics that
conducted SDTs and closing them was also something the NGOs needed to take up with
the govt.
The discussion was then thrown open to the audience. Dr. Manorama opined that if the
falling sex ratio continued, then the practice of dowry would stop and that of bride money
would start. Another lady said that it was important to treat every child as a human being
- not as a male or a female; society needed to accord respect to a woman, whether she
decided to get married or remain unmarried, whether she was having a child or was
childless. A doctor in the audience said that the dowry deaths were being encouraged by
women themselves- including mothers-in -law or sisters-in-law. A young college girl
responded to this very frankly and asked that this might be true, but what was the
husband doing at that time? If the husband was supportive, then no other relative could
cause harm to the woman. Another doctor ventured to say that there were a lot of
educated young people who were coming forward to undergo permanent sterilization
even if they had a single child. We needed to respect ourselves and other human beings
irrespective of sex. The purpose of the seminar was not to encourage the hatred of men
but to develop a feeling of mutual regard. A case wherein a junior engineer had asked the
doctor to kill his 3rd girl child was narrated - the doctor asked the person to donate the
child but the person refused saying that he did not want his wife to know that the child
had survived so that she could get pregnant a fourth time. Interestingly, this couple had
not gone in for a SDT because some local deity they had prayed to had purportedly told
them that they would get a son this time. The condition was so abysmal in some places
like the Erode Hospital that ayahs had to be posted to wards having recently born female
babies to prevent any killing. Dr. Manorama mentioned that some of the ultrasound scan
centers were telling the patient about the sex of the foetus as early as the 10/11th week of
gestation when the test could only predict with some degree of accuracy only after the
12th week of gestation- this accuracy was limited to 85% in the case of scans and 90% in
the case of Chorionic Villus Sampling. This was clearly just a ploy to cash in unethically
on the craze of Sex Determination.
5
Ms. S. Venkatappa spoke about the concerted efforts to implement the act. She said that
the purpose of such seminar was to sensitize people about the PNDT act. All the speakers
had expressed their commitment to the cause. And even the participants had been
convinced about the need to sensitize others; the need of the hour was the right
environment to empower people especially the women.
H.E. the Governor of Karnataka, Sri. T.N. Chaturvedi in his valedictory address
highlighted the need of establishing partnerships for removing social ills. He narrated
personal experiences of getting to know about cases of infanticide when he was serving
in Rajasthan. While the govt, was making efforts, support towards awareness and
consciousness was need. The problem was widespread and deep rooted and hence, the
society needed to be vigilant about the problem and continuously work towards helping
the message percolate to every part of the state - perhaps such seminars/workshops could
be organized in other pats of the state and the country. The declining sex ratio in Punjab
due to foeticide was surprising because one of the Sikh Gurus was emphatic in his
teachings about the women’s empowerment. It was not just the quacks and half-baked
physicians but also respected professionals with loads of degrees who were making the
Hippocratic oath hypocritical. It was unfortunate that the legislature had not enacted the
law but it was on the direction of the Supreme Court on the basis of a PIL filed by an
individual. The practice of SDT was an affront to the constitutional rights of the ‘would
be’ citizens of the country and violation of the dignity of the individual (the importance
of dignity has been enshrined in the Preamble to the constitution). Karnataka could
perhaps take the lead in encouraging a govt.- public interface for the purpose. The
seminar was a summing up and a call for concerted action in the future.
Sex Ratio( in the age group of 0-6 years; girls per thousand boys
♦ National (1991): 945
♦ National (2001): 927
♦ Karnataka (1991): 960
♦ Karnataka (2001): 949
Dr. Anant Bhan
6
Appendix 10
COMMUNICATION STRATEGIES
As a part of the Life Skills Training Program for trainers organized by
CHC on 18,19 and 20th March 2003, Mr. Maggimai Prakasam conducted
a session on Communication Strategies.
He began by highlighting the fact that life is based on relationships,
which are developed through communication. Many times, we are not
able to relate to others because of fear. Human communication is a
complex and difficult process.
D/
ZE/
ZF
In society, we live in various circles of closeness.
1st circle: Closest family (A)
2nd Circle: Friends, relatives (B)
3rd Circle: Colleagues (C)
4th Circle: Community (D)
5th Circle: Others (E)
6th Circle: World (F)
COMML 'NICA TION STRA TEGIES
i
Appendix 10
Our emotions are continuously dynamic and the ambient environment,
light; touch etc. can keep changing our emotions on a continuous basis.
It is only that emotion which we are feeling inside us, that we can share
with others.
At the time we are bom, we create a world around us, and relate to the
people around us. To have better communication with others, we need
to overlap our circles to influence each other. Also, we need to work
together to pool our resources and identify our Strengths, Weaknesses,
Opportunities and Threats (SWOT).
There are a few major stumbling blocks in this process: (1) What is going on (WIGO): IF we tend to assume that what is going
on in our mind is the same as what is going on in somebody else’s
mind, then there is ‘Conflict’ as all of us, even identical twins differ
in our thinking to various degrees.
(2) What is Selected (WIS): Humans are selective by nature and so
also in their relationships and communications. We usually select
what we want from the conversation; we need to improve our
selection process.
(3) What is means to you & me (WIMTU): This relates to how we
interpret the message- properly or not; meanings lie in people and
not things.
WIGO
COMMUNICATION STRA REGIES
WIMTU
WIS
2
<GOf^ V! 3lo
077 64
■
P°3 *
u
./
Appendix 10
We all differ in our upbringing and hence we also interpret new things
based on our past experiences. There are at many times differences like
cultural ones between various people; the way we talk, sit and behave
sends out messages and signals to other people based on their past
experiences. Only solution for better communication is to attempt to
overlap the circles of closeness. A lot of overlapping is especially needed
in the first 3-4 circles, as we have to walk with theses people for a long
distance in our personal and professional lives.
We often forget that every other person is equally intelligent. However,
the other person can sense this very quickly and she/he modifies his/her
behavior accordingly.
5
PEAK
4
EXPERIENCE
3
OPINION
2
INFORMATION
CLICHE
Levels of Relationship
('OMML 'NIC 'A TION STRA TEGIES
3
Appendix 10
Levels of Relationship
(A) Cliche- French; it is there, at the same time, it is not there
‘formalities’. We cannot remain in this level for too long as it causes
problems in relationships. Here, the interaction of two individuals
is limited to exchanging pleasantries like good morning, good
evening, Hi etc.
(B) Information- ‘facts’; when we share info, we are in the second
level of relationships; if we stagnate here, the relationship will not
grow.
(C) Opinion- according to us, what we feel; To apply T in any situation,
we need stronger ties; when we express opinion, we have to take
the responsibility for the same because we might be quoted in the
future; this is an important stage
because, here trust is built and
we come to know how assertive we are.
(D) Experiences- we need to share experiences; ‘SWOT’ is needed to
bring the two worlds of individuals together and increase the space
in the common third world.
(E) Peak- we should aspire to achieve; in the least, in most of our
relationships, we should reach the fourth stage.
♦ The more we identify with others, the more we relate to them. We
cannot put on a show for a long time.
♦ ‘ Your non verbal gestures are more important that your verbal gestures’
Sigmund Freud
Listening- 80% of our problems related to interpersonal relations &
skills are due to lack of listening properly; if we listen properly, we
accord respect to the person.
COMMUNICA TION STRA TEGIES
4
Appendix 10
WIGO- Hearing
WIS & WIMTU- listening; it is a process of selecting, organizing and
interpreting. Human brain is capable of doing this process at a speed
of 400-words/ minute at the maximum.
Causes: Poor Listening
(1)
(2)
(3)
(4)
Physiologically tired- it is better to tell this to the other per
son than to fake talk.
Emotionally preoccupied.
Language- not known, speech too fast or incomprehensibly.
Pre conceived notions- judging people prematurely based
on assumptions.
Good listening skills required: UPISE
Understand the other person.
Patience is necessary
Interest- head nod, eye contact, face to face.
Support
Empathy- put oneself into the other person’s condition.
Dr. Anant Bhan
March 2003.
COMMUNICATION STRA TEGIES
5
Appendix 11
Report of the Training Program at FRLHT between 14-16 April 2003
A three-day residential Trainers’ Training Program on Documentation and Rapid
Assessment of Local Heath Traditions (LHTs) was organized by FRLHT at their
sprawling new campus in Yelahanka, Bangalore from the 14th to the 16th April 2003, the
aim of the program being to orient the participants towards the richness of the cultural
heritage in the community health practices that our country possesses and to give hands
on training on rapid assessment and documentation of the same using classroom lectures,
discussions and field visits.
The total numbers of participants were ten, most of them with no prior experience in this
field. Mr. S.D. Rajendran and Dr. Anant Bhan represented CHC in the training. The
participants were picked up from Anand Rao circle on 14th morning and were taken to the
FRLHT premises.
After the participants had freshened up (as many of them had come from outside
Bangalore), the sessions began with the traditional lighting of the lamp and then an
introduction was given to Local Health Traditions and it was explained how they were
different from the codified systems of medicine (e.g. Unani, Tibetan , Ayurveda etc.).
The contemporary relevance of the LHTs was discussed in the next session and the fact
that these could help in better health care to the populace was highlighted especially with
regards to the key components of accessibility, affordability and compatibility. The
neglect and the causes for the downfall of the LHTs and the need to revitalize them was
explained.
A brief introduction to the Participatory Research Methods was given and the steps
involved elucidated. The ethics and the 1PR (Intellectual Property Rights) issues were
discussed, the facilitator being Mr. Ghate, a researcher on the subject at FRLHT. This
was followed by the explanations of various documentation methods, the methodology
involved, and the need for care during the process. A preliminary plan was evolved for
the field visit scheduled for the next day.
On the 15th April, a visit was organized to a Natti Vaidya Shri Thirumalaiah in Urdigere
near Tumkur. The participants spent around three hours with him and interacted with him
on various aspects of his practice, using the opportunity to do a documentation exercise.
The Vaidya also took the team to his medicinal garden and explained the uses of some of
the plants grown there. This was followed by a visit to a Natti Vaidya Sangha consisting
of around 15 women in Aladamaradapalya, a village nearby where groups were made and
the LHTs related to Post Natal Care were discussed and documented. The team then left
for Namadachillume where a MPCA (Medicinal Plant Conservation Area) has been
established in conjunction with the forest department. The team then returned to FRLHT.
The third day (16th April) started with analysis of the documentation done the previous
day and reporting of the same. An introduction to digitalization and the in-house software
designed by FRLHT for documentation of LHTs was the next session. Mr. Murthy,
administrator and Snr. Program Officer explained various promotional strategies w.r.t
LHTs and the experience of FRLHT in the same especially the work done in the field of
KHGs (Kitchen Herbal Gardens).
A visit to the Herbarium at FRLHT was organized where 2500 species of plant specimens
have been preserved on 25000 sheets of handmade paper of which 1500 species have
medicinal value. Many wet specimens have also been kept. All these have also been
digitally stored in a database making it easy for exchange of specimen information
between researchers without actually transporting the specimens.
An introduction to the methods for Participatory Rapid Assessment of LHTs was done.
Dr. Unnikrishnan from the Traditional Systems of Medicine (TSM) dept, then
summarized the proceedings of the three days and encouraged all the participating
organizations to initiate work on this important area. A formal vote of thanks was
proposed and the program drew to a cose.
Dr. Anant Bhan
17th April 2003
Appendix 12 (Preliminary draft)
Gender in Medical Education: Why the need
‘Its Friday night in the undergraduate boys’ hostel of the medical college and this is the
day when one finds the maximum hostelites in the mess room. This is because this is the
day of the week where almost on a religious basis; a fest of pornographic movies is held
starting from Hollywood skin flicks and then graduating through soft porn into hard porn.
The catcalls and the sexist comments reach a crescendo as the night progresses’.
‘September brings with it the fresh batch of students into the hostel and soon, it is time
for the annual freshers night. The juniors are made to ‘perform’ for their seniors. The
most popular performances with the seniors are the ones in which there are simulations of
the sexual act, jokes with sexual innuendoes, and usage of locker room banter. The
juniors who have not used these ‘creative’ ideas have to bear the brunt of more ragging
that their ‘wiser’ counterparts’.
‘It is noisy in the labour ward as many women are about to deliver. As they cry out in
pain, the interns on duty are busy playing cards, not at all concerned about the apparent
distress that the women are in; the ayah on duty keeps cursing the women periodically
and asks them to hurry up’.
The issue of the importance of bringing in gender issues in the field of medical education
is being widely debated with CEHAT and the AMCHSS having taken up the mantle of
also devising a short course in the subject. The young medical professionals who
graduate en mass form the Indian medical colleges have most of the time no clue about,
howto relate to a female patient & to address her special health needs. This is especially
true of many male graduates who sometimes just blank out when they have a young lady
coming in with specific complaints.
The dehumanizing way in which the practice of Obstetrics and Gynecology is carried out
in many teaching institutions and the scanty respect given to the patients in the
wards/delivery rooms/ operation rooms gives no opportunity for a student to learn the art
of making a lady patient comfortable before a pelvic/gynecological examination which is
almost an intrusion of the privacy of the individual, especially so in the Indian context.
The way the women are herded for the D&Cs, MTPs, IUD insertions in almost a factory
production line manner with a rare word of encouragement, succour or empathy only
serves to build up a stereotype in the impressionable mind of the student.
The lack of choice that the patient has in matters relating to her own health is frequently
reflected in the way she is asked to eat this tablet, get that test done, and many times in
the way the contraceptive choices are thrust on women without explaining the pros and
cons and the side effects of each choice. This is an example of the typical top-down
approach that ails our beleaguered health care system.
Many students when they join medical college come from backgrounds of having studied
in same sex institutions and it takes a long time for many to adjust to the atmosphere in
the co-ed medical institutions. When this is the time when a feeling of camaraderie
between the students should be developed, either the freshers are being ragged or are
being thrust into dissection halls and asked to cut up cadavers reeking of formalin without
any time given for adjustment.
There is also the issue of the paramedical workers being looked down upon by the
doctors and hence the students also imbibe the art of unfair treatment to them especially
the nurses (most of who are female) who are expected to be following each order to the
hilt and are almost never thought as team mates. Unfortunately, even the women
physicians fall prey to this mindset, thanks to the well-entrenched system & the trap of
the male hierarchy.
The focus in women’s healthcare is on the obstetric and childbearing aspects in the
reproductive age group of 15 to 45 years and many times not on the pre menarchal girl
child and the postmenopausal women. Many times, the elderly women who come to the
outpatient departments and wait in long queues to be examined for their age related
medical problems such as osteoporosis are just blatantly prescribed analgesics such as
‘Nimesulide’ and shooed off without even a proper examination and explanation about
the reason for the symptoms.
Young women interns and residents are sometimes bogged down by the excessive work
pressures in the clinical wards (as they work harder to garner the same respect as their
male contemporaries) and at the same time, they can expect no sensitivity form their
colleagues or seniors about their personal conflicts like family/societal pressures to get
married or if already married, to bear children.
Sometimes women present with vague and psychogenic complaints that are dismissed by
the ‘busy’ doctor without even realizing that this could be a pointer to the trauma
(physical, mental, sexual or otherwise) that the woman might be going through and is
expressing indirectly. This is not only restricted to the poor women only but affects the
women from all strata of society. Violence against women has many forms- rape, assault,
burning, incest, and sexual harassment at the workplace etc. Young medical graduates
who are predominantly uncomfortable examining female patients many times are unable
to pick up the non verbal cues form these women as they are unable to establish the
feeling of trust that is the foundation of a ideal doctor-patient relationship.
Perhaps the only encouraging trend has been the increasing ratio of female students
joining medical colleges over the years and the foray of female residents for post
graduation into ‘unconventional’ subjects like Surgery, Orthopedics etc. which were
earlier considered to be male bastions.
These are just a few of the reasons why the component of‘Gender in Medical Education’
has to be considered to be a priority issue by the academia.
Suggested Reading
Gender & Medical Education; CEHAT & AMCHSS; June 2002
Appendix 13
Community Health Awareness Program for the Jyotisadan Scholasticates
Brief Report based on the evaluation feedback
Dr. Anant Bhan
First Phase: 16th to 21st Dec 2002
Second Phase: 20th to 24th Jan 2003.
A training program was conduced for the scholasticates of JyotiSadan in a phased manner
on the dates mentioned above. The aim of the exercise was to give an introduction into
the fields of community health to the participants and raise awareness about social issues
and health.
The team members of CHC and various associates conducted the sessions and a field visit
to a voluntary organization was organized on one of the days of the session.. At the end
of the program, an evaluation form was given to each participant and they were asked to
rate each session as
* Useful/ not useful
* Adequate/ not adequate
* Additional comments/suggestions.
The participant was not required to reveal his name.
The training program was appreciated by the Scholasticate and they felt the session
would be very useful for them in their vocation of providing spiritual guidance and
support; the course and helped them in understanding a lot of issues related to health and
also the importance of life skills especially with regards to adolescents.
Some of the responses include:-
❖ The course is very relevant in our future ministry; when we are working in remote
villages, this course is going to help us a lot. My sincere thanks to every member
of CHC for this wonderful experience for each one of us...
❖ Personally, I gained a lot of knowledge from this course especially in the field of
sex education, HTV/AIDS, Tobacco, personality development etc. These are
essential for a healthy society and I hope you continue with these kinds of
programs to make better citizens in our country.
❖
It was wonderful and I liked it because the things that were taught were very
useful and practical- these things are connected with our day-to-day lives and not
like other intellectual subjects. The course does not need much intellect and is
suited even for ordinary people. As a whole- the course was very good and useful,
it was well arranged and the resource persons did a great job; probably it would
have been better if certain topics like Managing emotions, Self Awareness,
Alternative Systems, Mental & Family Health would be given a little bit more
time.
❖ Personally, I am happy to thank you for the valuable contribution to our life- it is
more precious than money. Indeed, we are grateful to all of you personally. Please
take this message to the uneducated and neglected. Enlighten them in all the
fields. We do pray for you and hope you will be able to carry out the task that you
have begun. May God bless al your endeavors.lt was a new experience for me
because I got to know the situation of the Indian people who are very poor - I
hope to do something for the people with the knowledge that I got from this
program.
<♦ I suggest that you conduct this course for all the poor people of India; I hope CHC
will reach every nook and corner of India within a few years.
<♦ All the sessions were very good but they should not go until late in the evening.
This course should be given to all the religious congregations. The faculty
members spoke simple English and it was very understandable.
♦♦♦ Wish you all the best and may God bless you.
♦♦♦ I like it because I am going to be involved in the community activity of people
and so I can impart all this knowledge to them. The course should be for more
number of days and sessions should not last beyond 4:00 P.M.
We got a lot of knowledge about CHC and health- it will be useful in the future
for us; thanks a lot and wish you the best.
❖ The course was new to me and I am very much inspired and enlightened by the
course. Personally speaking, it was a break through in my life- my whole
perspective in life has changed after attending these classes. The faculty has done
a wonderful and spectacular work over the past two weeks. You are really
motivating the people to lead a good and moral life. Excellent, please do keep it
up.
❖ May you be able to continue the good works you are doing for humanity. May
the almighty give all of you a long life to serve the people and may all your
dreams come true. Don’t look back and travel on the same track - wish you all the
best & may God bless you.
Dr. Anant Bhan
29 March 2003.
Appendix 14
I am writing to u today about two recent cultural experience Vasantahabba- the annual
festival of the dance village Nrityagram which has become a sort of cultural Haj for a lot
of people not just from Bangalore but from around the world and Eka Aneka- art for
integration on the occasion of Shivratri.
Vasantahabba
Started 12 yrs ago by the inimitable Protima Gauri Bedi as a small dream on a few acres
of land given by the Karnataka govt, on the outskirts of Bangalore , Nrityagram today is
the only dance village in the world , set up for the preservation and popularization of the
seven Indian classical dance styles and the two martial arts. It is also the base of the
world famous Nrityagram dance ensemble that has won many accolades for its dance
theatre performances.
Vasantahabba has grow as an event over the years - it started off with 1500 spectators
and this year the numbers attending reached the 40,000 mark- this included the lucky few
who managed to come early and squeeze themselves into the amphitheatre and watch the
performances live holding on with dear life to the cramped space they had and to their
bladders and the rest who had to be content to watch on the giant screens on the outside.
Held from dusk to dawn every year, Vasantahabba is held in the spirit of festivals such as
SPIC MAC AY. Entry is free and the sooner u arrive, the better vantage point you get. As
is the practise every year, the first performance is by the Beliappa and party with their
Dollu Kunita - the tribal drums of Karnataka. The high energy drumming and
accompanying acrobatic dances were a treat for music lovers and kicked off the festival
on a high note.
This was followed by the village ensemble of Nrityagram presenting Odissi, Bhartayam
and Kathak- this included the kids from the surrounding villageds who are given free
dance Issons over the weekend. Dancing with grace and beauty, they won a lot of hearts
in the audience with their skillful depiction of dance theatre.
Next on stage was Ms. Mandakini Trivedi, a senior Mohiniattam dancer from Mumbai
who presented excerpts form her woks where she had tried to expand the range of
Mohiniattam creating powerful visual impact.
Guru Jayarama Rao and Vanashree Rao, the famous Kuchipudi dance couple who have
been dancing together since 1978 brought to life the intricacies of this unique dance form
on to the stage and enthralled the audience.
The B’lore based Stem Dance theatre presented Contemporary Dance interspersed with
World Fusion Music by the Amit Heri Group. Creating an amalgam of various dance
forms and arts like Kalariyapattu and exploring the range of movement and athleticism
that the human body can exhibit, the Stem Dance theatre mesmerized the audience
dancing to an original music score. The interludes wherein the Amit Heri group presented
the fusion of Indian & western music incorporating various forms like Latin, Indian,
Contemporary, Jazz, Funk, Blues & European Music ensured that the audiences were
wide-awake as the time approached midnight.
With the end of the dance performances started the musical ones. Malini Rajurkar from
the Gwalior Gharana of Hndustani music exhibited the versatilkity and wide range of her
voice- unfortunately, a section of the audience, obviously never having been exposed to
Hindustani classical but instead fed on the techno-pop-trance genre of the likes of Britney
Spears and Eminem created a bit of the ruckus that spoilt the atmosphere for some time,
A young Carnatic flutist Shashank with his team was a revealation- having maturity
beyond his age in the music that he played and the zing and youthful vivaciousness, he
was very popular with the crowd.
The famous Grammy Award winner Pt. VishwaMohan Bhatt with his son Salil Bhatt
brought to life the Mohan Veena, essentially a modification of the Hawaiian guitar; they
played various notations including a few from the Grammy award winner album.. Pt.
Bhatt had to do an encore at the end of the performance when the audience pleaded.
Four o’clock in the morning and if somebody had manged to doze off, they were all
awakened by the high spirited response that marked the Qawwali of Nazeer and Naseer
Warsi from the Old Delh Gharana who presented the works of Sufi great slike Amir
Khusro and Bhakti saints like Kabir carrying the messages of unity and communal
harmony. Almost the whole audience provided the chorus when they sang the eternal
favorite Dum Mast Kalandar.
It was always going to be tough to be the last act but Taufiq Qureshi and friends
including Niladri Kumar ( Sitar), Sridhar( Mridangam), Karl Peters( Bass Guitar), Nishad
( Keyboard), Geetika Varde (vocals) gave an enthralling demonstration of the a range of
musical styles with a vruety of international percusson insruments that /Taufiq, younger
brother of Zakir hussain efoortleslly palyed.
The performances were peppered with the compering of Arundhati Nag( Aru akka as she
is fondly called) and the honoring of the artists by Nrtiyagram trustees including Lillette
Dubey, Lynn Fernandez, Pooja Bedi, Kabir Bedi etc.
Stalls outside the venue sold everything from food , nicotine, alcohol to guide maps. As
people started trickling out with the first rays of sunrise, one could see the contented
smiles that everybody carried having experienced a spiritual crescendo of dance and
music carrying the red earth of the ground on their bodies and clothes as testimony to
their attendance.
P S. Nrityagram conducts a summer workshop from July 1 5 to Aug 15 of every year to
give students training in Odissi or Kathak. The daily work schedule includes body
conditioning exercises Jogging, yoga, Pranayama, and informal discussions on the
theoretical aspects of dance forms. The residential program also requires involvement in
gardening, cleaning the gurukul and working in the kitchen. Besides being a basic
training program in classical Indian dance, the summer workshop is also a great
experience in community living and working in perfect harmony with nature.
You can also take guided tours of the campus throughout the year.
Nrityagram can be contacted at
Nrityagram, Hesaraghatta Vilaage, Bangalore-88
Tel:-91 80 8466 313/314
Fax:-91 80 8466 312
E-mail:- nrjtya£ram@v^
Eka Aneka- Art for Integration
This program is held every year on the occasion of ShivRatri and is also an overnight
affair. It is organized by the Bangalore based Prasiddha Foundation that works for the
promotion of the performing arts. It is an attempt to bring together artistes from around
India on a common platform.
This year even though it was the evening (1st Feb) of the India-Pak match, a fair amount
of people turned up at the venue of the performances which was the Chitrakala Parishat
to appreciate the artistes.
The program started with a Yakshagana recital, which is a folk art form of Karnataka
especially in the coastal belt and involves depiction of stories from the Hindu mythology.
It set the mood for a pleasant night in the open-air amphitheater.
Next on stage were the Carnatic violin brother duo of Ganesh and Kumaresh who had
been the youngest violin players to be accorded recognition by the AIR. They played the
some lilting classical tunes with the effective support of their percussionists.
Pratibha Prahlad, a celebrated Bharatnatyam exponent and the main person behind the
Prasiddha Foundation then enacted beautifully excerpts form various dance dramas.
Mahendra D. Tokay , an accomplished Hindustani vocal exponent chose some eloquent
Ragas to herald the onset of midnight.
But Rajendra Gangani, a young Kathak dancer from the Jaipur Gharana made sure
everybody was wide awake and paid riveted attention to the jugalbandi he performed
with the Table player and the portrayal of the mischief of Krishna and the anger of Shivatruly a treat for the eyes.
T R Srinath, incidentally a gold medallist in Food Nutrition then gave a Carnatic Flute
recital and regaled the audience with his melodious instrument.
Odissi is a dance form that is captivating with the associated grace of the dancer and the
costume- doing full justice to this was Sujatha Mishra, a famous dance teacher from
Puri.
The last on stage was Biswajit Sarkar with the Sitar and he did pull a lot of strings- quiet
tunefully though.
The festival ended on this high note in the wee hours if the morning with many invoking
the blessings of Lord Shiva - probably for the good fortune of the Indian Cricket team.
Anant Bhan
March 2003
Appendix 15
Reflections in Community Health
Dr. Anant Bhan, CHC
Community health at a field level has been in a sense radically different from what is taught
at medical schools. Medical students and interns think of the department of community
medicine as a department that does not arise any interest because they are not encouraged to
think, to reflect as to how they could use the theory and clinical skills that they learn at the
tertiary level institutions they study at to affect the lives of people not just at the out-patient
and inpatient level in hospitals but also in the community and in their homes.
When 1 tell my classmates, juniors and seniors about my interest in community medicine,
they wonder how 1 could be attracted to a subject that only deals with 'mosquitoes', 'toilets' or
the lack of them and how to make sure you are correctly chlorinating a well. I guess I cannot
fault them because they just have been taught theory in a textbook fashion without bothering
to take them to the field and making them understand how mosquito borne diseases like
malaria and Japanese Encephalitis has wreaked havoc in so many areas of our country, how
more than 70% of the diseases that the poor have can be prevented by ensuring sanitation and
safe drinking water. Their 'field visits' are restricted to doing school health check-ups where
they dole out Albendazole tablets by the dozen, at camps organized by philanthropic
organizations where impersonal medical advice and a couple of near expiry tablets are doled
out to hundreds of poor unsuspecting villagers who have been rounded up especially for the
purpose usually at the behest of some local leader or Swamiji-1 have been to camps where
more time was spent in inaugurating the camp, garlanding 'dignitaries' than in actually
interacting with patients. With the help of glucometers that a pharmaceutical company would
have gladly provided in the hope of increasing their patient base, blood samples are taken and
people are branded as 'diabetics'- no care is taken to ensure that the person receives health
education and understands the origin and the progress of the disease; the latest drug form the
pharma major's arsenal is prescribed- the young attending doctor feels happy that he/she has
done social service, the drug industry increases its profit margin, the organizing organization
makes a splash in the local media but the person who is labeled is soon conveniently
forgotten until the next cycle of camps start.
Is community medicine only practised by people who venture into field practice areas in
adivasi settings and return enriched with the knowledge of life and the vibrancy of the people
who unlike us do not feel that they are living their life fighting the odds but are content and
happy in their environment. Do those among us who decide to work with voluntary
organizations only practise it? Or can all those who are working in the field of health practise
it. Would an orthopaedician or a neurosurgeon who is getting concerned by the increasing
injury cases he/she is treating and makes an effort to network with the governmental agencies
and other concerned citizens to try to decrease the factors causing road traffic accidents not
be doing community health? Would a cardiologist who does not keep adding medications for
his refractory patient but tries to talk to him and analyzes that lifestyle modification in the
patient’s household with curbing smoking and changing dietary patterns is required not be
practicing public health. Would an emergency room resident who tries to take time off and
just listen to a young adolescent admitted repeatedly with attempts at suicide and gives
psychological support not be trying to practise holistic medicine.
The lack of linkages between medical academia and the voluntary health agencies results in
the prospective health practitioners never being able to fully explore the community part of
community medicine. There is also the problem of the approaches to medical education
which are still stifling and do not encourage the student to think creatively and to be able to
question- he or she just learns to believe what is printed in the textbooks and what his peers
and his faculty practise. So when he sees his professor shuttling from ward rounds to his
private practice in the latest imported car and spending more time speaking on the trendy cell
that he possesses than to the students and patients combined, the student imbibes that as being
the art & practice of medicine. Some institutions have tries to break free of this by
encouraging their students to think and to be comfortable working even in a community
setting but these institutions are far too few and have their own idiosyncrasies.
How many departments of P & SM have had the courage to question the govt's prioritization
of RCH and FP neglecting the other health programs? There are not many also which have
ensured the provision of comprehensive health care in the PHC areas allotted to them.
Encouraging students to interact with social scientists and paramedical staff to understand the
socio-economic dimensions of any disease prevalent has never been the forte of community
medicine teaching.
And so we have graduates emerging from the hallowed portals of medical institutions with
their degree certs in their hands and the Hippocratic oath on their lips armed with biomedical
understanding of disease but ignorant of the social, economical, political and cultural reality
of Bharat.
Appendix 16
Report on visit to Hakki Pikki (HP) colony
Date: 4th December 2002
CHC team members: Prahlad and Anant Bhan
Facilitated by: Vimochana, Bangalore.
As a follow up to the previous visit by CHC team member (Refer to
Prahlad’s earlier visit report) another visit was carried out on 4th
December 2002. Objective of the visit was to find out more details about
health situation, health problems and local practices community follow
about health. Along with this socio economic factors affecting their health
were also ascertained.
After the community was initially met, few leaders were requested to
organize meeting. Before the community could gather, CHC team
members, along with field worker from Vimochana went around the
habitation to find out about the environmental hygiene situation in the
area. This revealed that Iruliga living area (there is very clear
demarcation of living areas of these two tribes) is much more cleaner
than Hakki Pikki tribal living area. There are 150 households in the area110 houses belong to Hakki Pikki and 40 households belong to Iruliga
tribe. Iruliga live in more Pucca houses, while Hakki Pikki tribe live more
in Semi Pucca and thatched houses. Iruliga household have bathroom,
but without drainage facilities, while all the members in the area go for
open-air defecation. A few families live in houses that have been recently
built by the government and have drainage facilities. Discussions with
Vimochana team members also revealed that Iruligas are more organized
than hakki Pikkis and this has also might have led to shabby
surrounding in which Hakki Pikki population live.
Water supply is through bore well, which is connected to Mini Water
Tanks(at the time of visit ,a rainwater drain was being constructed in the
settlement).Government has relocated them in this habitat from 1962.
Government at the time of relocation also gave 3 acres of land per family.
But land is rocky and is not conducive for agriculture. Very few families’
practice agriculture (its carried out only in the seasons when adequate
rainfall is there and mainly Ragi and Jowar is sown. Most of the families
are into petty business.
Most marriages are stable and couples have between 3 to 5 children.
Hakki Pikki group told that Iruligas are not very religious, the HPs
worship Kabalamma(the main temple is in Satanur)- a silver image of the
goddess is kept in al the houses.
The HPs have peculiar names like High Court, British etc. and use the
Vaagri language that does not have a script and a mixture of various
languages.
Overall, both the tribes are quiet healthy and have many elderly
members- this might be related to their exercise habits (walking around
quiet a lot). The staple food in the Hakki-Pikki group is Ragi balls and
Sambhar. On Sundays and Tuesdays, the communities usually eat meat
(chicken/goat/pig). They used to hunt earlier but now it is very rare
because of stringent laws and the security in the area of the
Bannerghatta Park.
There is a government school in the area that has classes from standard
1 to 5. There are 2 teachers here, who stay nearby and have been
identified by Vimochana.
At the time of the visit, members of many households (of both sexes) were
busy in making artificial decoration material using raw material that they
had brought from K.R. Market- the final product is usually directly sold
by them only as they travel from place to place. Also, television and radio
has made an inroad into few houses and some houses had FM music
blaring away this later turned out to be also a source of discontent as
some felt that the younger generation was not working adequately and
instead whiling away its time watching television leaving their work
behind.
There are almost no visible petty shops in the settlement but there is a
govt, arrack shop that sells packets for Rs. 10 each. The habit of
consuming alcohol is almost a socio- cultural phenomenon here and
both men and women drink on an almost daily basis (this increased
consumption has occurred over the last 15 years).
Discussions with 15 to 20 community members (only very few members
could come as Ramzan time is best time for them to make some
business) revealed about health situation and practices prevailing in the
area. This meeting was the best testimony for the equitable gender
equations prevalent in the community (as both of them playing pranks
and teasing each other was evident). People told during the meeting that
major health problems include body pain, back pain, joint pains,
giddiness, headache, skin infections, chronic cough, heartburn, chest
pain etc. The children usually suffer from water borne diseases and
pneumonias (ARIs) . Some community members said that there were a
few cases of typhoid, malaria and ?cholera in the last one year. As the
Alcoholism and Tobacco consumption found to be rampant, causes for
many of the health problems could be attributed to these two phenomena
besides the lack of hygiene an indoor smoke due to chulhas.
Some of the older community members said that all these problems were
because the HPs were now being prevented from hunting foxes and other
wild animals for food (the HPs believe that fox blood is almost like an
elixir for all ills)
Community was told that they should prepare few volunteers from the
area who could be trained as health contacts. They should concentrate
more on the prevention, than depending upon outsiders for their health.
Community appreciated this idea and they promised the team that
volunteers would be identified.
Later they were asked to assemble in school for little checkup and advice.
Even during this period, most of the problems treated and advised are
from the range of the problems mentioned above. Drugs were prescribed
and some health education was carried out.
The nearest PHCs are in Bannerughatta and Kaggalipura but the HPs did
not seem to be happy with their functioning and instead prefer to go to
the private practitioners in Bannerughatta.
The team then assembled and left for Bannerughatta. While the
Vimochana team went to the local Grama Panchayati office, the CHC
team members visited the FOSA (Friends Of the Sick Association)
hospital at Bannerghatta. Interestingly, the HPs had not mentioned
about the FOSA hospital as a nearby medical center.
At the FOSA hospital, the CHC team met Dr. Basavaraj who is the RMO
there who explained about the hospital and took the team around on a
tour of the facilities. The FOSA hospital has been built by Mr. Ravi
Melwani, reputed businessman from Bangalore with the motto "Free
Service for the Poorest of the Poor’. There are 4 full time doctors, who
include a dentist and an ophthalmologist (all of them are salaried). A
couple of doctors visit on a voluntary basis once a week (e.g. a
dermatologist visits on Tuesday between 1000 and 1300 Hrs.
There are 2 outpatient examination rooms, 2 wards for inpatients with
30 beds totally, a dialysis machine, laboratory and X-Ray room, Minor
O.T. and Dental Surgery rooms. The hospital also has a well-equipped
O.T. for conducting cataract operations. There is a Dialysis machine and
also a Humanitarian Hands Coronary Care Unit with Tele Medicine
facility connected to Narayana Hrudayalaya and the Asian Heart
Foundation.
The paramedical staff includes 3 nurses, 2 dialysis technicians, 1 X-ray
cum Laboratory technician, 3 ayahs, 1 ward boy, 1 cook and 3 security
personnel.
At the time of the visit, a dental surgery was being carried out. There
were 26 inpatients in the hospital and these included patients with
stroke/ asthma/ recuperating from burns etc.
Near the gate there are 2 isolated rooms that house a HIV +ve lady and A
Hepatitis-B +ve lady.
Dr. Basavaraj said that the needy patients could approach the hospital
directly and he said that the hospital gets around 20-25 patients from
the HP settlement everyday. He said that the HP patients usually come
with complaints like asthma, dysentery, injuries, geriatric problems like
arthritis and a few have mental problems that have been initially treated
at NIMHANS.
He said that the HP patients, if admitted usually disturb other inpatients
because of their habit of consuming alcohol in the evening. Also, their
follow-up is quiet poor.
He said that FOSA hospital would co-operate in any health intervention
being planned for the HP settlement.
Suggestions;
1. To find out causes for lesser utilization of FOSA hospital by HP
population.
2. To discuss with Dr. Sudarshan about selling arrack in Tribal area.
Government bans selling of arrack in Tribal area.
3. Government Ayurvedic hospital needs to be observed during the
subsequent visits.
4. Ideally 3-5 volunteers from each group should be identified with
equal proportion coming from both genders.
5. Vimochana can try contacting few philanthropists and corporate
groups, which can support this kind of initiatives.
Appendix 17
MEETING AT ‘EQUATIONS’
Topic:- GATS and various sectors
12th November 2002
A meeting was organized at Equations, a NGO working for equitable tourism options.
This was one of a series of such meetings that have been taking place to try to develop a
framework for a workshop on GATS and various service sectors including tourism,
health etc. and also its effect on citizens. Mr. Naveen Thomas has been regularly
attending these meetings and on his invitation Dr. Anant Bhan( on behalf of CHC)
attended a meeting held at Equations on 12th November 2002 from 3: 45 P.M. onwards.
Mr. Benny (Equations Team member) and Mr. Rana Ghose, a volunteer initially shared
their work. The formal meeting started at 4:15 P.M. involving Mr. Suresh, a policy expert
and Benny from Equations, Naveen and Anant. Mr. Vinay Baindur from CIVIC,
Bangalore (a citizens initiative NGO) later joined the deliberations.
The discussions in the meeting initially revolved around the Asian Social Forum and the
various workshops that Equations would be involved in/ co-coordinating. Benny spoke
briefly about GATS as a WTO Services agreement and the need to involve all the various
organizations representing the sectors that would come under the purview of the
agreement. Mr. Vinay spoke about the 73rd and the 74th amendment and how CIVIC was
involved in the evolution of these. He also spoke about the emerging changes in the
functioning of the Municipality and other government services in Bangalore and the
increasing transparency that is being adopted after the Transparency in Public
Procurement Act was brought about in Karnataka. He also shared the plan of CIVIC to
hold a 2-day workshop on the 74th amendment in second part of December 2002.
Since ASF was coming up and both Equations and CHC would be actively involved in
preparations and conduct of the forum, it was decided to hold the workshop on GATS
after ASF in late January 2002. However, since CIVIC was already conducting a
workshop in December, Mr. Vinay was requested to explore the possibility of granting a
1-hour session to Equations and CHC for them to shore their experiences with the
participants and to build up the momentum for the proposed workshop in January.
Equations would explore the possible effects of GATS on the various service sectors and
CHC would give an input about the effect in the domain of public health and
environment (74th amendment and Public Health; Municipalities and public health).
The meeting was then concluded. Mr. Vinay was requested to discuss with his
organization and intimate to CHC and Equations about the decision as soon as possible fo
further action.
Appendix 18
Corruption in the Medical Examinations: can the students do anything
about it?
The fact that corruption has by now been firmly embedded in the medical profession is a
well-known fact. But when it is practiced in the examinations, it is bound to great despair as
the sanctity of the ‘guru-shishya’ tradition and the exam system is affected. Especially if
money exchanging hands during the course of exams takes place during final year MBBS
exams when the clinical skills are tested and is the final obstacle before the candidate is
allowed to legally practice the science if medicine and hence influence the health of the
community, it raises a lot of question marks about the quality if doctors that are being trained.
The corrupt examiners use a variety of ingenious means to collect the ‘bribes’. Some prefer
the broker system (the same professionals probably employ these brokers to collect money
from hapless patients and their relatives in the wards) while others prefer to do the honor
themselves; there have been instances where HoDs of some departments have sent out
unofficial notices declaring the amount of money to be paid for the subject for that year.
Even the students who are prepared well are so terrified at the prospect of failing because
they did not pay, that they spend the days preceding the practical exams not studying but
rather trying to find out whom to pay and how much to pay.
The incident 1 am describing took place a couple of years ago in a government medical
college before the final year exams. For the preceding decade or so, money had been
changing hands every year and it was almost becoming a tradition. As the exams approached,
there was a lot of curiosity about the prevailing rates of various subjects. This was the time
when a small group of students decided to make a difference- while they decided not to pay,
they also thought they would try and make an attempt to break the unholy nexus that existed
in the exams. So a few reporters in local leading dailies were contacted discreetly and the
issue was explained to them along with the need for maintaining confidentiality. A series of
news reports then appeared on the front pages of these papers for the next few days about the
rampant corruption in the examination system. Exams were a month away and the
sensationalizing of the media led to the college administration getting suddenly activated.
The fact that a concerned parent sent a copy of the reports to the Medical Council of India,
which immediately faxed a letter to the principal urging her to take action and the malpractice
section of the university deciding to converge on the college, was contributory. A meeting
was hastily arranged and some of the faculty members and the principal spoke to the students
asking them not to pay; this situation was almost funny as some of these Teachers’ had been
taking money with impunity in the previous exams and here they were talking about the
ethics of the profession. After the theory exams, the college appointed examiners with
credible credentials under the strict supervision of the university and for the first time in
years, a ‘clean’ exam was conducted. The results were not affected in any way and the overall
performance of the batch was quiet good.
This incident just goes on to prove that sometimes all it requires for an unethical practice to
be broken is for somebody to stand up and refuse to be a part of a system gone rotten. It does
not always need to be by making a big hue and cry but even a small stone thrown in the
darkness can sometimes find its target.
The examination continues to be free of corruption in that college to this day.
This is another incident that portrays the methodology used by the corrupt faculty members to
collect money. The exam was for the third year dental students of a college who were giving
their internal medicine clinicals. The students were approached through a broker by the
external examiner who happened from a neighboring medical college.
The students were asked to get a fixed amount of money in envelopes to a busy street near a
temple. The examiner was waiting there with the broker and he had parked his car at a safe
distance with the windows adjoining the back seat conveneintly rolled down. Making sure
that there was no direct contact with them, the students were asked to place the money- laden
envelopes in the backseat of the parked car and to disperse. This modus operand! gave the
examiner a chance to identify the students who had paid and at the same time he tried to play
safe by not receiving any money directly.
The following day the students who had paid were passed while most of those who had not
were flunked. The way our examination system is structured, perhaps it offered no
opportunity to the students who had not paid to protest as they did not have any proof and
because their classmales who had paid had kept them in the dark about the bribing process.
Nobody lodged a complaint and the examiner made easy money.
These true incidents show two different situations and different responses from the affected
i.e. the students.
I guess that while it is important that the relevant authorities take utmost precautions to
prevent corruption in exams, it is also important that the students have a resolve to not be
sucked into the vortex of corruption in medical examinations, which encourages the practice.
Dr. Anant Bhan
March 2003
A brief version of this write up was published in 'Issues in Medical Ethics Apr- Jun 2003 ’
issue
Appendix 19
Human Organ Transplantation Act 1994: A Discussion
An interesting exchange of ideas took place in a recent session of the Medical Law and
Ethics Course at National Law School of India University regarding the Human Organ
Transplantation Act 1994.
When the act was formulated, the main objectives of the act were
■ Regulation of the removal, storage & transplantation of human organs for
therapeutic purposes.
■ Prevention of the commercial dealings in human organs.
The human organ has been defined by the act as ‘Any part of the human body consisting
of a structured arrangement of tissues which, if wholly removed, cannot be replicated by
the body’.
Transplantation has been defined as The grafting of any human organ from any living
person or deceased person to some other living person for any therapeutic purpose'.
In the present circumstances, any patient of End Stage Renal Disease (ESRD) who has to
go in for kidney transplant has only two choices- either a compatible kidney is donated to
him/her or the patient ‘purchases’ (acquired donation) a kidney.
The donation of an organ can be from near relatives or from unrelated donors. Research
has shown that in India, only 10% of transplants involved donation from the relatives
while the remaining 90% were from non-related donors.
■ The near relatives mentioned in the act include son, daughter, mother, brother,
sister, father and spouse; an interesting factor here is the inclusion of the spouse
who is in most cases, not related genetically directly to the patient. This has also
encouraged the practice of a lot of Kidney Marriages wherein poor young
women are being married to patients requiring kidney donations so that the organ
donation acquires the sanctity of law.
■ The non-related donation of the organ can be from a living person (out of
affection /attachment) or from a cadaver. Sec (9), Clause 3 of the act mentions
that ‘If any person willingly come forward to donate an organ not influenced by
money but by attachment or affection, then donation can be allowed'. To prevent
misuse of this provision, there has to be an application submitted by the donor and
recipient to an authorization committee constituted by the state govt, who is
supposed to look into the level of their ‘attachment’ and ‘affection' and its
genuineness. In many cases, the patient’s brother’s servant, driver or gardeners
have had ‘affection’ for the patient but not the patient’s own relatives who
perhaps were more ‘attached’ to their own kidneys.
In Karnataka, in Mandya district, there is a village where the kidney trade is so
flourishing that it is called ‘the single kidney village
The Karnataka state authorization committee has only rejected four out of the more
than two thousand applications it has received. In the neighboring state of Tamil
Nadu, a Frontline expose in July 2002 revealed that the authorization committee had
not kept a record of the applications received and had only rejected one application
among the scores received in the previous year. Surprisingly, the act mentions that
there is no need to keep a record if the application is accepted but a detailed record
has to be maintained with reasons if the application has been rejected.
The act does not put any emphasis on the follow up of the donor’s health by the
operating doctor or the nursing home and so in many cases, the poor donors are now
suffering from complications arising from the surgery. While the donor usually did
not have any problem in the first two years post donation, later on, the donor suffered
more financial losses on his/her own treatment than the amount of money he/she
received for donating the kidney.
Though the Centre has promulgated this law, it is applicable only in seven or eight
states, which have ratified it (health being a state subject).
Interestingly, Brain Stem Death has also been defined under the act-k It is that stage at
which all the functions of the brain stem have irreversibly and permanently seized
and certified so by an authorized person (professional); the decision has to be ratified
by a board of medical experts which consists of four members the doctor in charge
of the patient, the doctor in charge of the hospital, an independent professional and a
neurologist who have to certify the brain death on a prescribed form'. If the patient
had indicated his/her willingness to donate his/her organs or if the near relatives are
willing, then an organ donation(s) procedure can be carried out. However, the
relatives also have the right to refuse donation even if the patient had been willing.
The procedure involved in organ donation in the case of unclaimed bodies has also
been enunciated in the act.
Some glaring lacunae in the act include: Advertising for receiving organ donation is prohibited but advertising by a
person wanting to donate an organ is not.
❖ No adequate provision to prevent misuse of the term ‘affection/attachmenf.
❖ No provision for the post retrieval care of the donor.
The inclusion of spouse as a ‘near’ relative who can donate a kidney.
Interestingly, out of a thousand donations analyzed, 815 were from females and the
remaining by males.
A case where a lady from Kashmir received a kidney donation form an unemployed
youth from Assam in a hospital in Mumbai, the operating doctor being from South
India exemplifies the degree of national integration we have achieved in the kidney
racket.
Its almost as if the ‘Organ thugs are now operating with the sanction of the law’.
Dr. Anant Bhan
March 2003
An excerpt from this discussion was published in the ‘Issues in Medical Ethics ' Apr-Jun
2003 issue.
Appendix 20
IMA meetings: down in the dumps
The Indian Medical Association, Academy of Medical Specialities (Karnataka Chapter)
recently organized a South Zone Conference on the topic ‘Multi Specialities: Current
Scenario' on 8lh February 2003. The venue was the picturesque Nandi Hills resort, the
famous summer resort of Tippu Sultan on the outskirts of Bangalore.
Delegates started arriving at the venue from the wee hours of the morning in chartered
buses or in their own vehicles. The morning and afternoon were spent in the scientific
sessions dealing with various topics like Trauma Care, Imaging technology etc. and then
a guided tour of the venue was arranged.
A banquet was arranged at the venue from 7:00 P.M. onwards. Various branch leaders
were felicitated and then an orchestra started belting out various film songs, as most of
the doctors were busy downing their shots of alcohol. Around an hour and a half into the
show, came the real shocker- suddenly on stage appeared four ‘bar girls' suggestively
dressed and started gyrating to the music which also picked up tempo. That there were a
lot of families and in many cases, their own wives present at the venue did not deter
many of the medical profession from shamelessly herding around the stage half drunk
and trying to get nearer to the dancers and trying to shove money into their hands. This
continued for almost two hours with a few squabbles also breaking out regarding
proximity to the stage. Finally the orchestra called it quits and the dancers were escorted
away to their lodgings for the night.
It is incomprehensible why a prestigious organization like the IMA would resort to such a
cheap sort of entertainment for its annual meet, which was not just degrading to the
dancers but also to the women in the audience.
If this is the kind of entertainment that IMA meets come up with, one has to definitely
wonder about the falling standards and morality of the profession.
Dr. Anant Bhan
March 2003
Published in Issues in Medical Ethics Apr-Jun 2003 issue.
Appendix 21
PUBLIC HEALTH ASPECTS OF ACUTE
RESPIRATORY INFECTIONS
Dr. Anant Bhan
Community Health Cell,
Society for Community Health Awareness, Research and
Action
# 367, Srinivasa Nilaya, Jakkasandra 1st Main,
Koramangala 1st Block, Bangalore - 560 034
Phone- 5531518/5525372
E-maiI:- drbhan@sify.com
PUBLIC HEALTH ASPECTS OF ACUTE
RESPIRATORY INFECTIONS
Abstract for the Presentation
Infections of the respiratory tract are the most common human ailment. While they
are a source of discomfort, disability and loss of time for adults, they are a substantial
cause of morbidity and mortality in young children and the elderly. In India, ARIs are
one of the major causes of death in states and districts with high infant and child
mortality rate.
The poster will attempt to examine the public health aspects of Acute Respiratory
Infections and the various factors involved such as environment (including housing,
industrialization), nutrition (including breast feeding), low birth weight. Vitamin A
deficiency and other host factors, poverty, overcrowding, poor ventilation, unclean
surroundings, occupational factors and lack of awareness etc. The SEPC (Social,
Economic, Political and Cultural) Analysis of the causative factors will help in
understanding the associated problems.
The importance of locating action for prevention and control of Acute Respiratory
Infections in a comprehensive health care context by strengthening primary health
care services to provide better Maternal & Child Health facilities, universal
immunization, improved nutrition and decreasing indoor smoke pollution will be
highlighted.
2
Introduction
Infections of the respiratory tract are the most common human ailment.
ARIs are the leading cause of death in children under 5 years killing an estimated of
4 million children annually.
40% of the Global mortality due to ARIs is accounted by India, Nepal, Indonesia &
Bangladesh.
A report by the DGHS, Govt, of India indicates that ARIs contribute towards about
one fourth to one third of all under five deaths in India. (Mar 1991)
Most young children worldwide have 4-8 episodes of respiratory infections per year.
The risk of an Indian child dying of ARIs is 30-75 times higher than his / her
counterpart in the developed countries.
Upto 40% of children seen in health clinics are suffering from ARIs.
ARIs are responsible for about 20-40% of admission to hospitals.
Measles has an annual toll of around 30 million cases & 9 lakh deaths, (2500 deaths
daily) predominantly in children. Measles thus kills more than half of the 1.6 million
children who die annually from Vaccine Preventable Diseases. [WHO Bulletin,
2001, 79(6)]
Measles global vaccine coverage is currently only 74% - it needs to be at least 90%
for its eradication to be possible.
Upto 10% of survivors of Measles may suffer disabilities, such as blindness,
deafness and irreversible brain damage [WHO Bulletin, 2001, 79(6)]
The pandemic of HIV/AIDS with increasing number of people affected & their
susceptibility to ARIs is an important focus area
Major causative organisms of ARIs
Bacteria
Viruses
Other Agents
H. influenzae
Adenoviruses
M.pneumoniae
S.pneumoniae
Rhinoviruses
C.burnetti
B. pertussis
Influenza viruses A,B,C-
Chlamydia type B
C. diphtheriae
RSV
Enteroviruses
3
Anatomical Classification: ARIs
r-
Upper Respiratory Tract Infections
■
Pharyngitis
■
Tonsillitis
■
Sinusitis
■
Otitis Media
Mid Respiratory Tract Infections
•
Laryngotracheobronchitis
‘
Epiglottitis
Acute Lower Respiratory Tract Infections
■
Bronchiolitis
■
Pneumonia
* Lankinen, K., et al. Health & Disease in the Developing Countries
London: Macmillan Education Ltd.
Treatment decisions in children with cough or difficulty in hreathing-the WHO case
management strategy
Signs & Symptoms
Cough or cold, no fast
breathing; no chest
indrawing
Respiratory Rate
RR
Age
60 or > < 2mths
50 or > 2-12mths
40 or > 12-60mths
Chest indrawing
< 2 mths infant with
cyanosis, severe chest
indrawing, inability to
feed, grunting,
convulsions, etc.
Classification
Therapy
Where to treat
No pneumonia
Home remedies
• Inhalation
• Herbal/others
Home by parent
(mother)
Pneumonia
Cotrimaxozole orally
for 5 days**
Home by trained
Community Health
Volunteer (CHV)
Severe pneumonia
IV/IM penicillin
Hospital
Very severe
pneumonia
Chloramphenicol
Hospital
4
**The major disadvantage of using Cotrimaxozole however is the increasing rates of
resistance of the two major pathogens that cause bacterial pneumonia S. pneumoniae and H.
infleunzae. Recent studies in some parts of Asia and Africa have shown resistance rates
between 30 to 60 percent. The alternate antibiotic, amoxycillin, is about twice as expensive as
cotrimaxozole, which deters its use by the national programs. Furthermore, the standard
dosage recommendation is three times a day. The compliance with three times a day dosing
drops to 60 percent or lesser. Both these factors work to the disadvantage of amoxycillin use.
Proximate Factors
Poor Housing & High Population Density
Poor housing with overcrowding is a very important risk factor for the development
of ARls especially in the developing countries. The incidence of ARIs has been
especially found to be high in families that live in ‘kutccha’ houses rather than
‘pucca’ houses- this is related to the presence of more dampness in the former.
Agarwal DK and Katyar GP, (1981) and Gupta S and Krishnamurthy K A (1970)
found that the morbidity incidence was significantly higher in those children who
lived in ‘kutccha’ or mixed houses as compared to those living in ‘pucca’ houses. In
many instances in rural areas, the practice of keeping the child on the floor (which is
made of mud) increases the chance of exposure to the dampness and thereby increases
the risk of respiratory infections. Parental education in this aspect is thus very
important.
In a study in Bangladesh, it was found that the risk of acquiring AR Is was 3.33 times
higher in low socio- economic index, 3 times in no access to piped water, 2.39 times
in low housing index, 1.9 times in mother’s age below 20 years. (Rahman MM,
Shahidullah M, 2001)
The presence of dampness within houses as seen in certain western countries like the
U.K. is also conducive to the spread of ARIs. Large families (with more than three
children) that live in close proximity e.g. in slums lead to the most susceptible
population- the children and the elderly being vulnerable to ARIs. The lack of
adequate ventilation in these crowded settlements is also an important factor-‘good
ventilation is not just the replacement of vitiated air by a supply of fresh outdoor air
but also control of quality of incoming air with regard to its temperature, humidity so
as to provide a thermal environment that is comfortable and free from the risk of
infection’. (Park’s T.B. of P & SM; 16"' Edn.; Pg 509)
Kumar V et al (1982) in India showed that there is a greater likelihood of ARI in
large families than those with fewer families.
It is important to remember that these poor families also have a poor intake if
calories and proteins that leads to increased Protein Energy Malnutrition.
5
Also, high population density in urban areas with poor quality of air due to high
degree of industrial and vehicular pollution leads to frequent irritation of airways,
making the person susceptible to respiratory infections. The risk of RSV infections is
doubled in infants living in industrial populations, probably due to overcrowding.
(Clarke et al. 1978). Children living in areas with high air pollution have more
respiratory diseases (Douglas & Warren, 1966) and measures to control
environmental pollution appear to be beneficial (Lunn et al 1970). Especially during
the winter season, smoke combines with fog to produce smog that makes breathing
very difficult.
>
Poverty
Poverty is an issue that is related to the person’s housing status, educational status
and also the degree of environmental sanitation s/he maintains. It is also inextricably
linked to the purchasing power of nutrients- a well balanced diet is immunoprotective and can keep the person healthy. It also helps in quick recovery during
convalescence.
Poor people might look upon disease as a burden and hence they wait till the disease
progression has reached a late stage and is not resolving. They at many times may not
be able to afford the travel and treatment involved in managing the complications at
the referral level.
>
Lack of Hygiene/ Environmental Sanitation
Poor personal hygiene makes the entry of pathogens easier and increases
susceptibility to infections- it also promotes repeated infections. Inadequate
environmental sanitation makes the spread of infections easier at the community
level. The need for education about the importance of hygiene at the individual and
collective level is imperative to control the spread of infections esp. ARIs.
>
Malnutrition & Vitamin A deficiency
Biswas et al (1999) found ARI incidence to be significantly higher in
undernourished children of poor socio economic status. Malnutrition causes
increased susceptibility to infection and decreased local & systemic immunity; there
is also inability to fight infections; the respiratory muscle drive and the cough reflex
is weakened making the entry of pathogens into the respiratory tract through
aspiration easier. These factors together with the impaired regeneration of the
respiraotory epithelium increase the susceptibility to, and the persistence of ARIs.
6
Undernutrition and respiratory infections make each other worse- this can lead to
malnutrition & death (it is thus a vicious cycle). Pneumonias are 20 limes more
common in malnourished than well-nourished children. In malnourishment, the IgA
is also generally reduced which results in delayed recovery from infections and also,
infections tend to be severe in malnourished subjects. There is decreased food intake
and increased metabolic requirements during ARIs. There is also a fair amount of
intestinal loss especially in measles.
Vit. A deficiency makes a child more vulnerable to respiratory and other infections
esp. measles; similarly, respiratory infections can change mild Vit. A deficiency into
severe deficiency (that can lead to xerophthalmia and blindness)
Vit. A also has an effect on the maintenance & regrowth of epithelial cells that line
the respiratory tract.
Management of ARIs with regard to Nutritional care
*
Ensure adequate hydration
*
Reduce fever (as appetite will accordingly Is)
*
Mouth care
*
Frequent foods
*
Extra foods during convalescence
*
Special supplements (Vit. A, Iron, Zinc etc.)
-ARI NEWS. 1988
Indoor Air Pollution
*
Coal & Biomass Fuel
Globally, around 50% of people, almost all in the developing countries rely
on biomass fuels for domestic energy. Exposure to indoor air pollution esp.
to particulate matter from the combustion of biofuels (wood, charcoal,
agricultural residues and dung) has been associated with respiratory disease.
These materials are burnt in simple stoves with very incomplete combustion
and consequently, women and young children are exposed to the high levels
of indoor air pollution everyday (Bruce N etal, 2000). Hence, it is important
to advocate the use of innovations like smokeless chulhas that will reduce
the quantum of indoor air pollution. There is the added gender factor also
related to this as the women who are the caretakers of the sick especially the
children are also constantly exposed to the indoor air pollution and may in
many cases have respiratory problems themselves. A more systematic
approach to the development and evaluation of interventions is desirable,
with clearer recognition of the interrelationships between poverty and
dependence on polluting fuels.
7
*
Tobacco Smoke
The smoker inhales only 15% of smoke from a cigarette but 85% is released
to the environment as ETS (Environmental Tobacco Smoke) - this smoke is
a well-known causative factor for respiratory disease. Maternal Smoking
influences incidence of respiratory illness in children mainly through an
antenatal effect.
>
Maternal Literacy; Health Education & Awareness
Education is a decisive factor in health improvement, and moreover, basic education
is the foundation of health education, a major component of health promotion.
Education is decisive in improving health, and reducing mortality, particularly infant
mortality; several studies have shown that educating the male parent alone does not
have a significant positive impact on infant and child mortality if the mother is
illiterate. Other studies confirm that the wide differentiation in child survival is
closely related to the differences in the educational level of the mothers. Evidence
also points to a close relationship between educational levels and a prepared
acceptance of family planning, birth spacing, improving the health of mothers and
better care & health for children. It is important to remember that education has been
emphasized as a principal means of improving a woman’s health status and that of
her children and family- lack of education acts as a major contributing factor to the
feminization of poverty. Nearly 2/3rds of the world’s illiterate adults are women;
most of them living in the developing countries of Africa, Asia and Latin America.
A quarter of the world’s girls are estimated to be out of school, compared to about
1 /6th of the world’s boys. (TILEM, NLSIU, 2002).
In the present context, education is related to the lack of awareness about ARIscauses, signs and symptoms, when to report and management. Health education of
families and community involvement in childcare practices related to ARIs is very
important. In particular, strengthening the ability of mothers to recognize early the
severe forms of ARIs to provide supportive care for sick children can make a lot of
difference in reducing the mortality associated. There is also a need for promotion of
breast-feeding and also the promotion of healthy and clean environment through
community education.
It is essential that parents who are at the forefront of clinical management of
children with ARIs need to understand the difference between the child with a minor
self-limiting illness and a more serious one that needs treatment.
>
Inappropriate feeding and weaning practices
Infants inadequately breasts fed and weaned early and improperly are susceptible to
under nutrition and infection. Breast milk also contains adequate Vit. A for the first
4-6 months of life, to help protect against ARIs.
Artificially fed babies even if adequately nourished suffer from more episodes of
serious ARIs (pneumonia & bronchiolitis) than breast-fed babies. Nasopharynx is
the entry point for respiratory viruses and bacteria; breast milk coats the
8
nasopharynx during the feeding process and makes entry of these pathogens less
likely while formula foods have been proven to make the entry easier.
Human milk contains antibodies and other factors like secretory IgA. lysozymes,
specific inhibitory substances for viral infection and anti staphylococcal factor that
prevent microbial attachment to the respiratory epithelium. These humoral
antibodies and other host resistance factors play a crucial role against both viral and
bacterial agents. (Ghai OP, 1990)
Young mothers should be told that breast-feeding should be continued during the
child’s illness and convalescence.
>
Preterm and Low Birth Weight Babies
They are more susceptible to various infections especially AR Is primarily because of
their low immunity status. The protective maternal antibodies are transmitted to the
fetus during the last ten weeks of gestation.
Low Birth Weight is indirectly a reflection of the health and the nutritional status of
the mother and the care she receives during the pregnancy; hence better antenatal
care would decrease low birth weight incidence and ARI morbidity.
In studies Bhakoo ON (1987) reported that lower the birth weight of babies, higher
are his chances to develop infection. The same author in a rural cohort study in 1985
had showed that the ARI deaths among LBW babies were significantly higher
(7.1%) as compared to their normal counterparts.
>
Access to Primary Health Care Services
*
Distance from the nearest Primary Health Center is important as this
influences the decision of the sick to report early or late.
*
Regularity of visits of the Primary Health Centre staff- this can help in
picking up the cases early and prompt initiation of treatment.
*
Availability of adequate staff at the health centers to be able to attend to
patients judiciously.
*
Provision of essential drugs which may be life saving.
♦
Transport and referral mechanism in case of serious cases has to be
effective.
*
Training of Community Health Workers / Volunteers (CHWs / CHVs) or
Trained Birth Attendants to identify the types of ARI, start treatment and
refer when required- this has been shown to work and has been found to
drastically reduce the morbidity and mortality associated with AR Is when
combined with indigenously developed implements like a breath counter for
effective diagnosis.
-SEARCH, Gadchiroli experiment; Bulletin of the WHO. 1994, 72(6);897-905
*
Strategies that could help here could be: Improved and standardized case management at both the PHC &
referral levels, which includes early discrimination of the mild and
severe ARIs by families, local community representatives and PHC
workers, supportive measures and anti microbial treatment.
Health education to the community about ARIs
■
Improved Primary Health Care through ARI case management.
Encouragement of the community involvement.
Improved child care practices.
Proper referral systems
Y
Health Care System
In the present healthcare system, there is excessive stress on curative aspects. Health
education is not given adequate emphasis, though it is vital for preventing the
occurrence and spread of ARIs. Also, there is a need for continued effective teaching
and training programs for the paramedical staff for ARI management. The
paramedical staffs esp. the Ante Natal Midwives (ANMs), being understaffed are
usually overworked also.
Availability of appropriate and effective drugs especially antibiotics at all the levels
of the healthcare system is vital.
Surveillance of the ARI mortality at the level of Anganwaadis and the subcentres
can help in evaluation and development of adequate facilities al the primary and
community health centers.
Broader Factors
Immunization Programs
In the past couple of years, there has been an increased incidence of Vaccine
Preventable Diseases except Polio (WHO SEARO, 1998-2000) because of selective
focus on the Pulse Polio program. This needs to be addressed. Coverage is still an
issue with a part of the population not having access to immunization. Strengthening
of existing immunization programs is needed. Also, research is vital for the
production ofcheap & effective vaccines for the primary prevention of ARIs.
10
>
Disasters - Natural / Manmade
There is a lack of system of emergency medical response in our country, which
suffers form disasters- natural or manmade on a regular basis. Refugee camps,
public shelters have conditions (abysmal sanitation and over crowding) conducive to
spread of ARIs. There is an urgent need to evolve a system to address the needs of
emergency medical care in the country. This holds true also at the global level
wherever disasters occur or conflict is ongoing.
In areas with famine, measles, ARIs and diarrhea with dehydration may bring about
an increase in infant mortality. When people migrate and settle down on the
outskirts of famine-hit areas, poor hygiene and overcrowding may facilitate the
spread of endemic communicable diseases (WHO, 1989).
>
Migration, Displacement, Occupation
Economic hardship and drought leads to migration to urban areas where the families stay
in crowded slums with limited space; these migrant populations also carry the diseases
endemic in their areas with them. This is a situation wherein ARIs can occur easily.
Occupation- certain vocations promote an environment favorable to respiratory
infections, some of them being: -
(i)
(2)
(3)
(4)
(5)
(6)
(7)
>
Agarbathi workers- work in one-room tenements with little or no cross
ventilation.
Beedi Workers
Vegetable cultivators - they usually spray large amounts of pesticides without
even the minimum precautions.
Brick Kilns.
Cement Industry
Manufacture of plastic bangles/glassware.
Sericulture- child labour intensive; long hours; exposure to ‘Sericin’, a protein
that may have a relation to respiratory disease.
Lack of intersectoral coordination
*
At the village level, there are various departments working that are directly
involved in the health of the people. Its very common to find coordination
between these various departments missing.
Dept, of Women & Child Development - responsible for Anganwaadis
and nutrition supplementation
Dept, of Education department- school health
Dept, of Rural Development & Panchayati Raj - Water supply and
Sanitation
Dept, of Health & Family Welfare- all the national health programs.
11
>
*
ARI control strategies have to be integrated with other programs such as
control of Diarrhoeal Diseases, Immunization and Family Planning,
Maternal & Child Health.
*
Public Health Engineering is sometime found to be dismal like in the case of
‘Junta Houses’ which were built by the govt, -they are small tenements with
two windows and a door; the animals sleep, chulhas, washing areas and
sleeping quarters are all within this area only.
Economic Policies (Liberalization, Privatization and
Globalization)
These are promoting disinvestments in health and selective health care leading to
economic devastation in some areas; the worst affected are the poorest of the poor.
There is also promotion of huge projects that cause displacement and migration- e.g.
the Bagalkot Upper Krishna dam that displaced the local populace to small
dwellings with zinc sheets that are virtual ovens during the day.
Cost of all drugs including the essential ones is expected to rise after 2005 with the
WTO regulations coming into effect.
>
Role of the Medical Profession
There is a lack of standard treatment guidelines for ARIs in the medical community.
There is also the problem of indiscriminate and unethical usage of the antibiotics,
whether indicated or not leading to increased antibiotic resistance. The ARIs have
been considered as the ‘bread and butter’ of general practice. In many cases the
natural history of the mild disease also is not allowed to progress because the
treating physician is ‘trigger happy’ in prescribing antibiotics thus not allowing the
body’s immunity to respond and fight back. However, caution needs to be taken in
this regard in the cases of malnourished and the immuno-depressed who might need
antibiotic cover because of their status. The process of treatment has become overmedicalized with inadequate time given to health education for patients/families.
There is a tendency to prescribe antibiotics in almost all cases of ARIs without
realizing that most of the cases are caused by viruses and would not respond to
antibiotics (unless there is a secondary superadded bacterial infection). In this
aspect, the WHO case management also is defective as it stresses the use of
antibiotics. In the Indian context there is also the problem of self-medication without
any formal training- also, most patients do not complete the whole course of
antibiotics facilitating the development of antibiotic resistance. There is also
misinformation about drug usage and hence there is usage of antibiotics like
Ciprofloxacin in the pediatric age group in ARIs when it is specifically
contraindicated in that age group.
In 1991, the Indian Medical Association carried out a survey on the prescribing
practices of 1,000 of its members. They were asked to indicate how they treated
12
viral respiratory infections like colds and coughs. The results are of concern in that
over half treated all cases with antibiotics, and a further quarter gave antibiotics to
50 percent of their patients. (ARI News, 1992)
Appropriate usage of antibiotics is not only a public health priority- it constitutes the
best care for the patient. Avoiding antibiotics when not necessary can also prevent
antibiotic associated complications & is in accordance with the physician dictum
Trimum Non Nocere’ (First Do No Harm).
Most children with cough and cold need no drugs at all. The illness resolves usually
in four to fourteen days. Supportive care is all that is needed, and can help relieve
symptoms. Rest, continued feeding and herbal medicine or local health traditions
will be enough. It is important to remember that in ARIs, usually there is no role for:
Antihistaminics & nasal decongestants.
Antiseptic & anesthetic lozenges, sprays and gargles.
Cough medicines.
■
>
Irrational combinations of cough suppressants with expectorants and
mucolytics.
Promotion of research work
According to an estimate, only 0.2% of pharmaceutical research is devoted to acute
respiratory infections, TB, Diarrhea, while 18% of deaths are attributable to these
diseases. So this is a priority area that needs to be taken up.
- www.taccl.org
HIV & ARls - a public health concern
ARIs are likely to be more common and more severe in HIV positive individuals,
and episodes are likely to be more prolonged and to become recurrent. Pneumonia
has featured prominently as the cause of death of people with HIV; hence they have
to be very careful to avoid getting ARIs.
In the early stages of HIV, especially in children the causes of pneumonia are the
same as that for general childhood pneumonia. Recognition and management should
follow the ARI standard case management guidelines. Response to treatment is
generally good. In the later stages of infection, when the children might have
developed AIDS, a much wider range of pathogens cause pneumonia. Treatment
should start as for very severe pneumonia; however, it may need to be changed to
cover unusual organisms. At this stage, the response to treatment and the prognosis
is generally poor.
13
IMCI approach
Integrated Management of Childhood Illness (IMCI) - an approach developed by
the WHO and UNICEF is now the principal strategy for reducing ARI mortality. Il
does so by promoting:-
* Prevention through reduced air pollution, improved nutrition
breastfeeding and immunization.
including
* Early recognition of disease by caretakers and improved home management.
* Prompt recognition of symptoms and signs of pneumonia by health workers.
* Rapid treatment with antibiotics in accordance with national treatment policy.
* Rapid referral of the most serious cases.
However, the IMCI approach needs to be adapted to the larger issues, as it does not
address many of the determinants in the causation of ARIs (some of which have
been discussed above) comprehensively.
>
Emerging concerns
*
Tobacco marketing change- younger customers and women are being
targeted by the tobacco transnational corporations.
*
Hitchhiking microbes
*
New viruses- this is exemplified by the recent spread of the SARS virus
around the world.
*
Drug resistance
*
Dumping of ineffective drugs in developing countries by the big
pharmaceutical houses.
(See also Veronica Bailey et al, online resource)
*
The inadequate focus on ARIs in the geriatric age group, which all around the
world is expanding with the increasing life expectancy, needs to be addressed.
[NOTE
Insert Appendix 1 and Appendix 2|
14
References
i. A.T. Bang and R.A. Bang; Breath Counter: A new device for household
diagnosis of Childhood pneumonia; Indian J Pediatr 1992: 59: 79-84
2. A.T. Bang and R.A. Bang, P.G. Sontakke et al; Management of childhood
pneumonia by traditional birth attendants; Bulletin of the WHO; 1994; 72(6);
897-905
3. Abhay T Bang, Rani A Bang et al; Reduction in Pneumonia mortality and total
childhood mortality by means of community based intervention trial in
Gadchiroli, India; Lancet; 1990; 336; 201-206.
4. Acute Respiratory Infections and its control ( in under five children); Directorate
General of Heaalth Services, National Institute of Communicable Diseases,;
India; Mar 1991.
5. Agarwal D K and Katiyar G P; ‘Influence of Environmental factors on Under 5
morbidity’; Indian Pediatrics’; 18(8) ; 545; 1981.
6. ARI News, Issue 12, December 1988, Pg 3, produced by AHRTAG, London
7. ARI News, Issue 23, August 1992, Pg 7, produces by AHRTAG, London.
8. Biswas A, Biswas R, Manna B, Dutta K, Indian J Public Health 1999 Apr-Jun;
43(2); 73-5
9. Bhakoo ON; ‘Pneumonia in the newborn’ Indian Journal of Pediatrics; 54; 199-
204; 1987.
10. Bruce N, Perez-Padilla R, Albalak R, Bull World Helath Organization 2000;
78(9); 1078-92
11. Clarke SJR, Gardner PS, Poole PM, Simpson H, Tobin JO; 1978; RSV Infection:
admission to hospital in industrial, urban and rural areas.
12. Douglas JWB, Waller RE 1966; Air Pollution & Respiratory functions in
children, British Journal of Preventive & Social Medicine 20; 1-8
13. Ghai OP; ‘Textbook of Pediatrics’, 1990.
14. Gupta S and Krishnamurthy K A; ‘Morbidity and Mortality
Indian Paediatrics; 7; 563; 1970.
in Children’;
15. Health Situation in the SE Asia Region, 1998-200, WHO SEARO publication.
16. Health Law & Ethics: An Introduction; TILEM, The National Law School of
India University; 2002; 49,50,60
15
17. Kumar V et al; ‘Infant Mortality in a Rural Community Development Block in
Haryana’; Indian J Pediatrics; 49; 795-802, 1982.
18. Lankinen, K., et al. Health & Disease in the Developing
Macmillan Education Ltd.
Countries; London:
19. Lunn JE, Knowelder J, Roe J W 1970 Patterns of Respiratory Illness in Sheffield
Junior School Children; British Journal of Preventive & Social Medicine 24;
223-228.
20. Park’s T.B. ofP & SM; 16th Edn. ;Pg 509
21. Rahman MM, Shahidullah M., Risk Factors for Acute Respiratory Infections
among the slum infants of Dhaka city; Bangladesh Med Res Counc Bull 2001;
27(2); 55-62
22. WHO (1989), Coping with natural Disasters: The role of the health personnel
and the community
23. vvww.tacd.org
24. Veronica Bailey, Karen Boatman; Acute
w w w. who. i nt/about who/en/p reventing/acute.htm
16
Respiratory
Infections;
THE PARADIGM SHIFT FOR DEEPER UNDERSTANDING & PREVENTION
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PARAMETER
FOCUS
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TECHNOLOGY
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COMMUNITY
SOCIAL, ECONOMIC, POLITICAL,
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PHARMACO
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CLINICAL
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SOCIAL POLICY AND POLITICAL
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