Health for the Millions, Vol. 10, No. 1-6, Feb. - Dec. 1984
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- Health for the Millions, Vol. 10, No. 1-6, Feb. - Dec. 1984
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HEALTH FOR THE MILLIONS
Vol X No. 1
In this issue :
Pg, No.
February 1984
T Vijay end ra
Why Appropriate Technology in Health Care
This issue of HfM was put
together and produced by :
Sr Celine P
S Srinivasan (Editor)
Belter Eyesight Without Glasses
Augustine J Veliath
2
5
China Reconstructs
Alex J Dass
Chinese Children Improve Sight
Purabi Pandey
L K Murthy
Ponnamma George
Padam Khanna
9
Dr P K Selhi
Rehabilitation Technology: Need for a
Cultural Change.
12
Aspi B Mistry.
Marilee Karl
A Male-dominated Movement
17
S Srinivasan
Portrait of a Doctor as a Crusader
21
Dr Gangwal and the Sidabh Nidan Kendra
Dunu Roy
From Technological Practice to Technological
Theory
25
AT Reports
32
News from the States
Owned and published
by the
Voluntary
Health
Association
of India,
C — 14,
Community
Centre,
Safdarjung
Develop
ment Area, New Delhi 110016,
and printed at J K Offset
Printers, Jama Masjid, New Delhi.
37
Chinu
A Monastery Hidden by a Distillery
38
Book Review: The Double-Edged Helix-Science
in the Real World by Liebe F Cavalieri
Further Reading on Appropriate Technology.
42
<1
participate
rol.
AT and All That
Appropriate technology
is a doubly
misused term.
Firstly, a lot of
techno
logy that is not appropriate is dumped as
appropriate.
Secondly, a lot of things
are dubbed as technology-even the manner
of speaking, writing, behaving,
which can
hardly be called technology.
That would
probably not be so bad, if it were not to
make the entire concept of AT banal,
if
not trivial. Worse distortions occur when
powerful, moneyed organisations and indi
viduals appropriate the concept of AT to
look good and feel good.
And these I do not sell for gold
Or coin of silvery shine
But for a copper half-penny
And that will purchase nine9.
Such half-baked Abhimanyus keep comple
ting new AT designs to keep their Menai
bridges from rusting.
Probably there are
only a few who do AT and make AT work for
others.
We write of a few such in this
issue of HfM.
- S Srinivasan, Editor.
This issue of Health for the Millions
examines some aspects of technology, appr
opriate and not so appropriate, as related
to health care.
Yet almost every issue of
this magazine in the past has focussed on
health care through the lens of appropri
ate technology.
This is not suprising as
anyone who works for low cost health care
of the poorest people necessarily develops
a healthy disrespect for,
and in some
cases totally disregards,
much of current
technology to which only the rich have
access.
For many engineers,
technologists and
others of the elite class, AT never is and
never was.
Others consider AT a still
born child or in some cases,
a god who
promised and died young.
And then
there
are those individuals and institutions who
claim to be doing and propagating AT.
If
they were asked by the poor what exactly
they do for a living, they would reply if
they were truthful like the old man in
"Through the looking glass":
................. I look for butter flies
That sleep among the wheat:
I make them into mutton pies,
And sell them in the street.
I sell them unto men
Who sail on stormy seas,
And that9s the way I get my bread...
A trifle, if you please.
................. I hunt for haddocks9 eyes
Among the heather bright
And work them into waistcoatbuttons
in the silent night.
HEALTH FOR THE MILLIONS
FEBRUARY 1984
1 told you not to dabble in harnessing solar energy and to
.leave all that to the scientists...!
f
Courtesy : "Science Smiles", R K Laxman)
age health workers, teachers
etc.) available in the community
and
their supplementation with a well
structured referral services.
4)
Promotion of indigeneous research
and traditional therapies along with
modern scientific inputs.
5) Low cost hospital equipment,
ing, aids, etc.
build
This gives us several areas of applica
tion of appropriate technology in health
care.
Examples
Some examples of appropriate technology
in health care that one could site are:
the Jaipur foot experience under
the
guidance of Dr. P. K. Sethi (see HfM issue
October
79);
*
the latrines for the urban
poor of Sulabh Souchalaya as an example of
appropriate sanitation (see HfM December
'79 and August ’81);
the smokeless chula
experience at Nada near Chandigarh under
the guidance of Ms.
Madhu Sarin;
the
Bangarpet Tablet
industry as a case of
uvMFrrhiuimmim,
To
ouRTIWK-
The
amd
Alb- Agricultural
Mow
I^of Alb- - 'MaFr .all
•4
&
-
—//—
CrttUX.iAl
feo/n ^U‘*.vwJT ’-rnOSJ
do lo iocak w lAC
a
smnpeir,,
6IVIWA
us MICAS’ /W>z,/!
appropriate organisation and technology
(see HfM', December *
79)
and so also the
Sulabh Nidan Kendra at Jaipur (see 'Portr
ait of a Doctor as a Crusader'
in this
issue of HfM): the three tier system in
Tirunelveli, Tamil Nadu,
using the India
Mark-II water hand pumps (see HfM, August
1981); specific aids such as the garment
for mass nutrition screening
and the
audiometer for screening
children for
hearing loss
(see HfM, August
'78 and
February *
82); and so on.
Alternatives
in
training personnel,
like courses for VHWs, the nurse anasthesia course being conducted by VHAF
for
nurses;
health care institutions making
their own tablets,
sanitary pads,
I.V.
fluids,
etc. also reflect a search for
relevance and for low-cost health care.
Therefore they could be termed as attempts
towards an appropriate technology of heal
th care.
However a word of caution is in order:
These examples can be considered appropri
ate only at a particular place
in a
particular context.
Persons trying to use
these ideas in their own area may need to
suitably modify them.
UPKARAR - A manual of aids for the
multiple handicapped is an illustrated
guide of examples and ideas. Disabled
persons, parents of disabled children
and those professionally concerned in
advising and. selecting equipment for
disabled children will find this use
ful. This project has been coordinated
by Ranjan Sen of the Spastics Society
and designed and illustrated by Jogendra Panghaal of Life Tools. Limited
number of copies are available at Rs.
SO per copy plus postage from VHAI.
WANTED
A qualified doctor with specific
tude,
for working in the tribal
Apply to:
The President
M.B. Jain Trust
Pandav, DAHOD 389151
Gujarat
HEALTH FOR THE MILLIONS
apti
area. '
FEBRUARY 1984
SR. CELINE
P
Better Eyesight Without Glasses
Glasses never 'cure' defective vision-they make the eyes worseand as long as one continues to wear them there is no possibility of
ever regaining normal sight.
The author, Sr. Celine P., is one of those persons, who practises
what she advises others. Sr. Celine, over 40 years of age, stopped
needing spectacles at all, six months after she started practising
the eye exercises described in this article.
She is not the only one to do so. An R & D engineer in an
electronics firm in Bombay had short sighted vision and was wearing
spectacles of 16.5 dioptres power. After starting these exercises he
improved his eyesight to 2.5 in two months, and in another four
months restored his vision to normal. Chinese school children are
known to practise these exercises regularly.
These exercises are known to help in cases of shortsight, long
sight, astigmatism, old sight, squint and cataract. Cures are also
reported for colour blindness, night blindness, nystagmus, amblyo
pia, etc. Surely these exercises deserve the much misused label of
appropriate technology. Label or not, they deserve to be widely
known and to be researched further. A caveat however is in order:
Beware of the eye specialist and the spectacles manufacturer who
stand to lose by these exercisesand would be eager to dump them as
unscientific.
The author in her workshops (conducted with Sr. Carol Huss)
demonstrates these exercises along with those belonging to the
Chinese Yoga system. The latter are akin to the eye exercises
practised by Chinese school children, described in the following
pages. The author's contact address is: Sr. Celine P., Medical
Mission Sisters, P.O. Sandipani, Bibwewadi, Pune-411037
At the begining of the
20th century,
Dr.
Horatio Bates of New York, an eye
specialist, discovered that most eye trou
ble
could be cured by removing
the
underlying causes.
Dr. Bates'
theory
is
that the eye adapts itself to varying
distances not by changing the shape of its
crystalline lens but by changing the shape
of the eye balls-i.e. the eye accommodates
itself to varying distances by means of
the eye muscles with their varying pull on
the eye ball.
Eye glasses are an unsatisfactory subs
titute for normal vision.
It is fortunate
that many people for whom glasses have
been prescribed refuse to wear them, thus
HEALTH FOR THE MILLIONS
FEBRUARY 1984
escaping not only much discomfort but also
much injury to their eyes.
As refractive
abnormalities are continually
changing
from day to day, from hour
to hour and
from minute
to minute, even under the
influence of atropine, the accurate fitt
ing of glasses is of course impossible.
The cornerstones to this
regaining normal sight are:
*
method
of
Acceptance of the fact that your eye
is like any other part of your body
equipped with full power to recupe
rate under proper guidance.
It
is
not a thing in itself, apart
from
the rest of you.
5
Realisation that strain is the cause
of impaired sight, not the result of
it.
Recognition that, since this is so
relaxing to the eye, releasing it
from strain is your first
step
towards regaining normal sight.
Determination
to
use
the eyes'
correctly.
When one comes
with
eye trouble,
instead of giving a lens, ask him: What do
you eat? How is your elimination? How
much sleep do you get? What are you
worrying about? Do you like your work?
Is your emotional life alright? How much
fun do you have?
Head ache is often connected with the
eyes.
But glasses are not a treatment,
they do not help more than taking an
aspirin for head ache.
Find
out the
cause.
It may be tooth trouble or diet,
anything like any other disease.
2. SNELLEN TEST CARD.
Keep the card 5 or
10 feet away from you.
Read
the
4
smallest lines without glasses easily and
lightly.
Blink after each letter.
Do it
with each eye separately.
Stand as you
read the card and sway slowly and smoothly
from side to side.
Now if you stare at the‘final letter,
you will notice that all the letters on
that line begin to blur.
It is beneficial
to close your eyes quickly after you see
the final letter, open them and shift to
the first figure on that line.
Then close
your eyes and remember the first figure.
You will be able to read all the letters
TEST CARD
Fifty Feet.
A
C G
The exercises are the same for any eye
condition. They vary in length.
In each
condition
one or more
is
especially
beneficial. Since all the exercises help
the normal eye function you are
free to
try any exercise.
The oftener, the sooner
the recovery.
Continue till the autonomic
nervous system has established paths which
the eye activities follow unconsciously.
When one eye is weaker than the other, it
should be exercised separately to bring
the vision to level with the other eye.
Thirty Feet.
Twenty Feet.
F E P
Fifteen Feet.
Eye exercises
1. LONG SWINGING is a very good relaxation
exercise and is es’sential for every eye
treatment.
It releases tension on the
neck, shoulders and lower back and enfor
ces the shifting of the eye.
5 minutes or
more at a time.
Feet 12" apart,
hands
loose squarely facing one side of the
room.
Turn the body to the right until
the line of the shoulders is parallel to
the wall at the same time lifting the heel
of the left foot.
The body and head are
turned
180 degrees. While rotating,
the
eye should be kept open.
Try to feel the
objects moving fast backwards; 16 complete
turns a minute is the best speed.
Helps
to relax the whole nervous system.
There
should be a gentle and conscious blink at
each end.
6
L Z O D
Ten Feet.
C
N
A
G
B
Five Feet.
H
A
ZZ
O
Q
Three Feet
Z
U
K
L
T
A
P
Two Feet.
S
R
O
C
C
D
N
THE SNELLEN CARD
HEALTH FOR THE MILLIONS
FEBRUARY 1984
on that line by closing your eyes for each
letter.
It takes only a minute to rest the
sight with the card.
If you spend five
minutes in the morning practising with the
card, it will be a great help during the
day. Also keep a record of each test in
order to note your progress from day to
day.
Record the vision in the form of a
fraction, with the distance at which the
letter
ought to be read as
the
denominator.
For example,
20/20 is nor
mal, 10/20 less than normal,
25/20 better
than normal.
3. FOR EYE STRAIN—blink and shift frequ
ently.
Keep the Snellen card at 5-10 feet
distance and read one letter at a time.
Blink after each letter, for 10 minutes.
First with both eyes, then with one eye at
a time.
Weak eye more than the strong.
Do it 15 minutes a day.
4. BLINKING—once
seconds is’ good.
or
twice
every
10
5. SUN SHINE—close the eyes, face the sun
and gently move the head from side to side
to ensure the rays fall on all parts of
the eyes with equal strength.
10 minutes
three times a day, helps to draw blood to
the eye and relaxes the muscles
and
nerves.
When you have become used to the
strong light, raise the upper
lid of one
eye and look downward as the sun shines on
the sclera.
Blink when the desire to
blink comes, or when you lose the power of
relaxation.
One cannot get too much sun
treatment.
Morning Greetings:
Look at the rising
sun,
briefly,
only when it is
just
appearing red on the horizon.
Imagine
good eyesight.
Think of good reasons why
you need it.
Also sun your eyes
in the
daytime, looking into the sun with closed
eyes-you will see a red colour.
Sun bathing: Spend as much time as
possible in the sun, sand, water,
grass.
Walk barefoot, wearing as few clothes as
the
law requires, using eye glasses only
when absolutely necessary.
They filter
out some essential rays needed for compl
ete health.
6. COLD WATER—dipping your hands in the
water, raise them full of water to within
HEALTH FOR THE MILLIONS
FEBRUARY 19841
2" of your closed eyes, then gently splash
it on your eyes.
Repeat 20 times,
then
dry yourself and rub the closed eyes
briskly for a minute or two with the
towel-eyes glow and freshen and
tone
considerably.
7. PLAYING THE BALL FOR 5 MINUTES—Stand
comfortably with legs apart.
Take an old
tennis ball and gently throw the ball from
left hand to right hand.
Keep the eye
balls in the centres of the eyes,
follow
the tennis balls by the movement of the
neck only.
Gently blink at each end.
This is the same as vertically holding the
index finger 4" away from the eyes and
turning the neck fast in both directions.
8.
SHORT SWING FOR 5 MINUTES—On
a
foolscap black paper draw pencil
lines
paralied to the width, at 1" distances
width a margin of 1" on each side.
Cut
out alternate rectangles inside the mar
gin-like bars of a window.
Fix it on a
walx at your height.
Stand comfortably in
front of it with hands on waist and legs
apart.
Keeping the entire body, neck and
eye balls straight, start swinging the
body side ways like an inverted pendulumDon't move the legs but raise the heels
alternately.
Blink gently once at each
end.
9. FORWARD SWING FOR 5 MINUTES--keep a
lighted candle on a table in a dark room.
Sit on a stool in front of
it,
so that
your eyes are at least 1-1/2" away from
the candle.
Keep the body above the waist
straight and swing towards and away from
the candle.
Look at the candle
flame.
Blink gently at each end.
10. PALMING FOR 5 MINUTES—cover the eyes
with both hands.
Rest your elbows on the
table and see or imagine seeing total
black.
This helps to relax and increases
the sensitivity of vision by achieving the
memory of total darkness.
If you are
nearsighted, do the following while palm
ing.
Imagine seeing something clearly up
close, then imagine it moving slowly into
the distance, but staying clear.
Let your
but
eyes move slowly into the distance,
staying clear.
Let your imagination have
perfect sight.
If you are farsighted,
do
the opposite.
Imagine something clearly
visible that moves slowly closer.
You
might imagine walking towards a tree,
seeing limbs at first, then leaves,
then
7
veins,
and finally the little luminous
hairs on the stems, with tiny insects
crawling in the hairs, and their tiny legs
with even tinier
feet.
In imagination,
allow your sight to be perfect at all
distances.
If you can imagine seeing clearly at a
distance that is normally blurred for you,
this imagination helps remobilise the eyes
and the attention,
so that they work
together to provide better sight at that
distance.
Whenever you imagine something,
your eyes focus as if you were looking at
it.
Exercise your imagination, and let your
imagination exercise your eyes.
When you come out of palming, open your
eyes slowly, blinking softly.
Let your
self receive the world for a few moments
with all the wide-eyed, open-eyed wonder
you can find.
Cultivate a large mind, an
open heart, and an innocent eye.
Better
sight needs such a habitat to grow in.
Aids to vision
1. Memory and Imagination--look at a small
object.
Observe
its shape and
size.
After getting as clear a mental picture as
possible,
close your eyes and try to
remember as perfectly as you can.
Open
your eyes and look at it again and repeat
as before.
Do it for 5 minutes.
2. Central fixation—look at a
line of
print, then concentrate on one particular
word -in the centre of the line.
Then
close your eyes and imagine that you see
the
line or
the word in question more
clearly and sharper in outline then
select a part of it.
Then do as above.
3. Reading—you can read
any
amount
provided the eyes are relaxed.
Read with
out strain.
Use the weaker eye more than
the stronger one.
2. Move the eyes from side to side as far
as possible without any force or effort
six times.
3. Hold up the index finger of the right
hand about 8" from the eyes,
then look
away from the finger to any large object
ten or more feet away.
Do this fast ten
times, then rest a second.
4. Move the eyes gently and slowly around
in a circle and move them back in the
reverse direction four times in all.
Remedial neck exercises
1.
2. Drop the chin as far as possible on to
the chest keeping the neck relaxed.
Then
raise the head and allow it to fall as far
backward as possible.
3. Rotate the head first over the right
shoulder then down over the back.
Next to
the left shoulder and return to the first
position.
Repeat in reverse.
The neck
must be kept relaxed.
4. Turn the head as far to the
left as
possible keeping the rest of the body
still.
Return to the normal position,
then do it to the right 10 times.
The diet plays a major role in better
eyesight.
It should include green
fresh
vegetables, fruits, root vegetables,
nuts
and farm products like butter,
cheese,
eggs.
References
1.
Peppard, Harold M.: Better Sight
out Glasses. Jaico Publications,
Box No. 181, Bombay-400001
2.
Benjamin,
Harry:
Better Sight without
Glasses. Wilco Publishing House, 33,
Ropewalk Lane,
Rampart Row,
Bombay400001.
3.
Bates
William
H.:
Better Eyesight
without
Glasses. Granada Publishing
Limited (1979).
4.
Prasanna,
H. N. M.:
Perfect
Vision
without Spectacles.
Right Sight,
Post
Box No. 432, Bangalore -560004
Eye muscle exercises
1. . With head still and relaxed,
gently
allow the eyes to move slowly and regular
ly up and down six times with a second's
rest.
8
Shoulder roll.
HEALTH FOR THE MILLIONS
with
Post
FEBRUARY 1984
Chinese Children Improve Sight
The second class of
the morning
in
Peking's Chiutaowan Primary School is over
and it's time for recess.
But
the child
ren remain in their seats for a
few more
minutes to do their regular eye exercises.
Rhythmic music comes from the loudspeaker.
Closing their eyes,
the children do a
series of movements.
They begin by putt
ing their thumbs between the eyes and
pressing towards the nose.
Three and a
half minutes later, the children
run off
to the playground.
These exercises,
based on an ancient
method in traditional Chinese medicine for
preventing nearsightedness, are done
in
many of China's primary and middle schoo
ls.
Massage of points around the eyes
improves the functioning of the nerves and
blood vessels connected with the eyes and
relaxes the eye muscles.
Schools of cour
se pay attention to proper lighting: in
classrooms and correct reading and writing
postures.
Classroom seating is changed at
regular’ intervals to give each child a
chance to look at the blackboard from
various distances.
When looking at unfamiliar things-as in
schoolroom learning-the eyes strain to see
them.
It has long been known that this
produces an error of refraction.
Experi
ence has. shown that doing the eye exerci
ses
every day reduces and helps
to
eliminate this
"false nearsightedness",
improves the vision and prevents nearsigh
ted cases from getting worse.
Twel-ve-year-old Chang Huiming, for exa
mple,
used to have perfect eyesight.
But
constant reading while lying 'in bed or in
inadequate light at home caused her vision
to drop to 0.6-0.7.
Her teacher asked her
to do the eye execises every day and made
The Exercises
Exercise 1. Close eyes, put thumbs on the Jingming points, squeeze
and press toward the bridge of the nose (8 counts, 1 times).
Exercise 2. Press taiyang points with thumbs and with the side of the
second section of index fingers massage the upper and lower parts of
the sockets, first the upper part and then the lower part (4 counts). Then
massage the taiyang points with thumbs (4 counts). (Altogether 8 counts,
4 times).
Exercise 3. Massage the sibai points at the middle of the lower part
of the sockets with index fingers (8 counts, 4 times).
Exercise 4. With index and middle fingers massage the fengchi
points (8 counts, 4 times).
Exercise 5. Bring fingers together, place them on the sides of tho
nose, move up to the forehead, pass through the taiyang points on both
sides and come down (8 counts, 4 times).
Exercise 1
Things to remember:
1. Hands should be clean and fingernails
short.
2. Do not do the exercises if there are
boils or warts on the hands or face, or the
eyes arc injured or inflamed.
3. Concentrate your attention when
doing the exercises. Be sure you arc mas
saging the correct points. The movements
should be gentle and slow. Increase the
pressure until you feel the beginnings of
discomfort.
4. It Is belter to do the exercises after
reading or writing. Doing them regularly
once or twice daily will bring good result!.
HEALTH FOR THE MILLIONS
FEBRUARY 1984/
she says, "I can feel
see better."
my
eyes relax and I
Of the 27 children in one third-grade
class in Peking's Hsiaojunghsien Hutung
Primary School, before the eye exercises
were introduced,
eight were nearsighted.
Six’ months later the sight of six of these
had become normal.
Do you sec better now
Drawing by
Mino Ti
her pay attention to her sitting posture
and the proper use of her eyes.
In a few
months her sight returned to normal.
She
does the exercises every morning and again
before going to bed.
"When I do them,"
10
A class in Shanghai's Meichuan Road
Primary School No. 1 has a good record in
protecting its children's eyesight.
Since
they entered the school two years ago, the
sight of none of the children has deterio
rated and that of some has even improved.
In addition to the eye exercises, they
remind each other to sit correctly while
reading and writing, keeping their eyes
about 33 cm. away from the book and their
chest a fiSt away from the desk.
Natur
ally children won't sit inthe same
position for long.
Some keep a string
about 30 centimeters long around the neck
and tie the other end to the right thumb.
When reading or writing,
a taut string
means the. correct reading distance.
A
slack string reminds the child to correct
his posture.
Source:
China Reconstructs, Feb. 78.
HEALTH FOR THE MILLIONS
FEBRUARY 1984
Women Scientists Oppose Pill Distribution
.
"We,
the members
of the Hyderabad
branch of the Indian Women Scientists'
Association (IWSA) are seriously concerned
over the Health Ministry's recently anno
unced proposal to liberalise the distribu
tion of oral contraceptives (OC)
through
village level health workers (VHWs).
"While we fully realise the urgent need
to reach safe and effective birth control
to the rural and urban men and women, the
proposed pill programme will neither be
safe nor effective.
"At a meeting on March 9th, we discuss
ed the implications of allowing the pill
to be prescribed by the
lowest
level
paramedical staff, and we all unanimously
agreed that such a move will not only fail
to serve
the purpose of reducing the
population
growth rate,
but will
be
counter productive.
We therefore urge you
to drop the proposed pill campaign and
utilise the funds more effectively
for
augmenting the health services and popula
rising other methods of contraception such
as the barrier methods, the
intra uterine
devices,
tubectomy and vasectomy.
Also
the facilities for safe abortion need to
be improved in rural areas.
"Some of us are doctors and scientists
who know from past field experience
that
VHWs cannot be expected to ensure safe
pill distribution.. No training can by
overnight change this fact.
Also target
oriented incentives will result
in irres
ponsible pill promotion, which will even
tually backfire on the entire
family
planning programme.
Though oral pills are
effective if taken daily and safe for
women not having certain contraindication,
they cannot be prescribed for women with
past or present history of a variety of
diseases such as diabetes,
liver disor
ders,
blood pressure,
thromboembolism,
rheumatic heart disease, cancer,
depress
ion and others.
In addition, there are no
national data available on the prevalence
HEALTH FOR THE MILLIONS
FEBRUARY 1984
of these diseases in Indian women. A VHW
can never identify the women at risk nor
can one be sure that the women would
consult a doctor within 2-3 months- of
starting the OC as is envisaged.
A VHW
would not be able to ensure regular pill
intake.
If for some reason there is short
supply, he or- she may distribute the
few
pills all round, little realising the illco-o juences.
There is every possibility
that under a mistaken notion oral pills
wil be used (without success) to terminate
unwanted pregnancies.
OC taken
during
early pregnancy can be injurious to the
foetus.
The method failure rate due to
irregular OC intake is likely to be as
much as in other ‘safer methods such as the
barrier methods and much more
than with
the IUDs.
"In rural India,
prolonged lactation
provides natural contraception, with an
interpregnancy interval of 2-3 years.
OCs
known to suppress lactation
and
are
thereby
increase the chances of concep
tion.
Effects of contraceptive steroids
secreted in milk are not yet known.
Even
the
loop is not made freely available to
government and private doctors,
who are
keen to do family planning work.
The
services of VHWs can be better utilised to
motivate couples
to use these
safer,
reversible methods for spacing and encou
rage sterilisation of the husband or the
wife when the family size.-is complete.
"In the very few instances where the
women and the doctor feel the OC is the
best option, only a doctor should prescri
be
it and perhaps in those few * select
cases,
the services of the VHWs can be
taken to reach the pill packet every month
to the women and ensure that the women
come for check-up once in 3-4 months."
-Extract
from a letter dated
March 25, 1983 to Mr.
B.
Shankaranand, Union Health Minister
11
DR. P
K SETHI
Rehabilitation Technology: Need for a Cultural Change
When we look at
the vast size of our
country, our financial resources and our
achievements in the field of rehabi1itaion
since the time we gained independence,
it
is very clear that the problem of thephysically handicapped can never be solved
by merely trying to build more and more
large, well-equipped.rehabiltation centres
using sophisticated western technology.
I
have myself spent a major portion of my
lifetime trying to build such an institu
tion but my initial pride has gradually
been replaced by an increasing disillu
sionment.
It
is not only that
such
institutions are far too expensive for our
meagre resources, that they are not costeffective,
that the English
speaking,
technical jargon using professionals adopt
an authoritarian and contemptuous attitude
towards our poor patients and tend to
cater primarily to the needs of the urban
elite.
I have a more basic objection.
Under the pretext of helping the disabled
to become independent, such institutions
often make them very dependent on gadge
try,
dependent on professionaly trained
manpower, dependent on charity - by the
State or by the rich philanthropists.
Pity and charity, I have gradually learnt,
are demeaning to the self-respect of a
handicapped person.
Self-reliance - in a
broader context - is really eroded by such
institutions.
Of course there
is,
and there always
would be, a place for such institutions
especially to handle complex problems and
to provide a back-up service
for any
community based•rehabilitation programme.
What is badly needed,
however,
is to
change the culture of these places, clear
them of a lot of expensive deadwood and
get them sensitised to the needs of our
society.
I see a lot of potential
for
innovation in our existing institutions.
Without this, any community-based progra
mme would always suffer undesirable dis
tortions.
With 80% of our people staying
in remote’ villages we have to carry our
services to them and not wait for them to
come to us.
How to "reach
is the crucial question.
“Reaching the Unreached’’
Having worked with illiterate, though
highly skilled artisans, for designing and
developing artificial
limbs
and other
rehabilitation appliances, I have realised
that the common man, treated as an equal,
can quickly learn fairly -complex things if
we professionals are willing to share our
knowledge and skills with him.
Our people
are not stupid.
It is we who, by underes
timating their potential, have kept them
in ignorance.
There are numerous examples
by now, in the field of health programmes,
where extraordinary results have
been
achieved by sharing knowledge and skills
with ordinary people.
Look at what David
Werner has achieved in the remote moun
tainous regions of Mexico, Raj Arole with
his village health workers in Maharashtra,
Zafrullah Chowdhury at his. Gono Sasthya
Kendra in Bangla Desh.
We in the rehabi
litation field have much to learn
from
them.
WHO has recently spent a
lot of
effort in producing manuals
for
the
community-based rehabilitation programme.
Let us use them.
They need modification,
for sure,
but let us use the idea and
innovate.
The tendency to mechanically
use these manuals as bibles, of course,
should be resisted.
We have been, of late, trying to use an
alternative strategy
for our spastics.
Instead of treating the child in our
institution,
we are now teaching
the
family - the mother or the elder sister
the simple techniques of physiotherapy and
occupational
therapy,
using
equipment
which
they
can design at home.
The
results are far better for the simple
reason
that there is a much greater
emotional involvement and the child is
learning the whole day.
This has given me
new optimism, for here is an alternative
strategy which can enable the
families to
look after their own disabled.
HEALTH FOR THE MILLIONS
12
the unreached"
FEBRUARY 1984
Unfortunately such a people's movement
for the rehabilitation process has not yet
been encouraged and supported.
The use of
various kinds of media, especially tradi
tional
media using folk tales,
role
playing, puppetry etc. can be very effec
tive and while modern media would necessa
rily have an increasingly important role,
they would for a long time remain elitist.
Even in the field of prevention, which
the Leeds Castle Declaration so rightly
emphasises, the involvement of local peo
ple can play a very vital role.
About 90%
of surgery for polio that I perform is for
correction of deformities which are pre
ventable.
The deformities occur because
the parents do not know what to do.
If
the local rehabilitaion worker
in the
village could intervene right when polio
first attacks the child, most deformities
can be prevented by relatively simple
means and all the prolonged misery of
multiple operations avoided.
Here I would want to make a point.
When our national policy makers,
sitting
in Delhi, study the staggering figures of
the millions of people who are disabled in
our country,
I cannot blame them for
developing cold feet. "Where
are the
resources which can tackle such a massive
problem?" they
lament in anguish.
It
appears to be an unsolvable problem.
But,
shift your sight a little and look at the
size of the problems at the village level.
The number cf disabled per village is not
large.
It immediately becomes a solvable
problem. The need,
therefore,
for the
requisite knowledge by the people themsel
ves is absolutely crucial to this whole
issue.
is a
field where we should plunge
in
straightaway and resolve that all
the
bottlenecks - from production of polio
vaccine in our own country to the mainte
nance of an effective cold-chain,
to a
delivery programme which can reach the
remotest
village - shall be removed.
When, or. an average, I myself find six new
cases of polio registered every day at our
centre and many of whom had taken the
stipulated three doses of the vaccine,
I
have reason to be angry-angry at the
casual manner in which we have reconciled
ourselves to this problem.
Learning From Leprosy Workers
Leprosy is another scourge which ought to
be wiped off the face of our country.
iere
I must pay tribute to some really
outstanding work being done by several
groups of highly dedicated people who, at
great personal sacrifice, have selected to
remain in remote areas and work amongst
these people.
We can learn a lot
from
them-about the training of field workers,
about health education, about communica
tion technology and about rehabilitation.
And yet,
it is a curious fact that the
bulk of the medical network in our country
has remained out of contact with this
extraordinary group of dedicated workers.
Why these two streams have been running
parallel as it were and are not coming to
a confluence baffles me.
The polio story
I would not dwell on the well known
role of an effective polio vaccination
programme. This should be a fairly strai
ght forward proposition.
We should have
solved this problem years ago and yet we
have been dragging our feet on this.
'Why
should this be so?',
I ask.
We have
successfully
eradicated
smallpox.
How
were we able to achieve this?
Some very unpalatable facts would sur
face if an indepth study of the polio
immunisation story in India is made.
Here
HFALTH FOR THE MILLIONS
FEBRUARY 1984
13
Dr. P. K. Sethi holds up a Jaipur limb for inspection by Mr. Ham Chander, who
teaches craftsmen at the community based workshop.
(Photo: World Health, Dec. 1981.)
Camps - Conversion of the Routine into Celebration
Of late, the "camp" approach has gained
some popularity in the field of rehabili
tation. Watching the success of eye camps
and the family planning camps,
it was
inevitable that the International
Year of
the Disabled should have prompted some
organisations to use this delivery system
in the field of rehabilitation.
I have
many reservations about using camps as an
alternative to community-based rehabili
tation.
Camps can succeed where
the
problem is relatively simple to organise some standardised procedures are used and
a prolonged after care is not required.
For a much more complex problem like that
of the physically handicapped,
however,
such an approach seems to me
to be
unsuitable. A camp converts a routine into
a celebration. There is an atmosphere of
festivity. The organisers return and talk
in arithmetical terms of the large numbers
14
which attended the camp-as if
this is an
indicator of success. The local political
leaders exploit the occasion to boost up
their own image. But, after the tents are
unpitched, nobody bothers about the poor
handicapped.
They
go back-dejected-to
where they were and their earlier enthusi
asm which was whipped by the precamp
propaganda, gives way to gloom and despair
and they wait patiently for some unpredic
table future occasion when hordes
of
professionals may again come their way.
Usedin the manner in which they are self
reliance is not generated by such camps.
However,
having participated
in
some
camps, I see other kinds of possibilities.
A
camp could be organised for local
artisans, for instance, where they could
be shown how to fabricate simple, low cost
aids for the disabled. Or the village
health workers could be taught simple
methods of prevention of deformities in
polio. In short, the camp as a technique
for sharing of skills and knowledge with
the people may be a useful modality.
'HEALTH FOR THE MILLIONS
FEBRUARY 1984
Appropriate technology
Learning to communicate
The only way,
I repeat,
to meet the
problems of our disabled lies in the use
of appropriate technology and sharing of
knowledge with the people so that ultima
tely it is the community itself which
becomes equipped to look after
its own
handicapped. This implies that our policy
makers, our bureaucrats and above all our
health profession should realise
that
sophisticated technology,
imported from
the advanced countries is not only beyond
our meagre financial resources,
but more
important, it would widen the gap between
the top 10% of our elite and the bottom
90% of our poverty-ridden mases.
What we
need is a technology which caters to the
needs of the neediest (i.e.
the rural and
the urban poor),
which generates selfreliance (and not over-dependence on ex
ternal resources) and which is
in harmony
with our environment - then only can it be
sustained. A technology which fulfils the
foregoing criteria can be considered an
"appropriate technology"
(after Amulya
Reddy).
The stranglehold on professional know
ledge by vested interestes must be broken.
For knowledge to be shared we have to
learn to communicate with our people. Our
expensive education has removed us so far
away from the mainstream of our people
that we do not understand their language
and idiom and beliefs. How this great
divide between available professional kno
wledge and the recipients of its benefits
can be bridged is another task to which I
would attach the greatest importance.
Appropriate Technology is not primitive
technology, though there is nothing wrong
in utilising traditional
technology as
long as it serves our need.
I
find that
people are not even clear about
the
distinction between science and techno
logy. There can be a high science content
in a
low level technology and merely
because a technology is very expensive it
does not necessarily endow it with a high
science content. In fact, it often requi
res a high science input to make techno
logy simple; any fool can make a complica
ted thing. Appropriate technology,
in the
sense I am referring to, is a kind of a
dynamic mix, where traditional technology
is updated by new science inputs to serve
our everchanging needs. I would cite
the
Jaipur experiment of
designing
limbs,
using
many traditional materials
and
skills,
but designing the product and
testing it in a scientifc way,
as an
example of appropriate technology.
Such
experiments in the field of physiotherapy,
occupational therapy, communication stra
tegy, awareness programmes, teaching aids
using the most appropriate means to suit
our requirements should be encouraged and
supported by all concerned.
HEALTH FOR THE MILLIONS
FEBRUARY 1984
The Great Leap or a careful step forward?
From what has been stated so for, it
would seem to be obvious that we shall
have do deviate very considerably from the
existing way of thinking.
For utlising
such alternate strategies, one inevitably
looks around to find examples of work
already being carried out
by someone
somewhere. Such small-scale projects often
display success stories and it is very
tempting,
for our national planners,
to
use these as models and try suddenly to
replicate a project into a large progra
mme.
I would urge you to make
this
distinction between a small-scale pilot
project and a large-scale national progra
mme.
A retrospective review
of
such
attempts in various fields of development,
in education,
in agriculture,
in dairy
Even climbing trees is possible for an
amputee fitted with the "Jaipur limb".
(Photo: World Health, Dec 2981)
15
From "Low Cost Therapeutic Aids" by AHRTAG
development,
in health, shows a unitorm
feature. What was a highly successful
project
in a particular context
gets
distorted when converted into a national
programme.
It is necessary to do some
serious
introspection as to why this occurs with
such monotonous regularity.
A careful study of this replication
process would reveal that the small-scale
projects have many special features.
They
are usually taken up as a response to a
felt need,
their size does not pose a
threat to existing social, economic, poli
tical or professional interests, they have
a build-in flexibility,their communication
process is informal and personalised,
the
sources used are often out of proportion
to the activities,
with external donor
agencies or even the government pumping in
more money than will ever be available for
a large-scale programme.
Commitment of
high order is present because of a noble
cause or a charismatic leader.
There is a
value system which always characterises
most successful projects.
Replication or “Extensibility”
When replicated
on
a
large scale
national programme, this value system is
usually lost sight of. As a consequence,
those aspects of a project which are easy
to duplicate and involve the transfer of
physical
inputs: medicines,
buffaloes,
artificial limbs and the like, are likely
to be pushed in order to demonstrate
quantitative achievements. While the pro
ject often stresses outcome and software,
the movement to a programme might shift
the focus to inputs and hardware. Thus the
project might have kept the objective of a
rise in income or reduction of mortality
well
in front;
the programme may speak
exclusively of bank credit or fertilizer
distributed or number of patients in the
clinic and quantity of medicine given. If
we want,
in community based rehabilita
tion, to generate self-reliance,
build up
people’s capabilities, we should avoid the
term "replication", a term which has been
borrowed from the engineering profession
and which suggests a mechanistic process
of social engineering. I like Ravi Matthai's expression-"extensibility"-exempli
fying a
"people helping people" value
system by which each who benefits from the
service extends his knowledge and skill to
others. What we need to do is to identify,
incorporate and strengthen such extensible
processes in development.
We may need to ponder over some of
these issues. Because we have demonstrated
the necessary political will,
and we have
an operational bureaucratic network with
all kinds of community programmes going
on,
primary health centres,
integrated
community development scheme,
anganwadi
workers, community health volunteers etc.,
let us not assume that a little additional
input
for rehabilitation would
easily
solve our problem. It would be useful to
design,
as a first step,
some
pilot
programmes with a possibility of "extensi
bility" built into them and carefully
monitor and evalute them before turning to
a national programme.
The problems facing us in summary are :
What should be the role of large rehabili
tation centres, how to design a people’s
movement in the field of rehabilitation,
how to evolve training programmes so that
not only can we effect a transfer of
knowledge and skills to the ordinary man
but also promote a transfer of value
systems,
how to evolve a search strategy
for successful projects within our coun-
cont'd on Pg 31
16
HEALTH FOR THE MILLIONS
FEBRUARY 1984
MARILEE
KARL
A Male-dominated Movement
In addition to being a predominantly
western-dominated movement,
AT is also
very
much
male-dominated
and
maleoriented. The' male researchers and policy
makers from industrialised countries bring
with them all the prejudices about women
and technology found in their societies.
Most of the material
on
appropriate
technology hardly deals with women at all,
still less considers the impact of this on
women's lives. Just as the social,
econo
mic and political reality is ignored on
the pretext that technology is
"neutral,"
so are the partriarchal structures and
sexist attitudes.
Most technological advances and impro
vements, whether considered to be "advan
ced" or "appropriate," are
introduced
almost exculsively to men. In the field of
agriculture, men are the recipients of
training and have access to machines,
tractors, harvesters, improved ploughs and
irrigation systems in spite of the fact
that women are the major food producers.
In water supply men
are
trained to
construct and use pumps,
wells, filtering
systems,
pipes and faucets, in spite of
the fact that women have traditionally
been in charge of supplying water needs.
Planners then express surprise when men
and repair
are reluctant to maintain
systems. Women lose power when charge over
the water supply is transferred to men.
Does
lightening women's load in fetching
water necessarily entail stripping them of
control and status?
While some planners now recognise the
importance of women's role
in
water
supply, they still seem to have difficulty
in breaking down prejudices about women
and technology. In the materials prepared
□y the United Nations Development Progranme
for the International Drinking Water
Supply and Sanitation Decade 1981-1990,
nearly all the illustrations of traditio
nal means of water supply show women
carrying
water.
The material
clearly
points out that "women and childern bear
HEALTH FOR THE MILLIONS
FEBRUARY 1984
the biggest burden" in fetching water for
household needs.
It includes
a
good
article about how
village women's groups
in Kenya have taken steps to improve their
own water supply. Yet the great majority
of illustrations of improved water systems
show men building and running them. In an
article entitled "Maintaining the System:
Barefoot Engineers," the engineers shown
are men and are referred to throughout as
"he," e.g., "he is given two days train
ing" or "his job is to ensure.
"To avoid
sex-role stereotyping, non-sexist language
and stick figures could have been used.
For role reversal and consciousness rais
ing, images of women in traditionally male
roles could have been portrayed.
Areas in which men have no stake or
desire to take over (routine household
tasks of cleaning, cooking and childcare),
the experts have introduced singularly
inappropriate technologies,
demonstrating
their complete lack of understanding and
experience of women's lives and work. In
addition to designing solar stoves
for
women who cook before dawn and after dusk,
they have
invented maize sellers which
take longer to do the job than the women
themselves
and introduced pedal-driven
grinding mills in areas where women are
forbidden to sit astride.
Small technologies, if they were really
appropriate could do much
to relieve
overworked women. In her study on Approp
riate Technology for African Women, Mari
lyn Carr points out several areas where
appropriate technology could help women.
Male planners tend to
overlook these
because they do not even consider them
work
or because they undervalue
the
enormous contributions women make
to the
household,
community and nation.
These
tasks include:
fetching fuel and water,
food production for local consumption,
including planting, weeding,
harvesting,
hauling, storing and processing of foods,
cooking and housework. In many places,
women have to do this work under extremely
17
arduous conditions, in addition to bearing
and raising children and often working in
cash cropping or industry as well.
They
may
have to walk as much as 10 to 20
kilometers a day to haul fuel and water on
their heads and backs. Women's work is so
time-consuming and there is so much of it,
that it leaves women without sufficient
time to rest and sleep. "Free time"
for
relaxation, socialisation or other activi
ties is unknown. This takes its toll on
women’s health and that of their childern.
Questions about the division of labour
between men and women and about sexist
attitudes towards this division
which
automatically assign lower value and sta
tus to the jobs women do are seldom raised
or addressed.
Reinforcing stereotypes or liberating women?
In the developed market and centrally
planned economies,
women have
had an
increasing number of labour-saving devices
to help them in their household tasks of
cleaning, preparing food and cooking. They
are also wage earners outside the home,
yet all these women continue to bear the
double shift of all child rearing and
household
activities.
Men occasionally
help out but women bear the responsi
bility. From their experience, it is clear
that the introduction of labour-saving
devices and employment in wage labour by
themselves
do not address the
basic
questions of women's oppression.
While women's lives are very different
in different parts of the world, and while
political,
economic and social systems
vary, sexism is universal, and is a factor
that links women and gives them a common
battle to fight.
In industrialised countries, the appro
priate technology movement demonstrates
its prejudices about women's capabilities
and roles,
neglects women's needs and
desires,
and excludes women
from power
decision making and control.
In
the
booklet Something old,
Something
New,
Something Borrowed, Something Due,
Women
and Appropriate Technology,
Judy Smith
writes:
Few women are
involved in appropriate
technology for the same reasons that so
18
Foot - operated grain huller
("Simple Technologies for Rural Women in
Bangladesh", Elizabeth O' Kelly, UNICEF)
few women are
involved in traditional
science and technology. (Women make up 6
per cent of all U.S.
scientists with
college degrees in natural sciences and
engineering.) Science and technology are
considered men's work in this culture.
Women are not supposed to understand or
even be interested in these areas...
The AT movement appears to be a sex
role stereotype movement- relying on male
expertise. Men do men's work and women do
women's work. Men do the construction and
invention.
Women do clerical tasks and
make the coffee.
Most of the attention on appropriate
technology focuses on the traditionally
male technologies of energy and transpor
tation, rather than on traditional
female
technologies of food preservation
and
cloth production. Although women have a
long history of involvement with survival
technologies, their contributions are over
looked
in a society- which values external
success-linked technologies of engineering
and science...
Who's in the movement anyway? Who are
the experts? The founding fathers? Who's
deciding what is appropriate? Who talks at
meetings,
gets the grants and does the
HEALTH FOR THE MILLIONS
FEBRUARY 1984
inventing? Who's on the tech
who's on clerical?...
staff
and
Visit an AT project. Who works on the
solar collector? Who cans food in the
kitchen? Which technology is pointed out
with
pride?
How much time is spent
encouraging women to do men's work and
vice-versa?
The
focus of AT
in industrialised
countries is on simpler,
less energyintensive technologies.
What does this
mean for women? It usually means fewer
labour saving devices for household tasks,
less use of prepared and processed
foods
and synthetic fibers. Women are asked to
give up their gas, electric and microwave
ovens for wood stoves, to bake their own
bread and preserve their own food instead
of buying it from the shops.
They are
urged to buy or, even better, make clothes
of natural
fibers rather than synthetic
ones,
even though natural fibers require
considerably more care, especially iron
ing. They are asked to save energy by
giving up the use of cars,
which have
meant freedom of movement and from con
finement to the home.
It is not surprising that few women in
industrialised countries are willing tc
give up labour-saving devices and produ
cts,
given that the main
burden
of
*
household work and child care falls on
them,
and that,
for most of them wage
employment is a necessity not an option.
As one of the reasons for introducing
appropriate technology to
third world
women, development planners argue that it
will " alleviate women's burdens" in the
household and enable them to participate
in wage labour or "income generating"
activities.
There is an important lesson
to be learned, however, from the lives and
experiences of women in developed count
ries.
Labour-saving devices alone cannot
lighten women’s work load.
They
only
rearrange it somewhat,’ enabling women to
take on waged work in addition to their
unpaid work in the household.
Moreover, women's access to wage labour
means more and more things must be bought.
More money must be earned to pay for the
things which women can no longer provide
for themselves or which can no longer be
provided locally, leading to less selfHEALTH FOR THE MILLIONS
FEBRUARY 1984
sufficiency. As Elise Boulding says:
Packaged appropriate technologies con
taining all the recommended small
incre
mental improvements of food storage faci
lities, wheel-barrows, food dryers, flour
mills and high-protein multivitamin food
supplements will be sold to women, usually
by multinational corporations.
Whatever
cash surpluses their wage increases might
have
generated will thus be
quickly
absorbed in the national or even the world
economy.
What would appropriate technology be like if........
What would appropriate technology for
women be like if women were setting the
priorities and making the decisions? A
woman in a highly industrialised country
writes:
We don't even know what technology
could possibly do for women, because women
have no control over it...’ We don't know
how different that would be but we do know
what happens to women when they don't
control technology. A perfect example is
what has happened with birth
control
technology... When birth control techno
logy first appeared, it had very negative
effects for women. The kind of technology
that was made available was effective, but
it did a lot of damage to women's bodies,
and we have evidence that there was no
adequate risk assessment of that damage.
This technology was not controlled by
women,
women did not do the research,
women did not do the marketing.
What kind
of birth control would be available to us
now if women were the ones making the
decisions...
What would appropriate technology for
women be like if were not simply a matter
of providing labour-saving devices;
if it
were placed in the context of the ques
tions of the division of labour between
men and women,
in the context of the
social and patriarchal structures,
if it
included access to knowledge of technology
What women are doing
During the Workshop on Technical Coope
ration Among Developing Countries
(TCDC)
and Women, held by the Asian and Pacific
Centre for Women and Development in April
19
1978, participants analysed the implica
tions of new technologies and of TCDC on
women.
According to Devaki Jain of the
Institute ot Social Studies, New Delhi,
they concluded that "women's need were
different from men’s even if they were
both poor, and even if they belonged to
the same ideology; that this had not been
taken notice of in the design of institu
tions or in development strategies." The
participants affirmed the importance of
TCDC, but also the importance of changes
that would make this beneficial,
not
detrimental,
to women. Among the needs
they identified are: to document,
analyse
and disseminate experiences in addition to
providing directories of experts, institu
tions and training facilities;
to create
and support existing pressure groups for
women's concerns and interests.
Asian and Pacific
women
also met
together in November 1980 at the second
Appropriate Technology Workshop for YWCAs
of the region. Ruth Lechte reports that
the participants had the opportunity not
only to learn about practical matters and
equipment such as solar dryers and water
pumps,
but to discuss the whole idea of
appropriate technology and to try to see
it in a political context.
The partici
pants gave importance to consciousness
raising and awareness building on man>
levels and to overcoming stereotypes of
what is women's work and what is men's.
Women from both third world and indus
trialised countries met together in June
1982 to share experiences and information
about their work in the area of health and
medical
technologies. Organised by
ISIS
and the Women's Health Clinic in Geneva,
this third International Women and Health
Meeting brought together women working in
the self-help movement,
local
women's
clinics,
community health projects and
research. What is unique about
these
20 .
meetings is that the participants do not
come to hear panels of experts but to
exchange information and experiences about
their own work and findings, in areas such
as contraception, abortion,
child birth,
and infections, and to discuss the poli
tics of established medicine and how it
affects women. The meetings are opportuni
ties to analyse, reflect, share knowledge
of new and traditional health technologies
and to begin to devise health care systems
and technologies more responsive to the
need of all people.
Perhaps we should speak not only about
TCDC (Technical Cooperation Among Develo
ping Countries) but TCW (Technical Coope
ration
Among Women):
a new kind
of
information sharing and cooperation among
women from different parts of the world
who are developing and using technologies
which help them gain more control over
their lives and their communities. This is
a very different thing from the "tradi
tional technical cooperation for women"
described by the African Training and
Research Centre for Women which "meant
assistance in patron-client fashion from
women of industrialised countries
and
elite African Women's Organisations that
had internalised their ideals,
giving
instruction in embroidering pillows,
ba
king scones,
urging the acquisition of
nore electrical appliances." A new kind of
technical cooperation among women is not a
one-way flow of information from North to
South: it is South to South and South to
North as well. It builds on the great
store of knowledge and expertise women
already have and which, in many cases, is
in danger of being lost, and it opens the
way for new knowledge and new technologies
to develop, based on women's real needs.
Source: Appropriate technology by Marilee
Karl in Women in Development.
HEALTH FOR THE MILLIONS
FEBRUARY 1984
S
SRINIVASAN
Portrait of a Doctor as a Crusader
Dr. Gangwal and the Sulabh Nidan Kendra.
There are atleast three problems with
laboratory tests,
as far as the common
person is concerned:
(1) They appear to cost too much, (2)
They may not be reliable.
(3)
Doctors
insist on them whether one really needs
them or not.
Is there an answer to these problems ?
The answer is yes, atleast in one case
known to us-the Sulabh Nidan Kendra.
The Sulabh Nidan Kendra is a diagnostic
clinic on the Hospital Road at Jaipur,
where the minimum cost of most of the
common lab tests is Re. 1/- each;
the
tests are reliable; and because of the
person
who runs it the doctors
who
prescribe the tests are more circumspect.
Moving spirit
The Kendra,
an
undertaking of the
Barjatya Family Charitable Trust,
is con
ducted under the eagle eye of Dr.
Tara
Chand Gangwal,
the moving spirit behind
the diagnostic clinic.
Dr. Gangawal,
born 1903, is on his own
admission a 'rabid disciplinarian'. He has
held many varied positions in his cheque
red career-government physician in Jai
pur's SMS Medical College Hospital and its
predecessor the Mayo Hospital,
medical
officer of the Central Jail and Mental
Hospital of the erstwhile princely State
of Jaipur, personal physician
to the
Maharajah of Jaipur, railway medical offi
cer, and most importantly he has worked as
physician and surgeon in general medicine,
general surgery, ENT, Eye,
Ob/Gynae and
paediatrics.
But Dr. Gangwal could not
last long in many of his positions for
he is gifted with a sense of integrity,
service and a no-nonsense forthrightness.
These characteristics do not go (and did
not in colonial days)
with the softpedalling and the blurred vision required
HEALTH FOR THE MILLIONS
FEBRUARY 1984
in medical and government bureaucracies
for personal survival. Dr.
Gangawal, as a
result, started his own private clinic and
nursing home in 1949, where he practised
what is nowadays called low cost and
relevant health care.
Later he worked,
purely honararily, for a charitable diag
nostic clinic run by an industrialist,
Durlabhji.
Soon this charitable clinic
became a posh hospital, thanks to the
ambitions of Durlabhji, and with it the
low cost diagnostic clinic and x-ray unit
that Dr. Gangwal was in charge of
,
was
also forced to hike its charges.
These
charges suited only the richer and more
affluent sections, and Dr. Gangwal quit in
protest admixed with disgust.
It was about this time that help came
to
Dr.
Gangwal
in the
form of
his
childhood friend
(and now a well-known
film producer of Bombay), Tarachand Barja
tya,
and his son K.K.
Barjatya.
They
helped Dr. Gangwal to set up an indepen
dent low cost diagnostic clinic.
The
outcome was the Sulabh Nidan kendra.
Low cost tests
The Kendra, now 9 years old, is housed
partly in a converted garage plus a couple
of attached rooms of a residential quar
ter. The garage and the quarters belong to
Dr. Gangwal's grandson. The initial
inve
stment for the lab was Rs. 70,000/(see
box for a list of equipment
in the
diagnostic clinjiic) •
The expenses of the Kendra on the
average square out with the collections on
the
tests.
The staff pattern is
as
adequate as it is economical.
There are
two lab technicians who have been with the
Kendra for long. In addition there is one
non-technical assistant who helps keep the
premises clean and collects and labels the
urine and stool specimens. There are also
four to five trainees at any given time.
The senior
lab technician is paid Rs.
21
1200/- pex. montn.
Dr. Gangwal. and his
friend. Dr. S Mull, are honorary. Dr. Mull
xs a meteorologist, who retired from the
government as a deputy director-general.
The people who come for tests stand .or sit
in front of Dr.
Gangwal’s
table
in
respectful silence. Dr. Gangwal and his
friend.
Dr.
Mull,
sit at the
table,
collect each patient's request at the
beginning,
announce the patient’s name
when his/her turn comes,
and within a
minute the bill is made by Dr.
Gangwal
himself the money is paid and collected
by his friend, and the person goes
for
his/her test to be carried
out.
The
average time spent by patients to regis
ter,
to pay the charges for their tests,
give their specimens and go away is about
15-20 minutes.
The average working hours for the staff
of the Kendra are five and a half hours on
weekdays, every week day of the year, and
two hours on Sundays and other gazetted
holidays.
The Sulabh Kendra is open 8.309.30 A.M. on weekdays in winter and 8.00
to 9.00 A.M.
in Summer, for people to
register and give in their specimens.
They collect their lab reports usually the
same evening, when the Kendra is open for
90 minutes, for instance between 4.00-5.30
P.M. in winter. Only some special tests
like culture take longer.
Training and development
Another interesting
feature of the
Kendra is the four or five girls and boys
who are always hovering around with the
Equipment Requirements of the Diagnostic Clinic
Major items
Microscope with •accessorieslow power,
high power and oil
immersion; Mechanical stage-Condensor;
Photoelectric calorime
ter;
Electric centrifuge with
four or more tubes; Gas cylinder
with ring heater-2 cylinders;
Bunsen Burner;
Autoclave;
Hot
air oven; Refrigerator; Incuba
tor;
Distilling still;
T.
S.
Meter for protein estimation;
Water bath with rings;
Analyti
cal balance;
Physical balance;
Stop watch; Ph meter;
ECG mac
hine .
Glassware
Syringes 10 cc,
5 cc,
2 cc
and 20 cc; Test tubes 6 cc,
4
cc;
Centrifuge tubes; Folin Wu
tubes;
Beakers 500 cc, 250 cc,
150 cc, 100 cc; Pipettes 10 cc 5
cc,
2 cc, 1 cc; Micro-pipettes
0.2
cc;
Pipettes with mark
standard 10 cc
(with bulb), 2
cc;
Funnels glass 3" diameter,
5" diameter,6" diameter Flasks-
22
conical; Measure cylinder 250
cc, 1000 cc, 100 cc; Watch glass
3" and 1" diameter; Volumetric
flask; Burettes; Reagents glass
bottles-stoppered ; R.B.C. pippetes;
Haemoglobin pippetes; Sy
ringe needles assorted; Wintrobe
tubes and stand; Westergren tu
bes
and stand;
Coplin jars;
Staining dishes;
spirit lamp;
petri dishes; Widal tubes; Thermome ter; Durhams tubes; L.F.T.
Indicator; B.T. tubes.
Miscellaneous articles
Electric heater plate type;
Test-tube stand; Ryle's tubes,
Porcelain dish; Burette stand;
Pippete stand; Inoculating loop;
Rubber teats;
Nichrome
wire;
Forceps; Scissors; Glass-marking
Pencils;
Hand lens;
Wire bas
kets;
Glass cutting file; Pun
ching machine; Aprons; Whatman's
filter
papers;
Coarse
filter
paper.
(Note:
In addition the Kendra
has
differing
quantities of
about 100 different chemicals.)
HEALTH FOR THE MILLIONS
FEBRUARY 1984
lab technician, sometimes taking a blood
sample,
sometimes watching and learning.
These are the trainees, who come,
not
surprisingly, from even as far as Kerala.
Some of them stay for about •6 months to
one year, get trained and go for well paid
jobs as lab technicians elsewhere.
In a
few cases, they have stayed 'for two years
too. Dr. Gangwal said he was prepared to
accept trainees, "provided they have a
science back-ground in school
with a
capacity to learn." These trainees have
to make their own lodging arrangements.
In some cases,
they are given a stipend
too by the Kendra for the help rendered.
These trainees are accepted easily else
where because of the reputation that Dr.
Gangwal and the Kendra enjoy.
Non-exploitative
Most notable are the costs of the lab
tests at the Kendra. They are unbelieva
bly non-exploitative
in nature.
Routine
urine test (including microscopic)
costs
Rs. 1/- at the Kendra,
whereas elsewhere
in Jaipur it is Rs. 5/- at least.
TLC and
DLC at the Kendra is Rs. 1/- but at other
private clinics it is Rs. 10/-.
It is
interesting to 'tudy the costs of other
tests and related statistics of the Kendra
(see box).
The situation in other places
in India-both rural and urban-would ref
A Self-sufficient Lab
A glance at the statistics given below clearly show that in the Sulabh Nidan
Kendra the costs are totally met by self-generating funds.
1980
1981
1982
1983
(till Oct.)
33,503
-
28,741
8,570
23,353
829
20,057
776
52,535
4,199
45,595
4,300
41,478
11,466
40,973
NA
35,530
3,616
2,209
908
46
169
165
90
-
28,492
2,587
1,774
1,206
23
170
193
9
11
37,694
3,096
94
1,638
612
158
901
-
16,002
15,435
9,257
Statistics
No. of tests
No. of spl. tests
Income
Tctal collections
Bank interest
Rs.
Rs.
Expenditure
1)
2)
3)
4)
5)
6)
7)
8)
9)
Salaries & Allowances
Chemicals & glassware
Printing & Stationery
Electricity & Water
Repairs & Renewals
Clinic Expenses
Gas Charges
Books & Periodicals
Miscellaneous
II
II
II
II
II
II
II
u
;
it
Surplus
Excess of Income over Expenditure
HEALTH FOR THE MILLIONS
FEBRUARY 1984’
NA
23
lect similar exhorbitant charges, normally
explained away as overheads.
Even in many
voluntary hospitals, labs and even x-ray
tests and pharmacy are seen as income
producing departments or ’revenue cent
res ’ .
ties and measuring instruments available
in their countries.
Also,
the authors of
these textbooks,
coming from well-to-do
countries, have no concept of lab tests
for the very poor pockets of people in
India.
Fortunate are those in charge of such
labs in the country, for the many educated
let alone the poor illiterate-know
little of how they get milked of their
hard earned money when they fall sick by
this dubious network of doctors,
patholo
gists,
radiologists and drug retailers.
For such knowledge would probably provoke
the
ire
of the helpless into doing
something radical.
It is with this motivation,
that Dr.
Gangwal was also instrumental in starting
a low cost drug supply store,
in the SMS
hospital compound at Jaipur run on a noprofit-no-loss basis.
This drug
store
operates on bulk purchase and charges only
a minimum markup to cover
costs
of
operation.
"Our drugs are much cheaper,
atleast by 10%, than the ones sold by
retail shops next door, and our drugs too
are from the so-called standard compa
nies." But unfortunately these companies
treat this drug store like any other
commercial concern. They make no conces
sions
in
their drug supply charges,
inspite of the drug store being well-known
for its non-profit, service orientation.
Too many tests are ordered by most
doctors for a number of reasons:
due to
ignorance or lack of confidence
in their
diagnostic ability, due to compulsions of
retaining clients who in many cases are
impressed with the doctor who orders more
tests,
and
due to a faulty medical
education,
unnecessary and sophisticated
tests, tonics, x-rays and medicines.
Ano
ther most serious tendency is the ’rampant
commission slur', as Dr. Gangwal terms it.
This refers to the practice
of
the
pathology -lab or the x-ray clinic giving a
commission proportionate to the number of
tests or x-ray investigations ordered.
The commission’ is paid by the lab to the
doctor who orders it-the money of course
coming from the sick person,
the
’pat
ient ’ .
Not surprisingly,
the Kendra's facili
ties are not utilised to the extent they
deserve to be.
For Dr. Gangwal refuses to
be a party to the commission slur;
and
there are few doctors in Jaipur who would
want to recommend their patients to a man
who is sb unbendingly straight.
“A great
Dr. Gangwal also points out that the
Kendra makes its own reagents.
"We also
found that we can cut down costs by using
proportionately less reagents", points Dr.
Gangwal,
"Why can't I use
2 1/2 cc of
Benedict's solution, even if the textbooks
say
5
cc? We get the same results
anyway." The textbooks are generally for
eign,
and they go by the minimum quanti
"It
is
a
great
pity,"
Dr.
Gangwal
Low Cost Indeed!
The data below gives the charges of
some of the common tests and some special
tests at the Sulabh Nidan Kendra. A glance
at them reveals clearly that the charges
are appreciably lower than comparative
clinics.
Tests costing Re 1/each: Urine, stool, TLC
& DLC, TRBC & Hb, ESR,
BT & ET, Sputum,
Platelets,
Absolute Eosinophil
Count,
Semen, Malarial parasite,
PCV, Concentric
methods, Smears.
Tests costing Rs. 5/ each:
Blood sugar,
Widal, KT, Blood Urea,
Serum Cholesterol,
Serum Bilrubin,
ECG,
VDRL,
S.
Uric,
Urinary, S. Aik phos, S. Acide phos, SGOT,
Rh factor,
S.
Proteins,
S.
Calcium,
Urinary Calcium,
S. Phosphorus,
Urinary
Phosphorus,
S. Amyibase, Prothrombintine,
BUN, Lipids, Thymol, Turbidity.
costing Rs.
10/- each:
Culture,
Fractional Test Meal,
Pregnancy, Blood
group, SGPT.
Tests
Tests costing Rs.
(Thymol
Turbidity
Bilrubin.)
15/- cacti:
Liver F
S.
ALk
phos,
S.
cont'd on Pg 31
24
HEALTH FOR THE MILLIONS
FEBRUARY 1984
DUNU ROY
From Technological Practice to Technological Theory
The experience I am about to relate
took place in the space of the last six
years in two locations in the district of
Shahdol in Madhya Pradesh. One location
was a farm devoted to vegetable farming
and the other was a small repair workshop
dealing principally in diesel pump-sets.
At both locations my colleagues and I were
experimenting with the various possibili
ties in training village youth in such a
manner that they proceed from an apprecia
tion of thumb-rule methods to an underst
anding of the underlying scientific prin
ciples and,
if possible,
the
social
dimensions of any technical work.
Our
experiments have been of the nature of
responding in the best way we knew to
situations as they emerged.
In addition,
the number of '’trainees” (including our
selves) who went through this process was
considerably smaller than we had initially
hoped.
Hence, it would be presumptious of
me to offer any generalisations or evalua
tions.
However,
there are some insights
which my colleagues and I would like to
share with you.
We are conscious that we
are
in the danger of offering half-baked
prescriptions at this stage of our work.
Hopefully,
this presentation itself will
open us up to a detailed criticism and
correction.
Perhaps it is
necessary to know
something about Shahdol district before
presenting the essentials of our experi
mentation. The districtlies
in the eas
tern part of Madhya Pradesh and is neatly
bisected into two almost equal halves by
the river Sone as it descends from the
Maikal ranges and courses north-westwards
before making its sharp turn to the north
east on its way to join the Ganges near
Patna.
The area is undulating and provi
des the catchment which provides the Sone
with much of its water.
However, agricul
ture is primitive and single-crop with
almost total dependence
on the rains.
There is a fair degree of industrialisa
tion in the district with a giant paper
factory, a thermal power station,
several
HEALTH FOR THE MILLIONS
FEBRUARY 1984
coal and bauxite mines, and the railways.
Tremendous acceleration has taken place
since 1950 in the exploitation of forests
for timber and small
forest
produce.
Nevertheless all this commercial and indu
strial development has not benefitted the
local people and poverty is widespread.
Consequently,
there is massive un-and
under-employment in the agricultural sec
tor and a drift towards the urban
indus
trial sector for regular or marginal jobs,
which are however,
not available.
Some
indicators of the state of affairs
irrigation reaches out to about
2% of the
agricultural
land; minor
forest produce
alone yields an annual revenue of about
Rs. 3.5 crores; literacy is of the order
of 15%; normal agricultural wages are Rs.
4 for men' and Rs. 3 for women;
of the
total population approximately 30% is the
working population while over 5% have
enrolled in the employment exchanges for
jobs.
It is in such a context that we
tried to give
technical
training
and
relate it to growing levels of conceptual
understanding.
It is also important to note who this "we”
was,
as
it determined to a great extent
the training locations that.we chose and
developed. In this "we” there were essen
tially engineers-mechanical,
electrical,
and
chemical-a teacher-cum-writer/poet)
and a commercial artist :
all inspired in
some way or the other to contributing
their mite towards a change in society.
Some of us had some practical experience :
in
teaching,
running a small
press,
advertising, on the shop-floor of a large,
modern industry, and horticulture of the
backyard variety. It was with such back
grounds that we chose the roles that we
thought were best suited for us within the
socio-economic structure of Shahdol.
This
had to be so since one of the
facets of
our experiment was that we should be able
to earn our own living in the area.
I have already mentioned the
two
locations we finally chose.
The first was
25
a five-acre plot of land which we nad to
first clear of scrub, then develop into a
vegetable farm with a certain amount of
scrub, then develop into a vegetable farm
with a
certain
amount
of
contour
levelling and adequate quantities of manu
re and fertiliser.
Vegetable farming also
required adequate protection from animals
and pests,
hence a good knowledge of
crops, crop rotation patterns,
insectici
des and their dosing schedules, agricultu
ral equipment,
and farm planning.
In
addition a certain amount of information
on bank schemes, marketing practices,
and
extension facilities available was neces
sary.
In the inital stages none of our
team had this knowledge, We learnt on the
job,
consulting the handbooks and the
literature as and when necessary.
The second location was
a mechanical
repair workshop which originally began in
a small, hired, ten-by ten room situated
next to the local bus stand in a market
town. Later we shifted to a larger complex
we built on a plot of land outside the
town.
We began with a set of hand-tools
but gradually grew into a welding machine,
a pedestal drill, a lathe,
and a compre
ssor. From the beginning the custom mainly
consisted of diesel pump-sets,
newly acq
uired for irrigating the wheat crop,
but
later on it diversified into electrical
motors and switchgear, bullock-cart axles,
truck and tractor body work, cycle bottoms
and pedals and a host of other agricul
tural, office and domestic appliances. All
this required a good knowledge of and
experience in diesele engines,
welding
practice,
tooling,
and general chassis
work.
None of us had any of this.
More
again we learnt on the job,
opening up
machines and attempting to figure out how
they worked.
Thus, in both cases, for us, the so-called
trainers,
it was a matter of proceeding
from theory to practice. In this we were
aided by four factors : firstly
,
we had
the advantage of having collected
an
extensive technical library with informa
tion
on
virtually
every
aspect of
techology
(begged,
borrowed, and stolen
over many years); secondly,
we had adequ
ate material to practice on - in the case
of the farm, we had our "own"
land and in
the
workshop,
we had our own diesel
pumpset apart from what the customers
brought;
thirdly, we had liberal advice
2E>
from local farmers and artisans/mechanics
(sometimes, though, it became difficult to
sort out the wheat from the chaff),
and
fourthly,
we were all posessed of an
enormous confidence in our abilities (born
out of our ingorance) which paid rich
dividends in establishing our reputations.
But in all these I must stress again and
again that in our own movement from theory
to practice we had to constantly relearn
to apply the simplest scientific princi
ples to existing reality and
several
times,
to realise the presence of the
principle after practice had knocked us on
the head a number of times. In this even
the handbooks failed us. What for instan
ce, could we do with the advice that we
should check the compression of the diesel
engine if it was not starting? We finally
learnt that one checked the compression by
turning the engine with the valves closed
and if
the engine swung back then the
compression was all right.
In retrospect,
this
was
simple enough to establish
theoretically. After all, compression ref
erred to airtightness of the cylinder
while the piston was compressing the air.
Hence, to check one would have to see that
no air escaped and this could only be done
by moving the piston upwards
in the
cylinder on the compresion stroke and
listening
for air
leaks as well
as by
assessing whether the compressed air exer
ted a counter-pressure on the piston. But,
for us, it was never that easy to go from
theory to practice. Incessantly, there was
a dialectical relationship between the two
getting stuck in practice,
attempting to
look at the problem through our knowledge
of theory, solving the problem through a
mixture of understanding and tinkering,
relocating the theoretical principles und
erlying what had been done,
redesigning
practice, and, once again, the same cycle.
In a sense, we wore perpetually learning,
unlearning, and relearning and,
for that
matter, still are. Perhaps another example
will make this clear.
We were called to repair a Lister
type engine, manufactured in Rajkot.
The
engine was in a bad state of disrepair and
all
the bearings,
the piston,
the oil
seals, and the filters had to be replaced
along with a new nozzle and a new fuel
pump element. It took us a whole day just
to remove the two large flywheels whose
keys had got completely jammed.
Finally
we had to drill out the keys with a
I
HEALTH FOR THE MILLIONS
FEBRUARY 1984
portable drill. It took the farmer a week
to get all the parts from Jabalpur.
It
took us another two days to put the engine
back together. When we started it up it
fired all right but with every power
stroke it would make a dreadful whanging
noise. We checked everything over and over
again, the bearings, the piston,
the
gudgeon pin,
the gears,
the
flywheel,
since reason told us that it had to be
somewhere in the moving part.
We even
changed one of the gears which was worn
out. But to no avail. That night we sat up
late over the handbooks, arguing about
what could have gone wrong. For the next
three days we kept trying every trick we
could think of. Finally we had to give up.
The farmer paid us nothing.
Four months
later, on another diesel engine we noticed
that it was making the same noise.
The
fault was quickly located-a loose flywh
eel. It took us a minute more to realise
why we had not been able to locate the
problem in the earlier case.
The reason
was simply that we had hammered home the
flywheel keys in the first case with
additional strips of packing as the new
keys were too loose.
In a stationary
engine they appeared to be tightly wedged
in but the moment the engine started they
would come loose and the flywheel would
jerk along with the uneven motion of the
crankshaft,
giving rise to the whanging
noise.
I could give you many more such
examples but I hope the point is now
clear. Perhaps it is time to tell you
something about the trainees now.
For the farm we needed between ten tc
fifteen regular workers to maintain a
steady production of vegetables. The first
batch necessarily had to possess adequate
skills to dig earth and level
the
land
along the contours. Consequently,
for the
first batch we took boys and girls from
the Oraon tribe, a newly migrated lot who
were then landless but were gradually in
the process of acquiring land and had
acquired a reputation of being skilled
earthworkers. Later on, as these trainees
acquired skills in vegetable
farming they
moved over to their own land and subse
quent batches have been from the Gond and
Koi tribes,
some from poor farmer fami
lies,
and even some from richer farmer
families whose fathers had sent them to
learn the new skills.
All came
from
peasant backgrounds and had marginal read
ing and writing abilities, if any. For the
HEALTH FOR THE MILLIONS
FEBRUARY 1984
workshop,
on the other hand, we had a
greater variety of backgrounds,
though
here were no girls. We had boys who came
from small
farmer backgrounds,
others
whose fathers were railway workers, teach
ers,
landless labourers. There are both
tribals and non-tribals as well as a
couple from outside Madhya Pradesh. But in
spite of the differing backgrounds we soon
found some common features in the trainees
at both locations.
Firstly,
some of the trainees possessed
innate skills at handling familiar hand
tools like the adze and the spade,
others
did not, but in general there was a fear
or a hesitation to use unfamiliar tools
and equipment. Electrical equipment,
in
particular,
was something to stay well
clear of-and with reason,
I
suppose.
In
the workshop some of the trainees even
shirked clear of grease and oil. Secondly,
while some of the trainees, at least in
the workshop, claimed to have passed the
eighth standard (or ninth-failed,
as they
put it) almost all, literate as well as
illiterate, demonstrated an astonishing
unfamiliarity with measurement and calcu
lation. Simple additions and subtractions
were terrifying terrains,
leave
alone
multiplication and division. Thirdly there
was the unwillingness to say 'no'
either
to accept that one had not understood or
to deny what anyone of us, as trainers,
might be saying. They only said no if they
did not want to do something immediately.
This unwillingness was actually a reflec
tion of the prevailing social mores in the
area. And Fourthly, there was no experi
ence of consciously thinking of or plann
ing an activity.
In the course of our
interaction with the trainees we had to
find solutions to these problems. Further
more,
it had all to be done within a
Learn-While - You-Earn-While-You-Work sche
me.
We had to tackle the problems with
certain differences
in both
locations
because of qualitative differences in the
production process, which were,
in brief,
the
fact
that the
farm had regular
production and a regular routine while the
workshop was irregular as to both the
volume and the kind of work, being
totally
dependent upon an uncertain custom.
At the farm we designed regular classroom
sessions and games as part of
the produc
tion activity of the farm itself.
In the
morning when the trainees came there would
27
be a session of physical exercises, in the
afternoon there would be a literacy class,
and the evening before leaving there would
be some games. Apart from encouraging there
to learn to read a.nd write, these games
and exercises were essentially to combat
the problems I have /mentioned earlier. If
I give an example perhaps the point will
become clearer.
For instance
all the
trainees would stan d in a circle and go
through the motions of eating.
One person
in the centre would call out the names of
various eatables. Suddenly the person
in
the middle calls out the name of a non
eatable.
All those i who continue
the
motions of eating are then eliminated from
the game. Such a game inculcated the habit
of conscious attention and thought. Varia
tions
on the saime
theme during
the
physical exercise brought focus to bear on
numerals and patt-erns. These activities
were matched to the regular formal class
room sessions. In t he class (not a class
really; everybody w ould just sit under a
tree with a blackboard in front of them
and slates in their hands, or perhaps copy
books), we initial].y began to teach words
related to the environment, names etc.
Then the same lettc >rs would be rearranged
to give new word.' 5 and so on. Mathematics
was taught with
the aid of a decile
counter, geography with a globe.
And all
this
was relate-d to the measurement,
calculation, and
planning required for
vegetable product! on.
In the workshop
it was not possible to
follow such a curr iculum.
Here we bejeame
very much more
dependent on the actual
nature of the wor k itself and the occassional idle peric ids in between.
Since we
ourselves would
be on the job with th^
trainees working e ilongside or independen
tly, but in the s< ime place, they could be
participants in ov ir own learning process.
We took care to e: <plain whatever we were
doing or thinking to them.
When required
everyone would re- Lire to the blackboard to
discuss a particu Lar point. Trainees relu
ctant to respond, react, involve, or think
would at first be gently encouraged to do
so and later if s till adamant or recalci
trant,
would be
fo.rced to do so with
gleeful participa tion from the older trai
nees. It is proba bly a.n error to say so in
such company bu t we
have
found
that
colourful curses, very much a part of an
ordinary mistry * s life, are good educa
tional aids too. Through personal example
26
we endorsed a kind of slogan for the
workshop—"Stop and think" This slogan
would frequently be used later on by the
older trainees with the newer ones.
But
may be another example here would not be
out of place.
A job had come: cutting angle iron to size
and welding two pieces together at right
angles.
The job was handed over to a
trainee who had already learnt how to
weld. He accepted it without any dissent.
A few minutes later we found him cutting a
short piece. Enquiry revealed that he did
not know how to measure with a tape. Other
trainees scolded him for not saying so
earlier. One of us then spent the next ten
minutes explaining the basic principles of
measurement to the new trainee—just ade
quate for him to carry out the work. Later
on, in the evening, we all gathered around
the blackboard and a session was organised
to explain the principles of measurement
in detail.
But we soon found that the
trainee could not follow three-dimensional
views on the board. So a real part was
immediately fetched from the workshop and
the session carried on from there.
In
half-an-hour the trainee had picked up how
to take linear measurements and how to
chalk out the basic angles,
constantly
relating to work already done by him
during the day. Innovation was the next
step.
For this, though, we had to wait
until the older trainees had gained the
requisite experience. At the farm,
this
phase was marked by a disillusionment with
existing facilities.
For instance,
an
older well had failed and a new one had to
be built but obviously it could not be of
the same design as the old one. So we took
a decision to build an underground chamber
across a small stream to
catch
the
underground seepage
(the stream is dry
during the summer months)
and to feed it
into a well with the aid of the stream.
For the purpose we had to build an arch
over the underground chamber.
A local
mason was contacted for the purpose.
The
trainees helped to build the scaffolding
to support the RCC structure.
In the
process they used their undertanding of
building arches which they had picked up
from making trellisses for gourd plants to
climb on to. But the mason piled on so
much concrete that the structure collap
sed.
Work had to start all over again.
Similar experiences with local masons,
carpenters,
and smiths finally persuaded
HEALTH FOR THE MILLIONS
FEBRUARY 1984
the trainees to innovate on their own.
In the workshop,
the first sign that
trainees wanted to move ahead came when
they began to ask for reading material in
technical subjects.
They had seen
us
regularly referring to the small library
we had built up and wanted to do the same
independently. We managed to put together
some of the existing material in Hindi but
I am sorry to say that most of it is very
poor in quality. Nevertheless this was the
first step.
We tried to channelise this
further. When jobs came to the workshop
that we did not know how to handle we
would say so and a discussion would begin
with the trainees about how it could be
done.
Sometimes the customer would also
get involved. Trainees wold suggest cer
tain ideas and we would take care not to
dismiss them out of hand. Finally a method
would be commonly agreed upon as meriting
a trial. There would be a trial run, and
if it all went well, it would be adopted,
otherwise
it would be back to another
round of discussions, or even an interval
to think about it.
Once innovation begins
it is difficult to put a stop to it.
And
since it takes place within the context of
production and earning, the confidence of
the trainees builds up rapidly.
As this
process is something which is important to
our team we have always been at pains to
keep an eye out for it and to encourage it
and to make known our appreciation of it.
The most satisfying moment is when a
trainee solves a problem that we have been
unable to solve and then comes to teach us
about it.
However, we were
not very
satisfied with merely keeping training to
this kind of an ad-hoc level.
There must
be some more systematic way of approaching
the problem. Is there a way of conceptua
lly looking at the process of problem
solving? Are there any underlying commo
nalities between explaining measurment and
approaching the repair of
a pump or
building irrigation channels? To be frank
we are still not very sure. One of the
concepts we have advanced and are trying
to experiment with, is the idea of "conf
lict". We see a problem as a "conflict"
and the process of resolution of the
problem as a process of recognising the
conflicting forces, selecting, encouraging,
and understanding a new balance.
For
instance in a discussion at the farm on
how crops are dependent of the rain,
an
argument ensued as to the causes of rain.
HEALTH FOR THE MILLIONS
FEBRUARY 1984
One group held that God was responsible
for the rain, another felt there had to be
natural causes for it. This then, was the
first conflict. We tried to take the
argument further by pointing out the need
for establishing correlatable factors even
though God might ultimately be responsible
for everything. That led to a discussion
on why it rains more at some places than
others. This was the next conflict.
At the workshop it seemed even easier
to put this matter of conflict into the
training process. The design principle of
a diesel engine is based on the conflict
between the power of combustion of diesel
and the strength of the material required
to control it. This principle can be seen
to operate in terms of the wearing out of
piston rings, bearings, and valves, which
are the points at which repair takes
place. The wearing takes place even faster
in parts which are moving.
Hence the need
for lubrication which attempts to resolve
the conflict between the needs
for smooth
running and close tolerances. Once we
could get these ideas of conflict and
conflict-resolution firmly grasped by the
trainees they could apply them themselves
for innovative practice.
One of the exam
ples of such innovation Was when a trainee
who had been trained in diesel engine
repairs began, on his own,
caking in
electrical motors for repairs.
It was
further interesting to watch him, a young
boy who had earlier feared to touch the
welding machine, begin responding to farm
ers'
problems and going to the site to
repair electrical switch-gear. When we
asked him how he had picked up the skill
he responded,
"it needed some courage
(sahas)
and some
innovation
(jugad)."
(Actually, we find that the more difficult
an area to work in from the point of view
of facilities, equipment, and parts avail
able,
the more the initiative builds up
for jugad by the trainees).
By force of
circumstances, this innovation then becom
es appropriate technology in the true
sense of the word.
I should confess that our group at
present has no statistical evidence to
present
for this "conflict" approach to
training in concepts. We, however,
stron
gly and intuitively feel that this
is a
paradigm worth looking into. One important
reason why we feel so is because it makes
it easier to make the qualitative leap
29
from the technical domai- into the techno
logical
and thereby the social.
Our
understanding of society essentially deve
lops on the basis o a recognition of
social tensions and conflicts.
Hence,
it
seems probable that a person schooled in
the technique of looking at technical
problems from the viewpoint of conflicts
should be able to do the same for social
problems and thus integrate the two. As I
had mentioned in the beginning our objec
tive in Shahdol has been to encourage
youth to understand the social dimensions
of technical work. At this time,
I should
add, that when we say "social" we do not
really reduce our understanding of the
trainee as a "social worker" but as part
of a social strata. In other words,
our
attempt has not been to prompt the trainee
to think in terms of service to others but
to think of himself/herself as a member of
a particular social class and to under
stand the necessity for joint
social
action. At the
farm we have tried to
introduce this element into the curriculum
through extending discussions into fields
related to agriculture marketing,
the
government extension| services,
the role
of the middleman,
and so on - and by
including films and trips as part of the
training process.
We hope this enlarges
the perspective of the trainees.
The farm
trainees had gone to see one of the recent
commercially successful "new wave" films,
a take-off on the Mahabharat,
a tale of
five comrades in a contemporary setting
who fought against the domination of the
village by one- man. The trip back,
in the
night, was full of animated discussion.
The next day none of the trainees came foi
work. They had gone on "Strike" and came
back only when the bonus rate was increa
sed. Perhaps it is wrong of us to try and
draw a one-to-one equation in this manner.
On the other hand, it would also be wrong
to
ignore that there may be certain
relationships.
To put the matter to the
test we must look for supportive evidence.
We have noted,
for instance,
that the
Oraon trainees from the farm, have added
to the militancy of the Oraon immigrants
in the face of harassment by the police,
the landlords, and the traders.
But even
this is perhaps not adequate evidence.
We
must wait for more conclusive results from
jur work.
The trends in the workshop have been
slightly different. There has
been a
30
greater degree of informal
discussion
extending late into the night as trainees
have been welcome to stay overnight.
In
addition it has been easier to identify
the potential social class of the trai
nees. We cannot claim to have built up a
strong and socially conscious group of
trainees at the workshop itself
(perhaps
it was not our intention to do so) but we
can and do claim that once the trainees
leave and take up jobs,
their social
perspecive acquires a keen edge.
Trainees
have left the workshop at different times
to take up employment with the
M.P.
Electricity Board, the Railways, the Coal
mines,
the BALCO unit at Korba,
and the
P.W.D. In almost all cases we have found
them paying us periodic visits, wanting to
discuss the conditions of
work,
the
problems of the other workers,
the conf
licts
with management,
the widespread
corruption, the loss to the society as a
whole,
and their sense of dissatisfaction
with the state of affairs. Once again, we
do not wish to make outlandish claims that
the training at the workshop itself has
brought about this perspective.
It is
probably much more the impact of a total
environment—the camaraderie in the work
shop, the sense of alienation in the new
work-place,
the expectations from
the
family,
the
late-night discussions,
and
and so on. The workshop has probably only
a sharp and limited role. But we feel that
it is important to understand and further
refine that role.
Although I have already made several
disclaimers on behalf of our team, still I
have a feeling that this is beginning to
sound like a shrill propaganda piece for
our work. But by no means is our work a
model and successful show piece.
There
have been numerous failures.
Many of the
trainees have been disturbingly imper
vious, particularly the ones who came
through the Government-sponsored TRYSEM
scheme.
We have had to get rid of them
fast. Our major problem has been with the
economic aspect of the training.
"Learn
While You Earn" sounds very noble on
paper. I assure you its a frustrating way
to live.
The very fact that it provides
the conflicts so necessary for a learning
situation indicates that those conflicts
contantly impinge on the earning part of
it too. Both at the farm and the workshop
we have been horribly unsuccessful in
running completely viable units. If we had
HEALTH FOR THE MILLIONS
FEBRUARY 1984
been doing this for a living we probably
would not be in Shahdol today.
Grants and
loans have bailed us out from time to time
but in the absence of any grants
for the
last almost two years our position is
precarious. The farm limps along but the
workshop is more of a non-entity than
anything else right now.
And in the
absence of earning, little learning is
likely to take place. Perhaps this is
going to be one more test of our self
learning capacities.
If we overcome
the
present situation will
it lead
to a
greater social consciousness for us ? In
other words do we ourselves obey the rules
that we have set up in the training
paradigm for our trainees ? These are
questions that we have yet to answer
for
ourselves.
So once again-from theory to
practice!
cont’d from Pg 16
try,
how to avoid a mechanistic replica
tion process and identify processes which
are "extensible"-these are issues which we
have to face squarely.
My observations should not be miscons
trued as a damper to the aspirations of
those who want to replicate and extend. I
have been waiting and it has been a long
wait, when the desire to do something for
our disadvantaged handicapped seems to
have taken a concrete shape.
My only
submission is that before launching a
massive programme the historical impera
tives of the development scenario should
not be ignored. A shorter hop,
after a
careful study of the issues involved may
oe a more desirable strategy before taking
the great leap forward.
Acknowledgement is made to Prof. Ravi
Matthai and Prof. Ashok Subramaniam of
Indian Institute of Management, Ahmedabad
for my understanding about projects and
programmes
Prof Subramaniam's paper-A Small Step
to the Great Leap-would be very chastening
to our planners. Raj Arole and David
Werner have sensitised me to the need and
value of people's participation in any
health programme for developing countries.
Prof Amulya Reddy, of course, is largely
responsible for clearing away many cobwebs
which came in the way of an understanding
of appropriate technology.
cont'd from Pg 24
comments,
"that my own professional bre
thren are the main intruments
in the
exploitation of the nation as well as of
the patients, inspite of the fact that we
are so poor.
The unnecessary drugs,
be
sides, are harmful to the patients.
There
is so much unnecessary expense in inessen
tial .investigations, in addition.
inclu
ding the x-rays.
"Besides other measures,
I feel there
should be propaganda among the teachers in
the medical colleges so that these tactics
are highlighted in the would be medicos.
I feel it will not solve the problem
completely though.
The unscrupulous indi
viduals will go on indulging in these
wrong practices knowing them to be so,
deep in their hearts.
Still, it will help
to some extent atleast."
As I try to keep up with the brisk pace
of Dr. Gangwal on his morning walk,
I
cannot escape the feeling in me that here
is a man who is a memeber of a vanishing
tribe,
a person who is forthright and
HEALTH FOR THF MILLIONS
FEBRUARY 19R4
angry at our country's ills and at that of
his own profession, but yet somehow in a
quiet and benevolent way.
I was also
reminded of the old man in Wordsworth's
"Resolution and Independence"
who was
courteous of speech and when he replied,
"a flash of mild surprise broke
from the
sable orbs of his yet vivid eyes..........
coming together in life's pilgrimage;
as
if some dire constraint of pain,
or rage
of sickness
felt by him in times long
past............. "
For those interested in questions of
success and failure,
the Sulabh Nidan
Kendra is perhaps not a success from the
system's viewpoint.
How can anything be a
success
in a system so overwhelmingly
fragile and decadent? For the same rea
son,
the Kendra may not be replicable as
an experiment and is not likely to unleash
the forces of a health care revolution in
India.
The Kendra is at best viewed as a
product of some actions in some circums
tances.
And it happens to have
some
inspirational value for some others.
.31
AT
Solar Spreads
The Centre for Development of Rural
Technology
(CDRT)
at the Institute of
Engineering and Rural Technology (IERT),
Allahabad, collaborated with VHAI to run a
programme on Solar Equipment Fabrication
and Maintenance from October 29,
1983 to
November 26, 1983.
Seventeen trainees
participated in
this programme. Of these 10 were sponsored
from the hospitals, 1 from a development
programme and 6 were students of the one
year course in Health Equipment Maintena
nce
(HEMAT). The trainees came
from all
over India- from Mizoram,
Tamil Nadu,
Kerala,
Karnataka, Maharashtra, Gujarat,
Bihar, M.P., U.P., and Punjab. The age of
the trainees varied from 18 to 40. Most of
them had technical backgrounds and the
sponsored trainees were from maintenance
departments.
Reports
The first week was devoted to theory
lectures and study of the prototypes that
the trainees would be fabricating.
In
consultation with the trainees it was
decided that the thermosyphon type of
solar water heaters, two sterilisers using
parabolic concentrators and one box cooker
would be fabricated.
In the next three
weeks trainees
fabricated all these devices and tested
them.
On the cookers they cooked various
dishes. They showed remarkable skills and
aptitude in learning new things and were
very excited with their work. Many finish
ed their work before time.
The HEMAT
trainees fabricated an extra item- a small
solar water heater. This is being presen
ted to their parent institute,
the Nave
Technical Institute, Shahjahanpur, UP. The
rest of the products are being offered at
half price to the sponsoring organisation.
The importance of alternative sources
.of energy, particularly solar energy has
seen well established and accepted.
The
government of India has specially set up a
Department of Non-conventional Sources of
Energy. Many centres have developed appro
priate designs and some manufacturers are
marketing solar devices such as solar
water heaters and cookers.
The Centre for Development of Rural
Technology has done pioneering work in
this field. Their box cooker has been so
popular that they have set up a separate
Training-cum-Production Centre for it and
they market them regularly. Other products
like: Solar water heaters, Telks oven and
recently sterilizers are also marketed.
A similar course is being contemplated
for June 1984 and those who are interested
nay contact:
Sri H.C. Srivastava,
Dean R & D/Head,
CDRT, IERT, Allahabad-211002.
32
HEALTH FOR THE MILLIONS
FEBRUARY 1984
ORT as AT
A study was conducted in 1982 by the
Mission Hospital, Thandla, MP to find out
"the efficacy of treating simple diarrhoea
in under-five children with ORT",
the
simple
low cost appropriate thechnology
(AT) which has revolutionised the treat
ment of simple diarrhoea in children. This
study formed part of the 15 month course
in Community Health Team Training . (CHTT)
organised by VHAI, and was carried out by
two of the participants, Sr M Grace and Sr
M Shiela.
The 40 bed Mission Hospital is situa
ted in Thandla, a tehsil town in Jhabua
district of Madhya Pradesh. The town has a
population of 8756 and the villages in
this tehsil have a population of 1,36,547
(1981 census) The population is made up of
Adivasis belonging to the Bhil tribe.
The
Mission Hospital draws its patients from
these villages and is also running a
Community Health Programme in the nearby
village.
An analysis of the patients
attending the OPD in the year 1981 showed
that diarrhoea formed the largest compla
int.
Hence this study was considered a
necessary first step before propagating
ORT on a wide scale. It was hoped that the
outcome of this study would help decrease
cost of treatment of diarrhoea
for the
patient and the hospital; convince the
other team members as to the usefulness of
this simple treatment; and make it possi
ble to change the morbidity and mortality
patterns in the surrounding villages.
The study was conducted on children
below five years who had simple diarrhoea
(WHO classification)
and whose parents
were willing to stay in the hospital for a
day.
Those children needing antibiotics
were not included in the study.
Total
number of children thus selected was
30,
from those admitted between
June and
December 1982. The sample population was
admitted in the hospital,
history taken,
the children weighed and degree of dehy
dration assessed. Oral rehydration solu
tion
was made according to the
WHO
formula. The children were then given this
solution
according to the degree
of
dehydration,
age and weight. The time
taken for the disappearance of each sign
was noted and child discharged after all
HEALTH FOR THE MILLIONS
FEBRUARY 1984
the signs disappeared. The findings
shown in the table below.
are
Findings of the Study
No. of
children
2
10
7
7
1
3
Degree of
dehydration
Time taken for the
disappearance of
all signs (in hrs)
Moderate
Moderate
Moderate
Moderate
Moderate
Mild
6
8
10
12
24
6
The average time taken for the disappearnce of all signs for a child with
moderate dehydration was around 10 hours.
The amount of fluid (ORT)
given to such a
child On an average was 1540 ml. The cost
of this treatment worked out to be only
Rs. 1.25.
Based on the findings of this study it
was decided that in future children with
simple diarrhoea need not be hospitalized.
Even if there is need,
they can be
admitted for a few hours and once the
signs disappear they could be sent home
with the required amount of this solution.
HEMAT
The 4th batch of the Health Equipment
Maintenance Training programme (Hemat-IV)
is nearing completion and is scheduled to
end in June 1984. While it has
followed
essentially the same pattern
as
the
earlier 3 batches,
there has been an
increased emphasis on the human relations
aspect. Another major change has been the
introduction of a one month course on
Solar Equipment Fabrication at Allahabad
(see above) to strengthen the course at
the practical skills level. A one month
course in Automobile Maintenance will also
be introduceed this year.
The Health Equipment Maintenance
(HE
MAT) course was an outmome of the Health
Care Administration Education (HCAE)
work
of VHAI between the years 1974 and
1984.
The HCAE group in VHAI has sought to help
many hospitals and health care institutions
33
in better management and planned change.
Some of the values guiding this work have
been: community health and community par
ticipation,
decentralisation of
health
facilities away from urban and semi-urban
areas and towards impoverished rural sett
ings; demystification of medicine,
health
and related areas of a health institution
so as to make health care more accessible
to the poor.
The HCAE group has been running several
training programmes on health care manage
ment, keeping in mind this philosophy.
While pursuing these training progra
mmes,
the HCAE group identified several
needs for training and upgrading skills ir
many health-related areas. One of these
was
found to be the need for suitably
trained technicians in health equipment
and hospital maintenace.
A more immediate
need came up in 1978 when the HCAE staff
were requested to help one major teaching
hospital in South India for an intensive
development programme of the hospital.
A
particularly sensitive area in this hos
pital
was found to be the Operation
Theatres (OTs). There were six to seven
major
OTs in this hospital operating
simultaneously.
It was a big challenge
scheduling surgeries,
organising
human.
resources and material resources when so
many OTs operated simultaneously. The HCAE
staff were initially asked, to look into
this aspect too. It was found that many of
the
conflicts
were due to equipment
breakdown in times of crisis and due to a
lack of good-quality breakdown maintenance
service which could put the equipment in
order soon. Among other solutions to this
problem,
it was felt that the hospital
needs trained, reliable maintenace tech
nicians for this equipment and in allied
trades. This was in the period 1978-79.
The HCAE staff scouted the Indian scene
and found very little work had been done
on this aspect of maintenance.
The survey
revealed that there was a group that was
The table below gives brief details of the first 3 batches.
Year
34
'Jo. of
Graduates
Working in
Hospitals
Joined
Course Design
Industry • NTI
PGI
Special
Inputs
HEMAT I
1980-81
4
3
1
6 mths
6 mths Refrigera
tion & A/c,
Electrical
Trade.
HEMAT II
1981-82
5
3
2
6 mths
6 mths 10 day elec
tronics, 7
day human
relations,
AT, Smoke
less Chula
HEMAT III 1982-83
8
5
6 mths
4 mths 6 weeks
in va tours of te
rious chnologically
hospi interesting
places.
2
tals .
weeks elec
tronics &
radio repair
ing, human
relations.
HEALTH FOR THE MILLIONS
FEBRUARY 1984
doing related work- the Advanced Training
Institute
(Ministry of Labour, Govt.
of
India)
at Hyderabad which runs short-term
courses (for a few weeks)
on aspects of
electronics in cardiac equipment and in Xray equipment.
A second and more important discovery
was that Mr J C Mehta, the then Head,
Department of Hospital Engineering,
Post
graduate Institute of Medical Education &
Research (PGI), Chandigarh,
had done exc
ellent work in printing several useful
manuals related to various aspects of
hospital maintenance. Mr Mehta had the
collaboration of the Technical Teacher's
Training Institute (TTTI),
Chandigarh, in
curriculum designing. (This excellent doc
ument on
curriculum designing needs tc
be better known). But the PGI itself could
not proceed with the launching of such a
course for various internal historica.1
reasons.
One of the HCAE stai^ on VHAI chanced
upon this work done by Mr J C Mehta and
discussed with him at PGI
the possibility
of
a
long term coursee on hospital
maintenance. This was in March 1979. As a
result of this dialogue, it was found that
the collaboration of a technical institute
would be preferable. At this technical
institute the prospective HEMAT trainees
would undergo theory-cum-practice
in var
ious technical trades for six months. The
next six months would be spend in theorycum-practical training at the PGI work
shop.
A general course outline was also
arrived at modifying the earlier PGI-TTTI
design.
The next step of actually identifying a
technical institute took place only
in
June 1980.
This happened when an HCAE
staff member visited Nave Technical Insti
tute (NTI, Shahjahanpur) and put forth the
idea of a HEMAT programme. The Director of
NTI, Mr H P Garwick,
a dynamic engineer
readily agreed and expressed his enthusi
asm. The HEMAT programme was thus born in
June 1980 with the prospect of collabora
tion between VHAI, NTI and PGI's Hospital
Engineering Department.
Review and Reflections:
We have done a review of the Hemat
programme with regard to content design
and the feedback from the alumni
in the
HEALTH FOR THE MILLIONS
FEBRUARY 1984
hospital situation.
Though our sample is small, we have the
following tentative comments to make about
the Hemat programme.
The Hemat trainees because of their
formal training in health equipment main
tenance . prefer to work in health care
institutions.
However, by and large they
prefer work in urban/semi-rural
areas.
This inspite of our emphasis on appropri
ate technology and the need to work in
rural areas primarily.
Some
soon get
frustrated, and leave the health institu
tion to join industry.
Some join
an
industry straightaway.
Perhaps our emphasis on AT and the
importance of working in rural areas
is
not enough.
Another fact is that most
trainees from the formal technical
educa
tion system cannot be expected to work in
non-industry areas for long,
pressurised
as they are by forces of the market, peer
comparison in terms of salaries in indus
try,
etc.
There is a need to provide
attractive work conditions if they are to
stay in the health care sector, especially
the voluntary sector. A few of
them do
have their own inner motivations
and
compulsions to work in the rural areas and
to develop applications of technology in
the rural indian context.
However,
our limited experience with
sponsored trainees in Hemat,
and in the
solar equipment and smokeless chula cour
ses,
has been more encouraging.
For
sponsored trainees (especially those cho
sen carefully by the sponsoring institu
tion with regard to needs) the training
seems
to have greater immediacy
and
relevance.
The trainees have
co show
results back home.
They can choose and
concentrate on particular aspects of the
training.
We,
therefore,
feel that the Hemat
training would be better conducted
in
specific modules for sponsored candidates.
Modular training has the added advantage
of being limited in time-not more than
three months at the most-and therefore it
is relatively easier for the sponsoring
institution to spare their personnel.
Probably our solar equipment
fabrica
tion course
is a good example of an
35
effective module. Another module,
is the
one month automobile maintenance course at
Jullundur,
in February-March 1984, to be
part of the Hemat-IV programme.
Several
such well-planned modules in various parts
of the country would probably be an ideal
substitute.
Subabul toxicity problem solved
BRISBANE : Australian agricultural sci
entists believe that they have
found the
key
to . solving the
toxicity
problem
associated with the tropical forage legume
leucaen.a (or Subabul) .
Scientists of the Commonwealth Scienti
fic and Industrial Research Organization
(CSIRO) in Townsville,
north Queensland,
say that a microbial culture obtained from
the stomcichs of Hawaiian goats could be
transferred to. Australian
livestock to
break down the toxic compound present in
the legume.
The development Ls considered of major
importance
to the grazing industry in
northern Australia because leucaena is a
rich, source of protein for Animals and
grows in a wide range of soils,
including
heavy clays.
The problem with the plant is that it
contains mimosine, an amino acid, which is
N E W
broken down in -the digestive systems of
grazing animals to form a toxic compound
called DHP.
This in turn affects the
thyroid glands of animals and can cause
hair loss and restrict weight gain.
CSIRO Scientists noted that in Indone
sia and Hawaii the problem did not exist.
In experiments carried out by officers of
CSIRO's Division of Tropical Crops
and
Pastures,
four Australian goats, together
with locally grown leucaena, were taken to
the Research Institute for Animal Produc
tion at Bogur, Indonesia. Two of the goats
received
stomach fluid from resistant
local goats while the other two remained
untreated as a control.
The treated goats,
which had been
lethargic before
the
infusion and had
taken almost 24 hours to eat their daily
ration, became alert and within a week ate
the same ration in less than five hours.
The change appeared to be permanent.
In further tests carried out in Towns
ville, microbes cultured from the stomach
fluids of Hawaiian goats were tranferred
to
a steer and a goat with similar
results..
Toxicity symptoms have rapidly disap
peared from all treated animals,
indica
ting that the microbes can be
introduced
to lead to the widespread use of leucaena
in improved pasture.
INITIATIVES
Bombay Le Leche League (LLL)
B 13 Maher Tower, 85 Cuffe Parade, Bombay 400 005
Phone No': 212676 : Contact person Ms Kavita Mukhi
Le Leche (meaning "MILK') began in the US in 1956 and today is providing support and
encouragement to women who want to nurse their babies. It offers publications
including its manual and bi-monthly LLL news. The following services are provided
by LLL-ac'cess to Library, answers to all your queries, encouragement and help in
nursing. Informal monthly meetings held on the first Wednesday of every month at
10.30 a.m . at the above address. NO MONEY INVOLVED. LLL wants only to see your
baby get the best start in life.
SRUTI (Soc tiety for Rural, Urban and Tribal Initiative).
Contact person Ms. Poonam Muthereja
C-17, Ushci Niketan, Safder Jang Development Area, New Delhi 110 016.
Tel: 657191
SRUTI prov 'ides initial support - fellowships and some project funds to development
workers, a rranges relevant training and exchange programmes, publication of useful
documentat ion, organize special interest meetings of experts and like minded
individual s and organizations.
36
HEALTH FOR THE MiLLiuro
FEBRUARY 1984
News from the States
Delhi
Tamilnadu
Medical Institutions Meet
TNVHA Member in Maldives
The XXIII Annual Conference of the
Indian Association for the Advancement of
Medical Education,
held in Delhi
from
January 14-16, 1984 discussed the Role of
Medical Institutions in Planning the Comp
rehensive Health Care Programmes, Maternal
Health Care, Child Health Care, Integrated
Teaching of Mother and Child Health and
Family
Planning to undergraduates and
interns and the role of medical students
in strengthening Family Planning Services
in India.
The Arvind Eye Hospital,
Madurai,
a
member of the Tamil Nadu VHA recently held
an eye camp in the Maidive Islands. Dr. G.
Venkataswamy, who received a Padma Sri and
the Time-Life International Agency for the
Prevention of Blindness Award visited the
islands to make an assessment of the
requirements.
Nurse Anaesthesia
Batch XVII of the VHAI Nurse Anaesthe
sia Programme began from January 20, 1984
at Francis Newton Hospital
in Ferozepur,
Punjab.
Bihar
Silver Jubilee
The Kurji Holy Family Hospital,
Patna, celebrated its silver jubilee in
November 1983. The event was marked by
week long celebrations and thanksgiving. A
special souvenir, with special contribu
tions from old and young employees,
was
brought out on the occasion.
Madhya Pradesh
The first camp was held on the island
of Kulhudu fushi, a 48 hour boat journey
from Male, the capital town,
for the team
of 3 doctors, 4 surgical scrub nurses, one
refractionist and one theatre assistant.
Led by Dr. G. Natchiar the team performed
171 cataract operations plus a number of
minor operations.
Besides two future camps, it is planned
to bring Maldivians to the Aravind Eye
Hospital to be trained as opthalmic nurses
or opthalmic assistants to enable them to
work in some of the two hundred and two
islands
inhabited by a population
of
1,50,000,
of which 40,000 live in the
island capital of Male.
RUHSA
DCHM (Diploma in Community Health Mana
gement)
15 month course is run in association
with VHAI Delhi. It is designed as a
post graduate academic course and is
open to candidates from various discip
lines.
The course will begin on the
16th of July 1984.
Fostering Sprouts
In a paper on SPROUTS, MPVHA has giver.
clear instructions on How to Use Seeds and
Sprouts, How to Sprout and Avoid sprouting
errors. Alfalfa, Soyabean,
Peanuts,
Ses
ame, Mung and Lentil receive
special
attention. Write for the paper to execu
tive Secretary,
M.P.
Voluntary
Health
Association, Post box 170, Indore, M.P.
HEALTH FOR THE MILLIONS
FEBRUARY 1984
CIRD(Certificate Course in Integrated
Rural Development)
4 month course is open to all candida
tes including non-graduates. The course
will begin on the 16th of August 1984.
For more details,
please write to the
Programme Director RUHSA POST,
North
Arcot Dt. Tamilnadu-632209.
37
CHINU
A Monastery Hidden by a Distillery
Book Review:
The Double-edged Helix—Science in the Real World by Liebe F.
Cavalieri, Columbia University Press, New York, 1981. (Part of the
Convergence Series of books founded, planned, and edited by Ruth
Nanda Anshen. )
Our times have been characterised less
and less by science as a pursuit of pure
knowledge,
by good human beings called
scientists
locked up in their
ivory
towers.
Science has escaped the ivory
tower,
thanks to technology,
and
has
flooded the world with its unique combina
tion of cleverness, crudeness and bana
lity.
The markets-be it in the
first,
second or third worlds-have been pushing
technological products at an increasingly
shrill pace. So now we have bottled milk,
highly processed and costing more,
than
milk straight from the cows,
we need to
have fertilisers to increase
food produc
tion and pesticides to arrest any decrease
in the increase. Then we need irrigation
from dams for these fertilised, pesticided
land. However jobs decrease on the whole
for the masses. The Green Revolution has
made the poor see red. They are pauperised
even more. But still agricultural research
of the hybrid seed variety remains a
priority because of the emotional appeal
to hunger. In truth, this technology has
seldom
been questioned and apparently
cannot be,
because it flows from that
great god-Big Science.
Science innovates. Technology applies.
Applications lead to problems. These prob
lems are again thrown into the science
technology
melting pot for
solutions.
These solutions will never bite the hands
that feed science and technology,
viz,
government, military and industry--for who
likes to commit suicide if one need not ?
In turn the network of economic forces
created by the government
(that is half
educated politicians mainly), military and
industry control the directions of growth
of science and technology. In this fashion
is 'truth
*
pursued and *
'knowledge
created
in modern times. Examples? This book gives
many in the context of the recombinant DNA
discoveries, and in the process describes
the joys and woes of science,
and the
responsibilities of science and scientists
to society.
DNA Revolution
The advent of recombinant DNA brought
nolecular biology out from the purdah of
*
'pure
science. A sedate discipline, whose
main purpose was to understand the funda
mental character of systems having 'life
,
*
vas overnight changed into a potent weapon
for control of organisms and humans--for
better or
for worse. Many
cloistered
scientists have .had to forcefully face
questions of societal responsibility for
their
research, and had to be
more
accountable to an 'ignorant
*
public than
they cared. The recombinant DNA technology
once and for all removed the veneer of
political naivete of scientists and the
social innocence of their science.
That DNA is the genetic substance was
first shown in 1944. However the
full
impact of this discovery was not felt till
1953 when Watson and Crick postulated the
double helix structure of the DNA mole
cule, and made the understatement of the
century:
"It has not escaped our notice
that the specific pairing we have postu
lated immediately suggests a
possible
mechnism for copying the genetic mate
rial".
A paradigm shift
had occurred.
A
feeling of awe descended everywhere as DNA
was recognised as an eternal and deep
truth. Biological research slowly catapul
ted into a torrent of new findings. And by
1973, hell broke loose when H.O. Smith and
co-workers isolated restriction enzymes-enzymes that protect the bacteria
by
killing the virus—from E.Coli. This made
it
possible to produce specific
DNA
fragments and recombine segments of DNA
HEALTH FOR THE MILLIONS
38
FEBRUARY 1984
from different DNA fragments,
recombinant DNA technology.
leading
to
The discovery
accelerated findings
even further. The last 10 years have seen
an especially feverish pace of activity in
molecular biology.
For recombinant DNA
technology has immense potentialities in
medicine, agriculture,
and industry.
It
has opened the floodgates of manipulation
of all life.
Genes can be shuffled and
inserted into living bacteria. In agricul
ture,
nitrogen can be directly fixed by
transfering nitrogen-fixing genes
from
bacteria to plants, thus making nitroge
nous fertiliser superflous.
In medicine,
we already have some test products of
recombinant DNA technology
:
insulin,
somatostatin and interferon.
The costs
All so well for
science and its
benefits to human kind. But at what costs?
The hazards are there but are sought to be
minimised or glossed over by scientists
and technologists in the pursuit of their
careers. In agriculture for instance much
more research would be required before
nitrogen fixing genes are touted for the
super-green revolution. Nitrogen fixation
genes can only function in cells with an
exceptionally high energy output.
This
would alter the energy balance of the
plant and the crop and disturb other
ecological checks and balances in nature.
experiments being carried out in Stanford
University by Paul Berg.
Both Berg and
Pollack discussed privately and decided to
look for solutions in search of responsi
ble DNA research. Soon some other scien
tists were alerted and they joined issue.
The matter became a concern across acade
mic borders.
However what started as a
wise attempt soon got embroiled in politic
king, dishonesty and backtracking as many
scientists realised that public discussion
would only clip their research wings.
Double-edged
The double helixed DNA proved to be
double edged like much of science.
This
book documents this sordid
drama
of
scientists,
technologists,
senators and
others who worked sometimes
at cross
purposes, and sometimes together,
to save
the great edifice of recombinant science.
When the non-scientist public entered the
debate and started registering dissatis
faction at the lack of sufficient guide
lines to ensure public safety and environ
mental preservation,
the hitherto cons
cientious scientists started crying foul.
They recanted their initial
concerns.
"Freedom of enquiry and pursuit of truth"
was
seen
to be
invaded.
Even civil
liberties were seen to be a threat bv
E. Coli as a host for recombinant DNA
was convenient to many scientists
for the
simple
fact that already an enormous
amount of research had been done on E.
Coli as the host organism. Few scientists
were willing to start all over again. This
was/is inspite of the known hazards of E.
Coli.
Infections of the bloodstream by E.
Coli
(the bacteria usually used to mult
iply recombinant DNA) cause a large number
of deaths,
and the incidence of these
infections are known to be on the increa
se.
There are many other potential hazards
in recombinant DNA technology.
Concerr
over the hazards was first expressed in
1971 by Robert Pollack. Pollack pointed
out the potential danger of some specific
HEALTH FOR THE MILLIONS
FEBRUARY 1984|
The virus has isolated him. poor fellow. He was trying to
isolate the virus.
( Courtesy : ”Science Smiles”, R K Laxman)
39
these scientists. This required politic
king of great finesse as many of the
politicians at the US Congress controlled
the federal grants for research.
attempted to be the arbiter
purveyor of truth.
Once the genetic scene was found to
have vast industrial-economic potential,
big business clout stepped in with estab
lishment knowledge clout to protect ’free
dom of enquiry
.
*
The sad fact however was
that freedom of enquiry had been long
foregone no sooner than when
science
became big and wedded to sophisticated
technology. The mass of people were not to
bother in this enterprise of the learned.
Ti.ey were to remain passive spectators,
and somethimes specimen. As C S Lewis put
it in The Abolition of Man: ".... what we
call man’s power over nature turns out to
be a power exercised by some men over
other men with nature as its instrument."
Unqualified freedom of inquiry is not
a right but a privilege, a vestige of
science and technology that were believed
to be neutral. What’s good for General
Motors is not good for the world, necessa
rily.
Trademark shibboleths
Kurt Mislow, a chemistry professor at
’Princeton,
(whom Cavalieri,
the author,
quotes)
cuts through this bunkum
of
freedom of inquiry:
I will undoubtedly provoke cries
of inquisition and the like, but I
must nevertheless force myself to say
that I don't agree that freedom of
inquiry should be limited only if
actual hazards are perceived. I do not
agree that increased human knowledge
is of paramount importance. I do not
agree that the real enemy is igno
rance.
I think these are trademark
shibboleths which everybody accepts
without questioning.
I can think of
lots of examples where knowledge is
extremely dangerous. And in the search
for knowledge, you have to ask what
you are going to do with the knowledge
once you have acquired it.
No, this is not the deja vu scene of
Galileo. Galileo was found at fault for
using the scientific method itself. We are
not questioning that. We are only ques
tioning the blind fanatics of science and
technology. We are demanding a regulation
of technological applications, not a regu
lation of ideas.
Nor is this Lysenko's history repea
ting. In that case, the Soviet Government
40
and
official
Cavalieri, in this outspoken book (he
himself is a top-rate molecular biologist)
is of the opinion that science, as well as
technolgy, required a certain - amount of
societally oriented guidance at this point
of history. He is against the fashionable
Mt. Everest syndrome—the syndrome that
insists all knowledge should be pursued.
This was "excusable for Bacon or Descar
tes, who perceived no limits to
the
manipulation of nature by man, excusable
because the means of implementation were
not at hand. Neither of these men, nor
their philosophies, threatened society in
their time. But in our techonological
society, with its substantial scientific
resources, such an attitude smacks of
arrogant foolishness."
S.E. Luria, in an article entitled
"The Goals of Science", Bulletin of the
Atomic Scientists 33 (1977), likens scien
tists to ancient burghers :
For the enthusiastic scientist,
the scientific enterprise is a monu
ment to humanity’s intellectual power
and freedom—a modern equivalent of
the great cathedrals that the burghers
of the Middle Ages raised as monuments
to their newly found sense of economic
power and political freedom.
But, if science is a cathedral
raised in praise of intellectual free
dom, one must admit that too often,
under
the pressure of utilitarian
society, the cathedral of science has
come
to look like one of
those
monasteries one sees in the French
country-side, in which a modest church
is
almost hidden by a prosperous
distillery. The sale of products be
comes the justification for
being
allowed to pray to the Lord.
HEALTH FOR THE MILLIONS
FEBRUARY 1984
We Too
In the case of Indian science, the
distillery's products do not even inebri
ate. But the observations of Cavalieri
about recombinant technology are relevant,
even as we have formed a National Bio
technology Board another white elephant
soon created with the promise of genetic
panaceas to poverty, and spiced for good
measure with hazardous E. Coli. The public
will be told not to ask questions even as
its questions about that other monolith,
our nuclear scientific establishment, are
brushed off. Oh for the peaceful uses of
nuclear energy and the recombinant DNA!
BOOK NEWS
UN Policies May Be Based on Myths ?
A Million Villages, 4 Million Decades ?
was released by Earthscan in London (Price
3.00) and Washington DC (price $5 50) on
24th November 1983. The book contains 45
photographs, maps and diagrams of the two
villages, prints of which are available
from Earthscan on request. Write to Ear
thscan 110 Percy Street, London W1P ODE,
UK.
Since 1981, the UN has been engaged in
a "World Water Decade" designed to bring
uncontaminated drinking water and basic
sanitation to two billion Third Worlders
lacking these basic amenities. But, a
report from Earthscan, the London-based
international development information ser
vice, suggests that Third World villagers
may not be all that keen on clean water
and sanitation in the first place.
Written by two Indian journalists, the
Earthscan report, "A Million Villages, a
Million Decades ?", compares the global
generalisations of the UN Water Decade
with the experience of two nearby, but
very different,
south Indian villages.
Both the global and the village views, say
the authors, "contain inaccuracies, half
truths, oversimplification. In time these
become myths, partly reflecting the real
situation partly obscuring it."
"The UN's conferences, years and deca
des must inevitably sloganise, simplify,
generalise", the Earthscan report conclu
des.
"At best the result
is
a new
clarity, greater awareness,
a renewed
commitment to effective development. At
worst,
new global myths are added to a
million local myths."
The global water
HEALTH FOR THE MILLIONS
myths which influence
FEBRUARY 1984
the policies of both international aid
agencies and national governments
are
often based on "peculiarly urban preoccu
pations", suggest authors Sumi Krishna
Chauhan and K. Gopalakrishnan.
One village myth is that water which
tastes and smells good is safe to drink,
and one global myth is that the number of
taps provides a good measure of community
health. Vellakal, fof example,
is poorer
than the other village and has only one
community handpump. According to the acc
epted water decade myths, it should be
less healthy than Guruvarajapalayam vill
age, where higher incomes and more taps
ought
to reduce diarrhoea and
other
waterborne diseases.
In fact, Vellakal is
markedly healthier, probably because of
better nutrition and less cramped housing
conditions.
Appropriate technology generates other
myths, says the Earthscan report. Chlori
nation is being widely promoted by the
UN's water decade as one of the simplest
ways of purifying well water. But the
Indian villagers consider chlorination too
complicated a business, chlorine is not
always available, and measuring out the
quantity needed for each well is tedious.
Morever, they dislike the taste of chlori
nated water.
on ent other hand, the far more complex
technology of electric pumps at the many
village boreholes is handled easily in
both villages. Many families
organise
their lives round the hours when electri
city supply is switched on, whic’h often
means that both irrigation and domestic
chores such as washing are done in the
dark at night.
41
Further Reading on Appropriate Technology
1.
"APPROPRIATE TECHNOLOGY SOURCE BOOKS"
by : Darrow, Ken &' Pam.
Volume One & two
Appropriate Technology Project, Volun
teers in Asia Box 4543, Stanford,
California 93305, USA
Vol - I : 1976 : 304 pp
Vol - II: 1981 : 816 pp
2.
3.
"APPROPRIATE TECHNOLOGY DIRECTORY"
(Tools, Equipments, Machines, Plants,
Processes & Industries)
Appropriate Technology Development As
sociation (I)
Post Box 311, Gandhi Bhavan, Lucknow
226001,
UP 1977 : 280 pp
7.
"PRODUCING LOW COST VISUAL MEDIA"
by : Bale Kenneth
International Planned Parenthood Fede
ration
18-20 Lower Regent, London SW 1 Y 4 PW
England 1980 : 70 pp
8.
"APPROPRIATE
TECHNOLOGY FOR
WATER
SUPPLY & SANITATION" A PLANNER'S GUIDE
World Bank, Washington DC 20433, USA
1980 : 194 pp
9.
"EDUCATION & INCOME GENERATION FOR
WOMEN"
by : Jessie Tellis Nayak
Indian Social Institute, Lodi Estate,
New Delhi-3
1982 : 79 pp
10.
"WELLS CONSTRUCTION"
Action Peace Corps, Information
Collection & Exchange 806
Connecticut Avenue NW, Washington DC
20525 282 pp
11.
"GUIDELINES FOR DEVELOPMENT OF A HOME
INDUSTRY"
Action Peace Corps,
Information Col
lection &Exchange 806
Connecticut
Avenue NW, Washington DC 20525
1977 : 235 pp
12.
"HELPING HEALTH WORKERS LEARN"
A Book of methods, aids and ideas for
instructions at village level by :
David Werner and Bill Bower Hesperian
Foundation, PO Box 1692 Palo Alto
California 94302, USA 1982, or VHAI,New Delhi
13.
"SOLAR COOKERS AND OVENS - TECHNOLOGY
OPTIONS"
Consortium on Rural Technology c/o
FORRAD,
10 Panchsheel Shopping Centre, New
Delhi-17. 1982 : 56 pp
14.
"HEALTH FOR INDIA THROUGH LIVING FOOD
AT LOW COST"
by : Wigmore Rose Garden, 1 Mehar Abad
Ground Floor,
1/594, Warden Road,
Bombay 400 026 1978 : 72 pp
"MINI TECHNOLOGY"
by: Saubolle B R and Bachmann A
Sahayogi.Prakashan, Nepal
1978 : 76 pp
4.
"ECONOMICALLY APPROPRIATE TECHNOLOGIES
FOR DEVELOPING COUNTRIES"
An annotated bibliography
by : Carr (compiled)
Intermediate
Technology
Ltd, 9 King Street,
London WC 2E 8HN, England
1976 : 101 pp
5.
6.
Publication
"SMALL IS BEAUTIFUL"
by : E F Schumacher
Radha Krishna, 2 Ansari Road, Daryaganj,
New Delhi - 2
1977 : 288 pp
"BIOGAS TECHNOLOGY IN THE THIRD WORLD"
A MULTIDISCIPLINARY REVIEW
by : Barnett, Pyle & Subramanian
IDRC - 103 e, Box-8500, Ottawa, Canada
KIG
3 H 9
1978 : 132 pp
'2
HEALTH FOR THE MILLION^
FEBRUARY 1984
A Worker’s Speech to a Doctor
Are you able to heal ?
When we come to you
Our rags are torn off us
And you listen all over our naked body.
As to the cause of our illness
One glance at our rags would
Tell you more. It is the
same cause that wears
Our bodies and our clothes.
We know what makes us ill
When we are ill we are told
That it’s you who will heal us.
For ten years, we are told
You learned healing in fine schools
Built at the people’s expense
And to get your knowledge
Spent a fortune.
So you must be able to heal.
Too much work and the little food
Make us feeble and thin.
Your prescription says :
Put on more weight.
You might as well tell a bullrush
Not to get wet.
You’ll no doubt say
You are innocent. The damp patch
On the wall of our Hats
Tells the same story,
The pain in our shoulder comes
You say, from the damp;
and this is also the reason
So tell us
Where does the damp come from ?
How much time can you give us ?
We see : one carpet in your flat costs
The fees you earn from
Five thousand consultations.
—Bertolt Brecht
FOR PRIVATE CIRCULATION ONLY
WANTED — PROGRAMME PERSONNEL
VHAI requires Programme Personnel to work in its community health and allied programmes, with
experience in community health, training and/ or development of educational programmes and material.
Willingness to travel essential.
POST GRADUATES/GRADUATES IN MEDICINE, NURSING, NUTRITION, SOCIAL WORK,
SOCIAL SERVICES OR MANAGEMENT may apply to the Executive Director, Voluntary Health Asso
ciation of India, C-14, Community Centre, New Delhi 110016. Phones: 668071, 668072.
MAINTENANCE HELP AVAILABLE
Trained maintenance help is available from July 1984 when five participants of VHAI’s Health Equipment
Maintenance Programme (HEMAT) will graduate after a 2+1 years training course.
They have been trained in electrical work, refrigeration, air conditioning, carpentry, plumbing, simple
hospital equipment, building latrines, how to tap alternate sources of energy and simple medical electronics.
For details of graduates' biodata and other details, write to :
Ravi Srinivasan
VHAI, C- 14, Community Centre
S D A New Delhi 110016.
HEALTH ACTION SERIES—DIARRHOEA
The special issue of HfM on Diarrhoea is being reprinted in booklet form as Health Action Series I and
will be ready soon. For details and advance orders write to :
Augustine J Veliath
Voluntary Health Association of India
New Delhi.
Vol. X No.
,
At the time of the
crusades, Godefory de Bouillon,
Duke of Lorraine, had placed the
Double Red Cross on his stan.
.
HEALTH FOR THE MILLIONS
Vol X
No. 2
April 1984
Pg. No.
In this issue:
Mira Shiva
TB — How much do you know?
This issue of HfM was
put together and
produced by
Augustine Veliath (Editor),
Aspi B. Mistry, Mira Shiva,
Chandra Kannapiran, Gloria David,
Padam Khanna, P.T. Thomas;
K. Murthy and P. George.
L.
Owned and published by the
Voluntary Health Association
of India, C-14 Community Centre,
S.D.A. New Delhi 110 016 and
printed at J.K. Offset Printers,
Jama Masjid, New Delhi.
6
Mona Daswani
A Profile of Tuberculosis
10
Mira Sadgopal
Health "Care" vs The Struggle for Life
16
Indira Kotval
A Tuberculosis Control Programme
26
J.S Majumdar
Producution of Anti-TB Drugs
31
Annie George
Better Care in TB
36
VHAI Information Service—
Facts on File
46
(Continued from Cover)
dard when he took possession of Jerusalem in 1099, and, after his return to France,
it became the emblem of the House of Lorraine.
The Double Red Cross was considered singularly appropriate as the rallying sign
for the crusade against the most deadly scourge—Tuberculosis—which afflicts man
kind. Proposal for its adoption as the International Emblem of the campaign against
tuberculosis was moved by Dr. Sersiron, on October 23, 1902, at the International
Tuberculosis Conference in Berlin. The proposition was adopted unanimously.
The Council of the International Union Against Tuberculosis, Paris, in September,
1928, decided that National Associations which are members of the Union should
adopt this emblem with a recommendation to the effect that it be legally registered in
order to prevent its use for commercial purposes.
In 1957, the Tuberculosis Association of India requested the Ministry of Commerce
and Industry, Government of India, to patent the Double-Barred Cross in favour of this
Association and against fraudulent use of this emblem by others. The Central Govern
ment by their Notification No. 4 (3J-TMP/57, dated 13th July, 1959, included in the
section of the Emblems and Names, the Double-Barred Cross as the emblem of the
Tuberculosis Association of India.
The TB Situation in India
*
■
.
.
.
■
.
"If the significance of a disease is Mona Daswani, "A Profile of Tuberculosis,
measured by the ' number of victims
it Page 10) are to form the basis of the
claims, then all other diseases — must strategy against tuberculosis, much more
rank far behind tuberculosis. Statistics commitment is required in terms of re
show
that half- of mankind dies' from sources, both material and human.. While
tuberculosis
and that, when only
the the Sixth Plan outlay, for the National
middle, productive age groups are consid Tuberculosis Programme is Rs. 7 crores, it
ered, it carries off one-third and more. has been estimated that nearly Rs. 55
The public health services thus have reason crores is actually needed if the programme
enough to devote their attention to so is to be really effective.
deadly a disease ... It therefore seemed a
pressing duty, above all else, to institute
Notwithstanding the fact that TB control
detailed investigations into tuberculosis" is now part of the 20-point Programme,
(Koch, 1882)
"every time demands for increased funds are
When Robert Koch was writing these words
more than a 100 years ago, tuberculosis had
already started declining in western coun
tries as a result of the improvement in the
standard of living. Yet very recently the
World Health Organisation was moved to
declare that "the world is experiencing an
epidemic of tuberculosis. It is the most
important specific communicable disease in
the world as a whole..... " It becomes
abundantly clear that the burden of this
, epidemic is being borne most by the Third
World, where there has been no comparable
improvement in the standard of living and
where the number of TB cases is increasing
' yearly.
In India it has the status of
killer number one,
in the hierarchy of
deadly diseases, "the Captain of all these
Men of Death".
the
situation is
In this country,
particularly acute.
It has been reported
that almost 12 million people suffer from
TB, of whom nearly 6 lakhs die annually.
By the time you have finished reading this
editorial,
somewhere in India,
2 more
persons would have died of TB.
In the time
it takes to read this special issue on TB,
nearly 100 persons would have died of the
disease. Yet only ten of these deaths
would have been identified as being caused
by tuberculosis.
The Government's own estimate is that 10
million are suffering from this disease,
but barely 10 lakhs have been identified.
If case-finding
chemotherapy
and
•
HEALTH FOR THE MILLIONS
(See
made, the government trots out its old
excuse that finances are hard to come by".
Writing in the Sunday Observer (11-17 March
1984) Nikhil Lakshman reports further that
this is" a defense deflated by the esti
mates committee's findings that, except for
1977-'78, the actual amount spent on health
has always been half the proposed outlay.
In 1981-'82,
for instance, the sum sanc
tioned was Rs. 216.79 crores, while the
actual amount spent was only Rs.
100.85
crores.' Surely a part could go to fight TB
.... Surprisingly, in contrast,
the Bombay
Municipal Corporation (BMC) has undertaken
its TB programme on a war-footing. The
first organization in India to introduce
short term chemotherapy in its campaign,
the BMC has set aside Rs. one crore for
these drugs, organised 90 diagnostic cum
treatment centres and also started making
rifampicin for the city’s TB patients".
We have a first hand account of one
aspect of this programme from Indira Kotval
in Bombay ("A Tuberculosis Control Programme" Page 26 ) in which she describes
her experience in a voluntary organisation
working with the BMC.
v
In sharp contrast, in "Health 'Care' vs
The Struggle for Life"
(Page
16 ), Mira
Sadgopal from Kishore Bharati, In Hoshangabad, describes vividly, the problems in the
field,
in the rural areas,
where the
patient is literally at the mercy of the
medical establishment. J.S. Majumdar (Production of Anti-TB Drugs, Page 31
)
has
dealt with the dynamics and politics of
anti-TB drug....production
and
the ....
role of the
t ..
,
• .«>::•/J2 mini. • ■
.
APRIL
1984
.
i
multinational^companies.
While this is planned to be a special
issue on Tuberculosis, we do not in any way
see it as the final word on the subject.
In this first part we have laid more
•emphasis on problems in the field and
concrete experiences of individuals and
groups rather than on the medical aspects
of TB.
If the socio-economic and political
aspects seem underlined,
this is a cons
cious effort to make this issue into a
"curtain-raiser” for a more extensive and
in-depth debate, that we hope to follow up
in subsequent issues with the co-operation
and enthusiasm of our readers. The res
ponse to the diarrhoea issue has emboldened
us to introduce a "Readers Forum" and we
hope
that
this will be a continuing
feature. We invite not only feedback on
this issue and specifically on the script
for "Better Care in T.B."
(See Page 36 )
but also other' articles and news items both
on TB as well as on other health issues.
-Editors.
Readers’ Forum
Dear Averthanus, Mira and Augustine,
oral rehydration I believe that you
should mention the use of a naso
gastric tube before recommending the
need for intravenous fluids.
Health for the Millions, Volume 9, Nos.
5-6. Diarrhoeal Disease
Congratulations on a tremendous piece of
work.
You have really searched the lite
rature for practical and relevant aspects
of how to manage and control this problem.
If I can make any criticism, it is perhaps
that you have tried to include too much in
one issue so that some people may be a
little daunted about where to begin. As an
old friend of VHAI, and of each of you
,
*
individuallyI hope that you will permit
me to make a few comments about some of the
articles.
1.
2.
2
On page 3 you start with a definition
of diarrhoea which is very numerical.
The normal stool pattern has such a
wide range of variation that I always
think a practical definition is that
diarrhoea is a change from the normal
pattern,
to stools which are
more
liquid, or different in consistency and
appearance etc.
to give the mother
concern.
For epidemiological studies
you may have to adopt a particular
number as a cut off point in2' defining
diarrhoea.
On page 17 when discussing the^problem
of vomiting during administration of
3.
On pages 20 and 21 under the heading
antimicrobial agents I felt that the
lowest three asteriks do not seem_ to
follow logically from what you have
said above and could cause confusion.
At the very bottom of the page you end
with a sentence "Below we give some bf
the commonly misused antibiotics" and
there then follows immediately a table
of the only antibiotics recommended by
WHO! What you might have mentioned in
the section on antibiotic prescribing
is the danger of resistant organisms
from R factors and problems ’arising
from inadequate dosage.
While on the subject of antidiarrhoeal
agents,
it might have been useful to
give the references of two trials which
showed that kaolin was quite ineffec
tive. I will giver these below.
Recently I had reason to look through
the
literature on the antimotility
drugs including the opium analogues
Diphenoxylate and Loperamide. They have
both
been
shown to be remarkably
effective in 'rats, but all the clinical
studies so far are disappointing. MoreHEALTH FOR THE MILLIONS
APRIL
1984
over, they are potentially dangerous in
children because of their central seda
tive effects.
4.
On pages 28 and 29 I was very interest
ed .to see the relative costs and the
large number of oral rehydration pac. kets on the market. At first I was
confused by the statement that a packet
of Electral cost 7 NP!
5.
On page 38 you describe alternative
medicines for diarrhoea.
I have no
doubt
that some of these may
be
valuable, but perhaps it should be
pointed out that they should also be
subjected to clinical trials as applied
to kaolin and Diphenoxylate. The symp
tom pictures overlap confusingly.
In
some thirst and sweating, indicating
dehydration are not followed by any
recommendation
about
giving
extra
fluids, which we would consider important whatever medicine is being admini
stered. Symptom group G appears to be
steatorhoea and H dysentry or possibly
gi.ardia infection.
6.
On page 42 you describe traditional
remedies including simple fluids. It is
now known that rice congee mixed with
'Courtesy :
HEALTH FOR THE MILLIONS
APRIL
1984
an appropriate amount of
excellent for rehydration.
salt
is
7.
On page 50 you deal with
certain
controversies. There are
of course
philosophical differences between
a
home and pharmacy made fluid.
However,
the most important point is that for
each degree of severity there may be an
appropriate treatment. In extreme cases
intravenous fluid with precise replace
ment of lost salts and pH correction is
essential, while in the mildest cases
drinks of water can be useful.
8.
At the bottom of page 52 you state
"two-thirds of all illnesses in India
are related to water-borne disease". I
do not believe this is true in view of
the numbers of respiratory infections
and cases of malaria.
9.
I was happy to see on pages 60 and 61
the broad responsibilities which VHAI
feels it has in diarrhoea care. It may
be necessary to focus on a few of these
initially. In recent months I have been
particularly aware of the problem of
conflicting messages about the right
way to prepare oral rehydration fluids
and the consequent confusion in both
IOCU Action Pack
health workers and the lay public.
I
believe there is a real need to find
what is the most appropriate message on
a
national or regional basis
and
campaign for that message. Otherwise
many different methods of mixing salt
and sugar may result in wrong formu
lation of fluids which may be ineffec
tive or harmful. This can seriously
damage and undermine what is potentialy
a valuable and life-saving treatment.
To identify and • propagate the most
appropriate method is an
important
challenge.
With greetings and best wishes.
Yours sincerely,
William A.M. Cutting
Senior Lecturer in Child Health,
Dept, of Child Life and Health
University of Edinburgh
References:
Watkinson, M. (1982) A lack of therapeutic
response
to kaolin in acute childhood
diarrhoea treated with glucose electrolyte
solution. J. Tropical Paediatrics, 28. 306307.
Alestig,
K., Trollfors, B. And Stenqvist,
K.
(1979) Acute non-specific diarrhoea.
Studies on the use of charcoal,
kaolinpectin and diphenoxylate. The Practitioner
222. ,855-862. ,
The entire concept of ORT has been to reach
health care into the hands of the people,
especially the deprived sections of so
ciety. The etiology of diarrhoea and its
association with contaminated waters and
thus with poverty has been established
without doubt.
In this section, we assume that the people
who we are taking the message of ORT to are
poor enough not to possess a measuring
spoon. And in the same breath,
in the
Indian context, that too, we expect them to
have a tin, a pair of scissors, a pencil, a
bottle cap, a glass, wood, a drilling
machine and bolts and moreover the techn
ology to measure in centimetres and to be
able to drill into wood. Not to mention
the fuel required to burn pieces of wood. A
simple question could be asked - would it
not be more economical just to possess a
simple measuring spoon rather than all
these exotic items and gadgets mentioned
above? If the poor man had enough fuel to
make a measuring spoon, his children would
have had a much lesser chance of contrac
ting diarrhoea and therefore needing ORT.
If the aim of propagating the ORT is to
make people independent then it is nec
essary to be vigilant so that no further
dependence is created on either the medical
system or on any industrialist due to the
prescription of a complicated and even
unnecessary methodology. It would be much
simpler to tell the woman to give her
dehydrated child her down to earth "nimbu
pani" and I can bet she will add just the
right pinch of salt and the proper handful
of sugar.
We are very grateful to Dr. Cutting for
.hie insight and comments. As there has been
a tremendous demand for the Diarrhoea Issue
of HFM, we are reprinting this issue in
booklet form. Needless to say, almost all Sincerely,
, the suggestions and corrections mentioned
Ms. Manisha Gupte Awasthi
above have been included
- Editors.
Dear Sir,
Research Officer.
The Foundation For Research
Health
in
Community
This letter is with reference to your
October-December 1983
special issue on Dear Manisha,
diarrhoea and in particular to the section
on making measuring spoons for preparing a
Thank you for your letter. I truly
"special drink". I hope that section has appreciate the points raised by you.
been printed just as a joke,
becuase
otherwise in the Indian context it is
I must make a few clarifications first.
certainly appalling to realise that in the HFM ie geared to 'Health Personnel' in the
process o^demystifying medicine, what has field.
actually been achieved is pnly .further
mystification.
I agree with you that most poor people |
4 »
HEALTH FOR THE MILLIONS
APRIL
1984
do not have spoons and therefore, it is all aspect was not dealt with here.
theK more imperative that those involved in
training health workers can help the health
For those of us involved in health work
workers, produce for themselves standar- >in the field, it is painfully clear that
dized the measures. A health worker should most of the health problems have their
be familiar with the differences of volumes roots in poverty. Neither ORT nor health
of salt and sugar with pinches and scoops care is the answer to that.
of • different individuals. The
need to
standardize the measures to a safe limit is
ORT alone can never be an answer to
not mystifying ORT. Being involved
in even diarrhoea care, but ensuring some
training of different levels of health change in diarrhoea management, in
even
personnel in the field, I realize the 50% health institutions, is definitely not
confusion and chaos that exists regarding adding to mystification.
measurements related to simple ORT.
The creation of unnecessary dependence
If rehydration is started early enough, by well intentioned medical technologies is
simple solution, weak tea, rice kanjee, any a very genuine fear Manisha, which I^share
fluid will do. There is absolutely no need with you.
for measurements. Measurements are relevant
only for moderate and severe dehydration
I thank you very sincerely for your
and if health workers can share this in honest feed back.
turn with mothers as they are 'doing in
numerous community health programmes all With regards,
over
India,
I really don't see
any
mystification.
I Yours sincerely,
The central page that you were so Dr. Mira Shiva
critical about is from David
Werner's
'Helping Health Workers
Learn'.
These Dear Sir,
methods have been used in Latin America,
and I really see no reason why a little bit Recently for the first time I came across
of creativity and excitement cannot be y°ur
bimonthly
publication
added in the training programmes. Preparing 'Health for the Millions' (vol. IX: No. 5these gadgets is a team building exercise
•
in itself, for the trainers and the health
workers. It is not at all necessary to do Let me tell you it is simply excellent. It
it, if it doesn't make sense.
:has made the matter of Paediatric diarrhoea
management simple for me and
I
have
also
If you read the chapter on Traditional prepared some charts out of the issue to I
ORS, where the rationale of rice kanjee educate my patients.
etc, is given, you will realize that the
purpose of this diarrhoea issue is not to 1 wou^-d request you to send me "Health for
mystify. Talking about 'nimbu pani', nimbu the Millions" regularly at my residential
is not very easy to buy in
all the address.
villages
, it costs anywhere
up to 30 to 50 Dr. Jayesn N. Jam,
, .
. y
M.B.B.S.
vaise even where available.
________________________
Our objective is to get the hospitals
who
are
VHAI members to accept
the
rationale of ORT and incorporate it even in
the hospital situation. There is enough
material for training of VHW's and lay
^people. There is very little for doctors
cand middle level workers in the field. This
tissue is to fulfill that need..
Pleas© send your feedback to:
Editorial Team
Health For The Millions
Voluntary Health Association
of India,
C—14 Community Centra
S.D.A< New Delhi 110 016
Another issue of Hf/M had dealt with
water
and sanitation, therefore,
that
health for the millions
APRIL 1984
5
MIRA SHIVA
TB: How much Do you Know?
(For the correct answers :See page 25)
8.
1.
How many diagnosed TB
in India ?
4
6
8
10
2.
cases are there
Free
On payment
Million
“
How. many of
open cases?
9.
them are
Sputum positive cases only
Suspect cases contacts
10 . Treatment recommended is for
In India how many die of TB per year ?.
* 10 lakhs
15
30'
50
4.
Incidence of TB
more common in
Under the National TB Control Programme
treatment is offered to
infective, i.e.
1
Million
1.5
2.5
3-5
3.
Under the National TB Control Programe
diagnostic facilities and treatment are
supposed to be offered
12 months
18
20
24
11 . Short term anti-TB treatment is for
per 1000 population is
6 months
9 months
12 months
12 . The dose of INH recommedned is
Rural areas
Urban areas
Equal in Rural and Urban areas
5.
What is the percentage of
cases in the rural areas ?
20 %
40 %
60 %
80 %
6.
The incidence of TB is
Increasing
Decreasing
Same
7.
The number of TB cases is
Increasing
Decreasing
6
total
TB
100 mg - 3 times a day
300 mg as one dose daily
e
13 ; Which is the best diagnostic test for
Tuberculosis?
•
E s R
Sputum for AFB
Sputum culture
X-Ray
• •
•
.
.
’i»i
\
'
' ■
14 . Is Mantoux ( P P D testing) recommended
as part of the National TB Programme ?
Yes
No
15 . Is B C G recommended ?
Yes
No
'HEALTH FOR THE MILLIONS
APRIL 1984
1'6. The incidence of TB started falling in
UK in early 20th century because of
20.
Improved socio, economic status
Anti TB drugs
Vaccination
What kind of a problem is TB ?
PhysicalPsychological
Economical
Social
All
The highest incidence' of TB in the
world is in India and highest in the 21. In a district of 5 lakhs population how
community of
many cases of TB can be expected to be
found ?
Tribals
Tibetans
100
Katkaris
250
500
18. How many people does' an infective TB
case ( not on treatment)
infect in one 22. The health budget as a percentage of
year on an average ?
the total budget in the First Five Year
Plan (1951-56) was
2
4
2.6 %
8
■3.0 %
10
3.3 %
V
17.
19.
One out of how many cases
cough is a case of TB ?
20
25
30
35
of chronic 23.
The health budget in the 6th Five Year
Plan (1980-85) is
1.2 %
1.9 %
2.0 %
24.
The percentage of population
below the poverty line is
being 30.
10 %
40 %
50 %
80 %
25.
27.
MOST
Gita (3 years) with a rising weight
curve
In a child, where would you most often
expect to see lymph nodes enlarged by
TB ?
Munni with kwashiokor
Buntu Who
recovering
31.
Which of these is true ?
is underweight
from measles
is
and
An adult with infectious TB is usually
Completely well
All patients with TB are infectious
so ill that he has to stay in bed
Patients are only infectious if
live TB bacilli are leaving their
bodies .
Well enough to work
32.
A primary TB infection USUALLY causes
Which of these diseases is LEAST likely
to cause difficulty when you are trying
to diagnose TB ?
Malnutrition
Cerebral malaria
Which of these children is most likely
to have TB ? The child who
Chronic pyogenic lower respiratory
infection following measles
has had mild fever and a cough
a week
for
Chronic urinary infection
has had tender
neck for 3 days
his
Chronic pyogenic lower respiratory
infection following whooping cough
swellings in
33.
does
not recover several
after whooping cough
weeks
has a chronic
infection
upper
A child who has been given BCG
Will not become ill with TB
Is less likely to become
TB than a child who has
given BCG
has otitis media
respiratory
34.
29.
have
Sita with marasmus
Severe symptoms
No symptoms
Mild symptoms
28.
children
Poonam who is newborn
In a child's neck
In the axilla
In the groin
Under the jaw
26.
Which of these
immunity To TB
ill
not
with
been
used
for
APRIL
1984
BCG contains
TB presents as the child who
is not well and has had mild
and loss of weight
Toxoids
Living organism
Dead organism
Antibiotics
fever
has chronic abdominal swelling
35.
has had a high fever for 4 days
passes blood in his stools.
8
Which of these is not
preventing or treating TB ?
Thiacetazone'
HEALTH FOR THE MILLIONS
BCG
Penicillin
Isoniazid
PAS
36.
Which of these is true ?
TB in'children seldom presents as a
cough with blood stained sputum
A different kind
infects children
TB is a
children
of
TB
been well for 4 weeks and who has
lost two kilos in weight.
38. Harsha ( 3 years ) had pneumonia four
months ago. He was treated with peni
cillin and he recovered a little but he
still had a cough and fever and was
losing weight. He was given INH for 3
months and is now much better.
Should
he
organism
more chronic disease
Stop his INH
Go on with it for a year.
in
39.
Children get TB
often than adults
meningitis
less
Which of these diseases
slowest ?
Cerebral malaria
Tuberculosis
Tetanus
Septicaemia
Diarrhoea with dehydration
Children infect one another whereas
adults do not
37.
Which of these
to have TB ?
children is most likely
40.
Prabha
(6 months) who lias had a
cough for 3 days with respirations
of 80 per minutes
kills children
Ta-ra is 3 years old. His elder brother
(21 years)
is sputum positive. Tara
himself has no symptoms. He should be given BCG and
care register
Usha (5 years) with chronic abdomi
nal pain who has gained a kilo in
the last six months
put on the special
told that, there is no need to worry
and sent home
Asha
(18 months)
who is always
coughing and wheezing and who has
gained 3 Kg during the last nine
months
given
streptomycin,
and isoniazid
thiacetazone
given PAS (aminosalicylate) only
Vidhya (2 years, 38.2 C)who has not
given streptomycin only
LIFE SKETCH
ROBERT KOCH was bom on 11 December 1843, in Clausthal village in
the state of Hanover in Germany
*
He qualified as a Doctor from
Gottingen University in 1866. He set up a primitive laboratory in
his own backyard from where he launched a memorable hunt for mic
robes. He succeeded in isolating and demonstrating the microbe and
proved it to be the cause of TB ih just one year. He called it the
’•Tubercle Bacillus”.
Koch is known to have visited J.J. Hospital in Bombay and the Ins
titute of Veterinary Research in Mukteswar (U.P.). In 1905 he was
awarded the Nobel Prize in Medicine for his work on Tuberculosis.
Koch died of a sudden death caused by cardiac arrest on 27 May 1910.
(From Swasth Hind, June 1982)
HEALTH FOR THE MILLIONS
APRIL
1984
9
MONA DASWAN I
A Profile of Tuberculosis
Tuberculosis has been known to man from
ancient times; the earliest medical name
was,
’’phthisis”, derived from the Greek
word literally meaning to waste away.
In
1882> Robert Koch identified the cause of
the disease to be the tubercle bacillus.
Today we have all the weapons required for
control of the disease:
-
the BCG vaccination
tive measure
as
a preven
X-rays and laboratory analysis to
facilitate detection
effective
llus .
drugs
against the baci
However, TB continues to be a major health
hazard in the developing world.
In India
alone there are an estimated 12-15 million
people who suffer from TB, resulting in
half a million deaths per years(2).
X-ray of the chest which will show
a shadow, known as infiltration
presence of bacteria in the sputum
(distinguish between
saliva and
sputum, which is coughed up spont
aneously from the lung in
the
morning)
tuberculin or Mantoux test; if a
person has a natural resistance
they will show a positive reaction.
From the point of view of disease
control at a national level, there are two
fundamental issues to be considered
:
whether to choose a preventive measure such
as mass immunisation; or detection of all
infectious cases and treatment of these by
chemotherapy. The pros and cons must be
carefully analysed in the context of each
particular disease.
Disease Control
The main source of the infection is a
person who has already contracted
the
The BCG vaccine against TB has been in
disease.
IT is transmitted when droplets use since 1921. However, the effectiveness
containing the bacilli coughed into the air is still a matter of countroversy. A recent
are inhaled by a healthy person(3).
These study was conducted by the Indian Council
droplets pass into the lung where the
bacilli are able to multiply. Although the
most commonly affected organ is the lung,
the
infection may also occur in
the
kidneys, bones, meninges or even be dis
seminated throughout the body.
It
is
estimated that an individual who is a
moderately infectious case is capable of
infecting 10-12 other individuals within a
period of one year(4).
If such a case is
not treated, the person will survive for
about two years: during this time 20-25
healthy individuals face the
risk
of
infection.
The leading clinical
symptom is a
persistent cough. This may be accompanied
by fever, fatigue and loss of appetite. A
complete clinical diagnosis of TB is done
by:
10
HEALTH FOR THE MILLIONS
APRIL
1984
of Medical Research in Chingleput District,
Tamil Nadu(5). Between 1968-71,
2 l^kh
persons above the age of one month were
vaccinated. In the same area *
80,000
people
comprised the control non-vaccinated group.
For the next 7 1/2 years there was a
continuous monitoring of the incidence of
.TB in the area base on tuberculin tests and
sputum analysis. When the data was decoded,
it was found that the number of TB cases
was slightly higher in the adults who had
been vaccinated. Therefore the vaccine was
not effective as a preventive measure.
However this evidence was not extrapolated
to infants, and the vaccine is still used.
Since the discovery of streptomycin
there are a whole range of drugs effective
against TB. The major draw-back of chemo
therapy is the long duration of treatment
for 18-24 months.
It is difficult
to
motivate the patients to take the drugs
regularly. When treatment is not continuous
there
is
the danger of the bacteria
developing resistance to the drugs, causing
additional problems. However today there
are short-course drug regimens
of 6-9
months that are highly effective, of low
toxicity and well-tolerated(6).
Since the efficacy of the vaccine is
questionable and the primary source is the
infected population, it is now felt that
chemotherapy is more effective than vacci
nation as a control measure(7). A study
group set up jointly by the World Health
Organisation and the International Union
Against Tuberculosis in 1932 states that
the most powerful weapon is a combination
of case-finding and chemotherapy(8). The
case-finding will locate the source and
chemotherapy eliminate the overall risk of
infection in the community.
Althogh the causative
agent
is a
bacillus,
it is now accepted
that
a
combination of socio-economic factors serve
to aggravate the problem^ Undernutrition,
poor hygiene, lack of water and persistent
(infections such as diarrrhoea decrease the
level of natural resistance in an indivi
dual (9). The inadequate housing results in
^overcrowding
and a greater degree
of
jcntact vfith infected persons increases the
risk’"faced by healthy individuals (10) .
suffer from ailments of the lung as a
result of overexposure to dust and other
particles face a special risk. Infact, an
evaluation of the control programmes in the
country observed that TB is becoming a
disease of the elderly males(12). This is
interesting in that it serves to subs
tantiate the evidence that the most vulner
able groups are those working in quarries,
mines, textiles and other industries where
the
nature
of
the
work has health
hazards(13).
Occupational Hazards
In a small town in Madhya Pradeshi
called Burhanpur, the incidence of TB isf
150/1000, which is the highest in the
country (14). This a premier handloom and.1
TUBERCULOSIS IS CURABLE
The Story of Wise Vithoba
A flash Card Series
by
VHAI
and
FRCH
...pg 13
It is also recognised that certain
groups of people are more susceptible to
the disease(11). Among these those who
HEALTH FQR THE MILLIONS
APRIL
1984
11
Tuberculosis in Ancient Times
From the various skulls and other
bones which have been recovered from
different parts of the world,
tuber
culosis was found to be evident in
Neolithic man.
The Egyptians of ant
iquity ma,de statuettes,
engravings
and paintings on stone and recorded
some descriptions of consumptives.
Their mummified bodies have revealed
definite evidence of tuberculosis of
bones and joints. Tuberculosis as
was
evident in mummies indicated
that,
as early as 5000 B.C., man
suffered from it.
Hippocrates (460-377 B.C.)
also
devoted part of his attention to
tuberculosis.
He opined that attenttion to the tuberculosis patients was
a waste of time and that they were a
burden to the state.
In the famous
library of Leipzig, there is a folio
which contains information that Jesus
suffered from this 'condition.
During the dark ages,
all know
ledge of disease was lost.
Touching
the king's feet for the cure of
King's Evil (as tuberculosis diseases
were then known) wds prevalent during
the
11th
and 12th centuries in
England and elsewhere.
In Britain,
Edward the Confessor (AD 1004 - 1066)
exercised the right of touching the
tuberculosis patients for the relief
of the King's evil. Queen Anne was
the last English ruler who practised
quack medicine for the treatment of
King's evil.
Madhya Pradesh showed that among 8,822
colliery workers, 10 % had pneumoconeosis
and 118 of them had both pneumoconeosis and
TB(15).
Another deathly
respiratory disease
caused by exposure to high levels of silica
dust
is silicosis or the black
lung
disease(16). Silica exists in three forms :
quartz, tridymite and cirstolabite.
Of
these quartz is ubiquitous on the surface
of the earth and is used in abrasives,
refractories, ceramics, paints, fertilisers
and many manufacturing processes. Silicosis
tends to increase the individual's suscept
ibility to TB and also makes the symptoms
of TB more severe(17). The combination of
the two which is Silico-TB is fatal and
leads to death.
A study conducted on the plight of
agate workers near Surat showed the popu
lation to be highly prone to
various
categories of lung diseases(18). During the
processing of the stone, there
is
a
particular grinding procedure which produ
ces- a lot of silica dust resulting in a
high incidence of silicosis
among the
workers. There are other industries where
the working conditions are . filled with
occupational health hazards(19). A worker
in the engineering unit of a plant manufac
turing
motors found he was constantly
spitting lumps of black particles. He was
diagnosed as a TB case and the lumps found
to be small particles of iron to which he
had been over-exposed. Even in a-.'tailoring
establishment where workers stitch heavily
iStarched clothes all day the risks of TB
are unusually .high.
Government Programmes
From the Textbook of Tubercu
losis, the Tuberculosis Asso
ciation of India.
•. v .
The Indian Council of Medical Research
conducted a sample survey in 1955-58 to
provide a base for anti-TB work » in- 'fhe
country. The National Tuberculosis Progr
amme was finally launched in 1962 with ar
emphasis on (20):
bidi centre. There are powerlooms installed
in most houses where the workers are const
antly inhaling fibre and dust. Coupled with
—
early detection and treatment
poverty, squalor and congestion, the people
vaccination
rapidly develop a respiratory ailment call
training centres in each state
ed pneumoconeosis, which eventually pro
Rehabilitation
gresses to tuberculosis. Pneumoconeosis is
.research
also caused by prolonged exposure to coal
dust. A survey conducted in the richest However this control programme has failed
coal mining area in the country,
the to have an impact and the total, number of;
Jharia-Raniganj coal belt in Bihar and TB cases are actually on the rise. An
12
HEALTH FOR THE MILLIONS
APRIL
1984
expert committee set up by the ICMR found If the patient does return to the clinic
that the national TB programme was ineffe his case may be accurately diagnosed, often
ctive as the case finding was poor, there after several months. The lack of co
was incomplete registration of cases,
60- ordination between the place of diagnosis
70% of the patients were not completing and place of treatment leads to frustration
treatment and BCG coverage of children was and the compliance of the patient drops.
poor(21). Recently the government has in
cluded TB control in the Nation's revised The Community Approach
20-point Programme and the ICMR has identi
fied priority areas in TB Control and
A group from a Community Centre working
evolved
programmes to facilitate
it's with women from a slum community in that
control(22) .
area found that the best way to tackle the
problem was to involve the people in their
Let us take a representative area in own health care(24). The knowledge about TB
Bombay which is endemic for TB and examine being a health hazard was wide-spread,
how the government facilities operate(23). however the people did not know how to
There is a recognised TB clinic in the taokle it. The community centre got' itself
vicinity, and when a person develops a recognised as a drug dispensary. They used
persistent cough, he may visit the clinic. the clinic as a referral service, however
Here an X-ray is taken, the sputum analysed
and if both are positive a tuberculin test
done. There are 10 different drug regimens
which have been worked out and based on the
results of the tests an appropriate course
of treatment is prescribed. The patient is
told to get his medicines from a drug
dispensary close to his home or work-pl^ce,.
whichever is more convenient. As a follow
up measure there are health workers who
visit the patient at home after a couple of
weeks.
It seems like a fool-proof system on
paper, however what actually occurs is
confusion. A patient on going from the
clinic to the drug dispensary often finds
that his casepapers have not yet been
transferred, hence the dispensary does not
know what drugs to give him. He is forced
to make repeated visits to the dispensary,
which he can ill afford. If by some lucky
chance, however, he does manage to procure
the
drugs, he is not told that
the
treatment will be for a couple of months at
least. Hence he takes his medicine,
the
cough gets better, which to him is an
indication to stop treatment. However he
finds in a‘ few days the cough returns.
Therefore another trip to the dispensary to
get another injection or more dtugs. The
danger of stopping and starting treatment
in this fashion is that the bacteria may
develop resistance to the drugs and the
patient will not show a positive response.
Since the dispensary only hands out drugs,
they do not pick tip the incidence of drug
resistant cases. Thus when the patient
returns for further treatment they give him
the same regimen which may now be useless.
HEALTH FOR THE MILLIONS
APRIL
1984
1. This is Vithoba and his wife
Rukhmani.
They share the joys
and sorrows of bringing up their
family.
they have two children,
Krishna and Shoba. They have
been
living happily together
but.....
...pg
17
13
------------ ------------------ — - — . -
Koch’s Discovery
The real turning point in the history of tuberculosis occurred on March 24,
1882, when Robert Koch, a former country doctor from East Prussia, announced to
the Physiological Sodiety of Berlin that he had identified and cultured the
tuberclebacillus.
Though the infectious nature of tuberculosis was first established by Jean Antoine Villemin, he was not able to isolate the agent responsible for the
disease, and his report received a very hostile reception especially from the
then prevalent notions of the scientific world, dominated and propagated by no
less a person than Rudolf Ludwig Karl Virchow, the creator of modern pathology,
who had caused a revolution in medical thinking. Virchow then was the Director
of the Pathological Institute (Berlin) which had been specially built for him.
The Pooh Bah of Pathology that he was, Virchow scoffed at Villemin’s imperfect
proof and inability to isolate the causative agent.
Koch was well aware of the mistakes of Villemin and the reception Villemin's
paper had from Virchow and his cohorts. The lion of pathology
(Virchow)
dignified the meeting of the pathological society on that day (March 24, 1882)
with his presence. We can well imagine the shock he received when he sat
patiently listening to Koch’s accounts of his experimental proof, executed
without a flaw and complete to the last essential detail. Virchow sat silent
.witnessing the demolition of his dualism theory, the dogma he perpetuated for
the past 30 years, by a comparatively unknown Prussian doctor. Koch's address
over,
the Chairman called for discussion, but there was no discussion. The
audience was spell-bound. According to the version given by Ehrlich who was
present at the meeting, all eyes turned to Virchow as though demanding an
explanation. For once the Pooh Bah of pathology had nothing to say even though
the fortress of dualism propagated by him had come tumbling down and lay ruined
for ever. At the end Koch said, "I have performed my investigations in the
interest of public health, to which I hope they will bring greater benefit."
- adapted from ’’Pulmonary Tuberculosis"
by M.P.S Menon
they ensured that the papers were trans-I perfectly capable of doing the disease as
ferred on time. The people were informed \well
as
collecting
the
sputum
for
about the duration of treatment and each analysis(25) . However basic pathological
case carefully monitored. They were fore- facilities and an X-ray Unit are absolute.
warned about problems of drug resistance requirements for accurate diagnosis in thei
and pressure from the community was exer- case of tuberculosis. Thei important message
cised for difficult patients. The problem is that these are to be used as referral
was tackled at a community level using the facilities.
Increasing the
number
of
family as a unit, rather than singling out clinics alone will not reduce the incidence'
an individual.
of the disease. In fact the World Health
Organisation has recommended that tuber
culosis programmes be integrated into the
primary health care. For developing countThere is hope that with awareness and ries
this will translate itself
into
■health education it is possible for people reality only when the majority of the
to cater to their own health needs. Even in people gain access to a meaningful form of
the rural areas village health workers are health care.
14
HEALTH FOR THE MILLIONS
APRIL
1984
This article was written in September 1983
and we are grateful to Mona Daswani, The
Foundation
for
Research
in Community
Health, Bombay, and Centre for Science and
Environment, New Delhi for permission to
reproduce it in HfM:-Editors
10.
Stott, H.,How treatment has evolved.
World Health, p.24-28, January 1982.
,11. WHO Expert Committee on Tuberculosis,
Technical Report Series No.552, World
Health Organisation, Geneva,1974.
12. Chakraborty, A.K.,Communicable Disease
Control, All Indian Institute - of Hygi
ene and Public Health, Calcutta, 1980.
13. VHAI'S
role in TB Care, Voluntary
Health Association of India, New Delhi,
March 1983.
30th March
14. Divedi, U. , Indian Express,
1980.
REFERENCES:
15. Miners in
1983.
Death,
Daily,
13th
: A Slow Death,
16. Dogra, B., Silicosis
Economic Scene, 1st June 1983.
1.
Tuberculosis in Profile,
p.8-9, January 1982.
2.
10,000 TB Deaths in City Every Year,
Free Press Journal, 3rd June 1983.
3.
What everybody should know about Tuber
culosis, World Health, p.14, January
1982.
4.
Styblo, K., TB cases over the last 30
years, Economic Times, 22nd May 1983.
5.
Tuberculosis Prevention Trial, Trial of
BCG vaccines in South India for Tuber
culosis Prevention, Indian Journal of
Medical Researth, 70, p.349-363, 1979.
Fox, W. , Whither Short-course chemothe
rapy, Bulletin of the International
Union Against Tuberculosis,
56,p.3-4,
1981.
,21. Eswaran, L., TB Cases Up in
Economic Times, 22nd May 1983.
6.
7.
8.
9
World Health,
Sutherland,
I., The epidemiology of
Tuberculosis- Is prevention better than
cure,
Bulletin of the International
Union Against Tuberculosis,
56,p.3-4,
1981.
Tuberculosis Control, Report of a joint
WHO/IUAT Study Group, Technical Report
Series No.671, World Health Organisa
tion, Geneva, 1982.
Mahler, H., Def eat TB Now and Forever,,
World Health, p.3, January 1982.
.HEALTH FOR THE MILLIONS
APRIL
1984
April,
Oldest
17.
Rele, S.J., Silicosis : Man's
Curse, Daily, 11th May 1983.
18.
Clerk,
S.H.
Rastogi, S.K., Chandra,
H. , The Plight of Agate Workers in
Gujarat,
Science
Today,
p.45-47,
December 1982.
19.
Dogra, B.,
The Hazards of Working,
Indian Express, 17th October 1982.
20.
Park, J.E., Text Book of Preventive andSocal
Medicine, Banarsidas
Bhanot,
M.P., p.385, 1974.
India,
22.
Biomedical Research and the new
point Programme: Tuberculosis,
Bulletin, July 1983.
23.
Forest Road TB Clinfc, Byculla, Bombay,
Personal Communication.
24.
Kotval, I.,
Medical
Social
Nagpada Neighbourhood House,
personal communication.
Worker,
Bombay,
25.
The Foundation for Research
nity Health. Mandwa Project.
in
Commu
20—
ICMR
15
MIRA SADGOPAL
Health “Care” Vs The Struggle for Life
India’s people,
and the world’s people,
are faced with a gigantic health "care”
establishment. It is far from being a vaccum, a situation of "neglect" as most poli
ticians and planners would have us believe,
or sometime themselves believe. Like a huge
and ungainly bureaucracy,
it is both orga
nised and unorganised. Its various parts
are linked with each other in both gross
and subtle ways; equally,
the parts func
tion in contradiction with each other. Some
of the parts of the establishment succeed
in holding sway in certain spheres by
virtue of historical advantage and the
forces that back them at the moment. Any
group claiming to explore "alternatives"
must understand human health,
and likewise
any other sphere of human welfare
(like
education, economic development, legal jus
tice, etc.) in this perspective.
The indi
vidual man, woman or child is powerless and
thus always prone to being sucked, duped or
dragged into the establishment system.
India provides a magnificent panorama of
such a health care establishment. Most
obviously, we have in this country a giant
multi-tiered
Government-operated
public
health infrastructure, the bottom levels of
which are organised into something called
the "primary health care" system.
It is
topped by a spread of state hospitals and
national medical institutes as well as
various large central public health agenci
es. Ultimately, this government system is
empowered through finance by international
organisations and agencies like the WHO,
UNICEF, DANIDA, etc.
Second in consequence is the vast body
of ''qualified" Private Practitioners which,
although it is less organised and partially
thrives on its own disorganisation,
also
exhibits a hierarchy of influence and power
largely corresponding to the proximity of
its parts to the cities and the drug
industries. It includes graduates of "allo
pathic" medicine as well as graduates of
the ayurvedic colleges although most of the
/: •
16
latter depend on the use of modern allopa
thic medicines. The minimum requirement for
organisation to promote and protect and
protect the interests of their members as a
class is fulfilled by the Indian Medical
Association.
Taking third place in visibility, al
though it exerts the most pervasive and
devastating influence, is the huge drug
industry complex. There is a polarisation
within this group between competing indige
nous and multinational companies w'.ich is
unequal, so that indigenous industry either
succumbs or adopts policies in tune with
the multinationals. The multinational drug
industry profoundly controls policy and
practice within the Government health sys
tem as well as the behaviour of Private
Practitioners by plying central Governmnent
committees and deploying a large army of
medical representatives.
Fourth is a large group on the fringe of
the health establishment power structure,
loudly
named "Quacks" by the
Private
Practioners. It is a very interesting group
without any real political power or legal
sanction which thrives on the contradic
tions of the establishment, the extreme
powerlessness of the masses and the total
culture of mystification which maintains
this. This ' group finds its niche in the
rural areas and the lacunae of the towns.
A fifth group exists in the twilight
beyond the fringe, often indistinguishable
from the masses but merging
into the
category known as "quacks". They cannot
really be called part of the establishment,
but they are quite often the first, last,
and sometimes the only resource of the
poor. These are the village dais, the
bonesetters, the guinas, ojhas and bhagats
(faith healers and magicians). They are
traditional,
indivisable from the belief
system of the masses. The larger health
care establishment has an ambivalent atti
tude towards this section - it is largely
HEALTH FOR THE MILLIONS
APRIL
1984
ignored or riduculed. Recognising their
hold over the people, some members, such as
the dais, are sought to be co-opted by
Government training into the primary health
system.
Also according to establishment values
organised health services are operated to a
greater or lesser extent by large public
and private industries and by the central
Government for its employees. These are
also subject to the same pressures of the
health care culture which bear on society
in general and are only partially modified
by local or specific political conditions.
For practical purposes, we n/ay add to this
category the attempts of
a number of
voluntary agencies to provide proper and
uniform health services in project areas.
same doctor.
He also knows that • this
disease, if properly managed,
has a good
chance of continuing without
cure for
several years before the patient dies.
Furthermore,
the widespread attitude that
TB is incurable, supported by the vast
majority of cases which eventually end in
death, and the doctor's own observation
that patients cannot sustain regular treat
ment does not lead him -to nurture any
professional interest in obtaining a cure.
Therefore, neither is he interested in
proving the diagonsis. A private practi
tioner will avoid telling that
he is
treating a man for TB as long as possible.
Otherwise he is sure to lose his patient to
another doctor. Likewise,
sending him for
sputum test or X-ray, which may be availa
ble through the nearest government hospi-
Seeing the larger interconnecting struc
ture of the health establishment in this
way gives us an intellectual idea of its
magnitude, but what does it mean for the
common man and woman .in India?
For a start, we can listen to the
stories of hundreds upon thousands of men
and women suffering from tuberculosis in
our cities, towns and villages. Over and
over again we can see a plot thus exposed
in stark nakedness as each tells of the
struggle to be treated and cured by any
possible means.
For instance, a villager who gins cotton
may notice d gradual loss of weight and
energy and may be a cough for several
months.
But sc many of the
poor are
already ,exhausted and emaciated by life they find the line between relative health
and disease is imperceptively crossed - and
they think it is only "weakness". When work
becomes impossible they seek quick help
from private practitioners, knowing it will
cost, but anxious to get well and back to
work. They hope to get by with a strength
giving injection, a few pills may be, and a
bottle of life-giving tonic
which the
doctor will prescribe. So a couple of
chickens and some grain is sold to raise
money.
2.
For a month or two, Vithoba
has not been feeling well. He
often has fever.
He used to
enjoy Rukhmani's cooking, but
now he has lost his appetite. He
is losing weight. Rukhmani is
worried. She asks Vithoba to see
a
doctor. But Vithoba keeps
putting it off. She says to
Vithoba "You should show your
self at the health centre".
...pg 19
The doctor well recognises the story and
the appearance. He suspects it is tubercu
losis.
He knows the capacity of the poorthey will pay for the belief that they will
get well, and as long as that belief can be
sustained, they will keep on paying the
HEALTH
FOR
THE
MILLIONS
APRIL
1984
CCMMUniTV H-ALTH Cm
47/1, (First Floor) 3;. Marka
tai, would be giving him away, or privately
done, would use up available funds. He is
not interested in prognosis either - it
will be sufficient to see that the man gets
temporary relief and is kept fluctuating
within a safe margin between cure and
death, with an occasional .dramatic rescue
form death's clutches,
for as long as
possible.
What does the doctor's treatment consist
of,
aside from its psychological content?
First on the list is Streptomycin injec
tions, one daily if possible, which is more
likely impossible if the patient lives far
away. (He may be given tablets of Isoniazid
in various proprietary preparations
in
place of streptomycin, in which case he is
certain to be sent off with a couple of
impressive on-the-spot injections,
such as
liver extract and red-coloured vitamin B12)
Next,
he will be prescribed ethambutol
tablets
(under one of the marketed brand
names), a second line drug for TB which is
comparatively expensive but which is being
promoted by multinational companies through
their medical representatives as a firstline drug. Third, a corticosteroid hormone
lik^ betamethazone (again, under, numerous
|
brand names) will be routinely given or
prescribed by most private practitioners at
the start of anti-TB treatment, as it is
expected to bring about rapid relief from
symptoms and a specific false sense of
physical well-being which may be the major
factor in hooking the patient. Fourth will
be a large bottle of mineral and vitamin
tonic which also ironically contains some
thing to stimulate the appetite of the
person who is basically dying of hunger
anyway. Fifth, a syrup will be added to
suppress the cough.
The expense of the first week .of such— •
treatment works out as follows
(approxima
tely) :
1.
Inj.SM @ Rs.3.00/day X 7
21.00
2.
Tab. Ethambutol I twice/day
@ Rs.2.50/day x 7
17.50
Tab.Betamethazone 1 thrice/
day x 7 = 21 tablets
8.00
Vita-mineral tonic - single
large bottle
20.00
Cough syrup - single bottle
8.00
3.
4.
5.
74.50
The doctor's initial fee will vary, but
he will also take a daily fee for injecting
streptomycin. If he is a good dramatist
and psychologist, and the family is obvi
ously prepared to pay, he may set up an
intravenous drip and charge heavily.
Quite often, the person does not have
enough cash to-buy some of the medicines.
Typically, the tonics and non-TB medicines
will be bought and the anti-TB medicines
will be partially or totally dropped from
the list. (A survey done by Veena Shatrughna has shown that many1 doctors write the
tonics and less necessary medicines first,
perhaps to oblige the drug companies, and
the specific curative medicine last.).
Public service or private practice ?
with apologies to R.K. Laxman
18
How long is this to go on? We have found
that a doctor tells the patient initially
that his treatment may take a varying
period between two weeks to three months.
He may decide to further prepare a mental
frame by stating that the man is lucky that
the doctor has caught the "disease" at this
HEALTH FOR THE MILLIONS
APRIL
1984
stage because, although he doesn't have TB
yet, "There is a chance of it turning into
TB! "
Even if a man has collected enough funds
for the initial treatment, he may not be
able to follow up. After a varying number
of visits to the doctor, and, especially
after a marked improvement, he stops goinghe may go back to work. He also meanwhile
consult a gunia of his community about
warding of the risks of getting -TB, and
after certain divination the gunia advises
him to carry out certain rituals
and
sacrifice, which are usually done.
After some time, he again loses weight
and his cough worsens. He thinks about
returning to the doctor. The Doctor's men
tion of TB has scared him, and he is
ambivalent. He may do one of three things:
he may go to another private doctor or a
quack, he may go to the Government doctor,
or he may return to the same doctor after
all.
If he goes to another doctor, he goes
with a blank slate- he doesn't mention that
he has seen another doctor, or flatly
denies previous treatment.
Hence, a second
version of the first experience is likely
to unfold.
new cases of TB are clear and rationally
the full treatment of eighteen months is
provided under the National Tuberculosis
Control Programme.
After three months of treatment, sputum
examination is to be repeated
(if the
patient is still coughing up sputum). There
should be no more tuberculosis bacilli
detectable in the sputum. Then,
if not
before, an X-ray screening is called for if
feasible from the nearest TB X-ray facili
ty. The reduction in the extent of lung
damage is thus monitored every six months
until six months have passed since disapp
earance from the X-ray of the signs of
damage, when treatment may be officially
discontinued.
If progress is
satisfactory, Streptomy-
A streak of realism may hit him. He may
realise that the choice he has TB is high
now, and decides to see the government
doctor. At least he may get a clear answer
even if he doesn't have faith in the
government treatment.
The government doctor is a strange kind
of super human. He is invested with the
power to treat when he pleases at the
Government's expense. (He also carries out
a respectable private practice inzhis home
at the Government's expense). A patient
approaches him in fear and
trembling.
Diagnosis for purposes of initiating Gove
rnment treatment is obtained through sputum
exam or X-ray whichever is feasible. Anti
TB treatment is started on the doctor's
orders. He tells the patient he has TB, or
he says,
"There is chance of it turning
into TB" depending on the role he wishes to
play
in
the drama with the Patient1 Government Doctor or Private Practitioner.
Sometimes he adopts a dual role,
issuing
/Government drugs from the Primary Health
Centre for seeing privately at home, too.
Government rules
for
HEALTH FOR THE MILLIONS
the
3. As days pass, Vithoba gets
thinner.
His cough gets worse.
He coughs up thick sputum every
His coughing
keeps
morning.
Rukhmani awake at night. Vithoba
feels very tired. One day he
agrees to go to the doctor at
the Health Centre.
...pg
21
treatment of
APRIL
1984
19
cin injections are to be replaced after
three months by another drug,
usually
Thiacetazone (THZ) but it might be ParaAmino
Salicylic
Acid
(PAS). The PHCs
dispense Isoniazid and Thiacetazone
in
combined INH/THZ tablets to be consumed
daily for the total remaining period of
treatment. To ensure that a patient keeps
up regular treatment, he is supposed to be
called every month on a particular date
three days before the drugs with him are
due to finish. In case he does not turn up
within a few days,
a printed postcard
reminder is to be sent to him.
(If he does
not respond to three such reminders and he
has not died), he is known as a "defaul
ter”.
d)
e)
f)
3.
Problems
Issue:
a)
b)
c)
d)
e)
4.
doctor's impatience
mystification of doctor's role
poor relations/faulty communication
between PHC staff
of
Drug
supply
and Regular
genuine short supply to PHC from
District HQ
siphoning off of TB drugs into the
market
siphoning off of TB drugs into pri
vate practice
incomplete issue of drugs
doctor's failure to indent (malad
ministration)
Problems of Medicine Cost from the
Market when unavailable through govern.ment supply
high/rising prices of
essential
first-line drugs, especially Strep
tomycin injections
b) shortage of all first-line drugs in
the
market due to gross under
production .
c) increase in market supply of expen
sive second-line anti-TB drugs like
ethambutol, rifampicin
a)
5.
But what really happens to the ordinary
patient, or to our villager friend who gins
cotton?
brainwashing of doctors by medical
representatives
b) overproduction beyond licenced cap
acity of tonics, etc., by large and
multinational drug companies
hc) mystification among the masses abo
ut tonics and the desperation for
quick life-giving cures
a)
There are innumerable obstacles in the
way that ensure failure or treatment or
"default". We can list these, as follows:
1.
Problems of Diagnosis
sputum exam:
technician not availa
ble, or refuses
b) x-ray/screening facility distant,
expensive, out of order, x-ray pla
tes not available.
a)
2.
Failure of Communication
Doctor:
20
6.
Problems
of
Local
Inject Streptomycin
Arrangement
*
49-
unavailability of doctor/health wo
rker to inject
b) fee for injection daily
c) PHC may refuse to issue injections
to patient to take home
a)
to Patient by
a) intention, or lack of intention of
doctor to inform
b) patient’s fear
c) contradictions in the belief system
in society about disease
Unnecessary Medicine Cost on Vitamin
and Mineral Injections and Tonics and
costly Cough Mixtures
7.
•
Problems of Transport
a) distance
b) cost in time,energy,fare
c) irregular public transport services
HEALTH FOR THE MILLIONS
APRIL
1984
8.
The Social Milieu at Home
poverty - poor shelter, starvation
demoralisation
sex-?bias in 'case of women, especia
lly when childless or without living
male offspring
d) belief in magic and lack of scien
tific .concept of disease
a)
b)
c)
9.
Conditions of workplace and Occupation
economic exploitation
noxious physical conditions,
like
inhalation of cotton fibre and poor
ventilation, etc.
c) lack of safety standards
d) lack of alternatives
a)
b)
10.
Specific Malpractices
Doctor
ort has arisen from a couple of workshops
on issues related to rational drug therapy
organized in 1982 in joint collaboration
with the Medico Friend Circle.
During the
workshop held in Jaipur in August, evidence
from within the pharmaceutical industry was
presented by spokesmen of the Federation of
Medical Representatives
.Association
of
India (affiliated to the All India Chemical
and Pharmaceutical Employees- Federation, a
non-party trade union organisation) to show
that the large multinational drug companies
are manipulating the supply of anti-TB
drugs by producing essential first-line
drugs far below their licenced capacities
and promoting the newer second-line drugs
which are at present imported from abroad.
A number of field groups, including members
of the Medico Friend Circle, members of the
by PHC Staff and
,
a)
Private practice
b) misinformation
or non-information
of patient
o) failure to record (incomplete) iss
ue of drugs
d) neglect of monitoring schedule
e) failure to maintain treatment card
f) failure to contact defaulters by
postcard
Now, it is sufficient to say that the
average poor man of India who gets TB today
is likely to face every single one of these
obstacles, except 8(c)
as he is not a
woman. Inevitably, he becomes a defaulter,
or he dies, or more likely both. Are there
really any alternatives?
Numerous groups and individuals are mak
ing attempts to join with others,
to
challenge the might of the establishment.
The outlook of all at this point is at
best, partial. Again,
the
problems of
tuberculosis can serve as a useful referen
ce point for illustration.
Action
is
occuring at national, regional and local
levels. We will mention a few of these
efforts known to us which we consider
significant.
The Voluntary
Health Association of
India
(VHAI) is at present carrying out a
countrywide investigation, with the help of
a number of local and regional groups, of
the widely reported shortage of first-line
anti-TB drugs in the market and in the
Government TB treatment centres. This eff
HtALTH FOR THE MILLIONS
APRIL
1984
4. At the health centre, the
doctor examines Vithoba's chest.
He asks "Vithoba, how long have
you been having sputum?”
Vithoba : "For about one
doctor."
month,
Doctor : "I will give you some
cough medicine for your cough.
But if the cough is still bad
after five days, I would like
you to come back again. Before
you come please spit some sputum
into a clay pot and bring it
with you next time. We will test
-the sputum next time.”
...pg
23
21
..LOCKED OUT OF LIFE
vital information about the TB drug situa
tion has already been mentioned.
Some of
its regional units are particularly active.
State Voluntary Health Associations, and
local units of the Federation of Medical
Representatives are collecting
data to
assess the magnitude of the problem and
whether, as many suspect, the incidence of
TB among the people is on the increase.
The first weapon against the establish
ment is information. A second can be formed
from a "network of socially
conscious
health workers" (quoting form VHAI's appeal
for cooperation in collecting field data on
TB drugs and incidence).
The ultimate
weapon is a conscious movement within the
masses.
As in many parts of the world, we see in
India today, various attempts being made in
the
direction of building a conscious
people's movement. Only thus will it be
possible to really challenge the establish
ment on issues of health care and more
important,
to gather the necessary power
and democratic perspective for evolving a
real scientific alternative which rests on
social justice. At present these initia
tives are small and fragmented, particular
ly in the sphere of health action. There
fore they are weak in comparison to the
total strength of the establishment.
How
ever, the experience steadily being built
up and the link with other democratic
developments is significant.
On the regional and national level is
the surprising example of the Federation of
Medical Representatives' Associations in
India,
a
healthy, growing
non-partyaffiliated trade union organisation with a
vision of society which is somehow startlngly free from the blindfold of narrow
conomism.
This group's role in collecting
22
Another regional example is that of two
other non-party organizations in the seven
districts of the Chhatisgarh region of
eastern Madhya Pradesh - the Chhatisgarh
Mine workers Union (CMU) and the Chhattis
garh Mukti Morcha
(CMM). The
CMM,
an
organisation drawing strength from agricul
tural labour is constructing a peoples’
hospital and both organisations launched a
joint movement in 1981 which they call
’’Struggle for Health". At present, under
standing of health issues is crude:primari
ly a realisation of what is grossly wrong
and a struggle against blatant injustice.
Slowly and painfully these two organisa
tions are struggling to overcome their own
inadequacies, faulty habits and traditional
beliefs to build up a viable and just
health care alternative.
At the local level in areas where ther?
is. no established mass organization,
small
activities and micro-initiatives are being
carried out which begin to challenge parts
of the health establishment. This has been
the’ case in our own group's work.
In the
form of a series of three block-level
"Youth Leadership Training Camps" (Govern
ment of India) of Hoshangabad, we organized
groups of literate youth to study the
social aspects of the problem of tuberculo
sis by moving among the people and listen
ing to men and women with the disease tell
their stories. The campers compared the
people's experience with the provisions of
the National TB Control Programme
and
analysed
reason for the discrepancies.
They organized a diagnosis camp, poster
exhibition and cultural programme and a
public question-and-answer meeting in the
presence of the Government doctor and the
district TB Control authorities. Many con
tradictions arose which could
not
be
resolved.
At the village level, we initiated an
interesting experiment with the women of
the labouring class. The male villagers of
one large village had formed a labourers
union about eight months previously. One
day, knowing that I am a doctor,
a woman
named Bhagwati suffering from untreated
advanced TB dragged her emaciated frame to
my door. She related a story of neglect and
desperation. Her husband was an inactive
HEALTH FOR THE- MILLIONS
APRIL
1984
member of the union, although she was not
even aware of the existence of the union.
Her husband Kaliram had failed to take her
to the government hospital for diagnosis
and she insisted that the elders in her
family wanted her to die. We brought up the
case in the union meeting, but were shocked
to find total apathy towards her plight.
The only concern was that her husband, who
failed to attend meetings, was a scoundrel
and coward and not worth any attention at
all. It appeared as if his wife was only an
appendage of him. Up until that time, no
women had been involved in the
union
meetings. We decided to see how the women
would react to this woman's problem.
Approached individually and in small
groups the women's response on hearing that
TB is curable and the treatment provided
for through the Government PHC was sponta
neous. They decided to hold a meeting of
their, own to build up pressure for her
treatment. This they did in the meeting. I
agreed to act in a supervisory capacity to
see that the treatment given through the
PHC was started. At the time I was working
there voluntarily on a once-a-week basis,
so I was able to intervene to some extent.
We trained a local person
to
inject
Streptomycin and, on my responsibility, a
month's supply was issued from the PHC.
The initial phase
of treatment was
stormy. Bhagwati had high fever and severe
lung damage. We held an emergency meeting
one night to help the family, now alarmed,
to decide whether to take her to the
Government TB Hospital at Chhindwara. Four
women related stories of their relatives
who had gone to the TB Hospital.
In three
cases,
the victims-had died anyway. The
fourth person, alive and well, had gone
there twenty years before when the hospital
was run by a mission. Nowadays the hospital
is ridden with corruption at all levels and
over-crowded so that the expense is great.
It was pointed out that the modern treat
ment would be no different from that she
was getting at home from the PHC. So it was
decided that the wisest course was to
continue to take care of her at home.
In the first ten days, one or two women
began to visit her daily along with me,
turn by .turn. This was a hurdle for them,
as Bhagwati is a Harijan and, although all
the women were poor, they were nearly all
non-Harijans tribals. Muslims and low-caste
HEALTH ..FOR THE MILL IONS
APRIL
1984
Hindus who were used to strictly abiding by
the code of untouchability when relating to
Harijans. They had never set food on the
aangan of Bhagwati's hut and they had not
seen her about the village for several
months. It was an unforgettable sight when
one woman, seeing her shrunken form on the
cot, irresistably lifted aside her veil,
with which she had covered her face in
shame, and exclaimed, "Oh, my sister, what
has happened to you!"
The women were so excited at the first
two meetings that they decided to meet
frequently. At their next meeting the women
who had already visited the house described
Bhagwati's condition and observed
that
there were obstacles to her treatment at
home. Her mother-in-law was being nasty and
5. After another 2 to 3 days
Vithoba did not feel any better.
So Vithoba decided to see the
doctor again and get the medi
cine
changed. This time the
doctor said that Vithoba was
very sick, but that he would get
better
with
treatment.
The
doctor
said
that there was
tuberculosis in Vithoba's chest
and the in the sputum. Vithoba
had feared that he had TB for
some time. Rukhmani
believed
that this was their fate, and
started crying. But the doctor
explained that tuberculosis was
not a matter of fate but is a
- disease. This disease the doctor
said,
is caused by germs in the
'sputum.
...pg
25
23
uncooperative,
refusing to give her food
and continuously commenting that she would
be better dead. The rest of the family was
demoralised and the house was messy. I told
them that it was a problem for me as a
doctor to keep on giving necessary advice
to improve diet and hygiene which had gone
unheeded for a week.
They decided
to
control the mother-in-law and had a lively
discussion about a proper diet for a TB
patient and about fixing up Bhagwati’s
surroundings to make the place liveable and
hygienic. The next day one woman tackled
the feisty old mother-in-law and convinced
her to draw a truce in the battle with her
daughter-in-law until Bhagwati would be fit
to fight back again. Another woman sat on
the edge of the cot explaining to her
husband and eldest daughter what she could
be fed, how to arrange that part of the
hut, and how to dispose of infected sputum.
The heat was sweltering. The next day we
were surprised to find 'that Kaliram, a
bamboo worker, had woven a large overhead
fan and attached a long grass rope to -it.
The small children were kept at a safe
distance pulling the rope to and fro in
turns, singing songs to the rhythm of the
fan. The house was tidy and clean. The sick
woman's fever was much less.
She
was
smiling.
Her.mother-in-law was grumbling,
but about other things, and in masked good
humour. The :family had got the taste of
self-respect through social concern.Recovery was steady
for
some time
thereafter. At the end of one
month,
Bhagwati was anxious to get her sputum re
examined because she wanted to be able to
hold her four-year-old son on her lap, and
she wanted to sit-in at the women's weekly
meeting. She had lost her one-year-old
daughter a year previously,
probably bec
ause of naving infected her with TB. To
collect her sputum, she scrubbed a Strepto
mycin vial thrice with soap and boiled it
in water (so as not to kill any bacilli!)
and waited for the bus on the road from
MX DOCTOR WlU 'TILL
YOU THAT If YOU ARE TENS!
OR OiSrRAUMjr 1HEKE IS
OWE SURE U.AT TO FEEL
BETTER..
24
eight in the morning. The eight o'clock bus
did not come. At 11.15 she began walking in
the scortching sun barefoot. The PHC was
seven kms. away, and she was afraid it
would close, so she nearly ran the whole
distance. One hour later;
she reached the
PHC to find that it had closed at 12
o'clock. She waited until it reopened at
4.30 p.m. and proudly offered the vial of
sputum to the compounder-technician. He
grabbed the vial and threw it on the ground
shouting,
"We won't do your sputum test
seventeen times. Bring it after
three
months". Then she asked for her month's
supply of drugs, only to be told that the
doctor had gone and she would have to come
the next morning.
Bhagwati returned home exhausted,- down
cast, but amazed at herself that she had
been able to make the journey. Next’ day,
she had fever, but she was determined to go
back to get her medicines. Kaliram accom
panied her. He decided in addition, to take
her to the next town and get her first Xray done and the sputum test repeated
privately. When they faced’the PHC doctor,
they had to tolerate his sarcastic comment
that they had "become big people now". All
the drugs were given, but no amount was
recorded on the card. In the next town,
they paid Rs. 5/- for the sputum exam and
Rs.
24/- for an X-ray. The Sputum test was
negative. The X-ray showed cavitation, but
signs of active healing.
Probably because of the heavy exertion,
Bhagwati was not well for about two weeks,
but again began to pick up. The following
month she went to a wedding and took her
vials of Streptomycin and pills along with
her, getting them injected by an available
doctor.
In the fourth month she started
work again. She is a traditional dai as are
all the women of her caste. An orphan, she
had started her midwifery career at the age
of seven, as she described to me later. In
the
same
month, some other villagers
to HUSHEP Uf, of
SIMfLY UE WITH YOUR
HERD i»J tour WfllEK DISH! COURSE 6SCAUfrR ITWOUlP
ccHfUETtu Roia me
PROCr 4CHfANIE>.
HEALTH FOR THE MILLIONS
APRIL
1984
reported to me that she was catching
in the river with her nephew.
fish
In’ the fifth month, Kaliram discovered
that Bhagwati had brought back only white
tablets from the PHC. Streptomycin had been
discontinued, but he knew that anti-TB
drugs were necessary, and she had been
receiving both Isoniazid (white-coloured)
and Thiacetazone (yellow-coloured)
in the
form of combined light-yellow
coloured
tablets. He took the pills back to the
doctor the next day complaining squarely
that she had been given "only one" anti-TB
drug by mistake. He didn't flinch when the
doctor’s cold gaze hit him, and after a
moments's hesitation, the compounder was
called and told to exchange the white
tablets for the familiar light-yellow ones.
And so her treatment will go on, may be
without serious lapse until she is totally
cured. Kaliram now attends union meetings
when he can manage it. Bhagwati attends the
women's meetings. He farms his small piece
of land, and plays music at weddings. They
make bamboo baskets. She delivers babies.
They are people of courage,
like the
others.
In the meetings they don't talk
about TB, but of the struggle to survive
and thrive against the forces
of the
establishment.
This article by Mira Sadgopal of Kishore
Bharati, Hoshangabad was first published in
two parts in the September 1983 and October
1983 issues of the Medico Friend Circle
Bulletin. We are grateful to them for the
opportunity of reproducing it here.
HEALTH FOR THE MILLIONS
APRIL
1984
6.
In order to convince them
about these germs the doctor let
them look through the microscope
and see the germs that cause
tuberculosis. These germs were
found in Vithoba’s sputum. The
doctor said the germs spread
from one sick person to others
when they cough, spit or.sneeze.
But Vithoba and Rukhmani did not
remember much of what the doctor
said. They were too upset.
...pg
27
25
INDIRA KOTVAL
A Tuberculosis Control Programme
The Nagpada Neighbourhood House is based in
Byculla,
one of Bombay’s most densely
populated areas. It covers Ward D and E of
the Municipality (Population 4,44,666 and
4,54,490 respectively) and tuberculosis is
endemic in the area. Our concern is the
many unidentified cases who are suffering
from the disease but are not being treated
either because they are unaware, or because
fear and ignorance keep them away.
Objectives
One of our aims is to help the community
make better use of existing health faci
lities and not to duplicate
services.
Therefore when a patient came to us with
the symptoms of the disease we would refer
him to the nearest Municipal clinic where
investigations and drugs are given free.
Months later the same patient would cpme to
us for some other illness and we would
notice he was no b'etter. Invariably, on
questioning we would find either he had not
completed the tuberculosis investigations
or for one reason and another he found that
continuing with the treatment
was too
difficult. We therefore resolved to start
a programme in cooperation with the Bombay
Municipal Corporation whereby they would do
the investigations and supply drugs when
they found a positive case of tuberculosis
and we would be responsible for dispen
sation of drugs,
additional nutritional
supplements, follow up and continuation of
treatment until the patient was cured of
the disease. The strength of a voluntary
organisation lies in staff motivation and
the personalised service it can offer. We
thought that if we could couple
this
advantage with the facilities provided by
the government we might be able to run a
more effective programme.
Strategy
Accordingly we approached the Municipality
who were most cooperative and agreed to do
investigations and prescribe
the
drug
regimen. Once they had issued the patient
26
with their cards (in the name of our
clinic) they would issue the drugs to me
and I had to and account for them. It was
our duty to ensure drug compliance, bring
the patient for checks and any
other
necessary referrals.
We started with the idea of building up to
cover 100 patients and their families. We
intended to focus on the family as the unit
and to give nutritional inputs to all of
them; build up health awareness and equip
them all with an understanding of the
disease,
its spread and its consequences.
We believe this is the only realistic
approach if the patient is expected to
complete treatment with the help of his
family. Starting with screening all con
tacts we built up the programme slowly and
presently have 88 patients under our care,
many of whom are siblings and relations.
Environmental conditions cannot always be
changed but much can be done to help the
patient understand the nature
of
the
illness, the reasons for regular medicine,
the meaning of drug immunity and
the
futility of_ interrupted medication. Once
the person undertands the reasons he is
more likely to participate in his own cure
and then the battle is won.
To bring this message home needs time and
concern for the client. With
a large
impersonal
clinic and several
hundred
patients this is not possible. Our strategy
emphasises individual counselling and in
formal health education as an integral part
of the programme.
Problems and how we overcame them
The Municipality supplied us with a month's
supply of drugs for each patient and at
first we issued them accordingly. However,
we soon realised that in the initial stages
very careful monitoring of the drug taking
had to be done to ensure the medication was
being taken correctly. When on a multi-drug
regimen,
patients who were unlettered,
HEALTH FOR THE MILLIONS
APRIL
1984
would find it very confusing to remember
the dosage for each, inspite of •the fact
that we gave them separate bottles and
coloured stickers on each to indicate the
dosage. Certain drugs, particularly Rifam
picin, has unpleasant side effects, and
patients would either omit or limit the
amount of this medicine as they wanted. It
was only when they returned with
the
bottles that we would realise this, and a
month would already have gone
by. We
therfore decided to issue drugs on a once a
week .basis, and found that it took approxi
mately three weeks to sort out all indivi
dual problems concerning the drugs.
The other advantage of this weekly issue is
that we use the day as a meeting and
discussion day. Sometimes we show audio
visuals, at other times cooking demonstra
tions of soya bean meal or ragee
(which we
supply as nutritional supplements), are
carried out. Women are encouraged to show
how they cook green and iron rich veget
ables and group discussions on various
issues related to the disease are held. It
is at these meetings that many of the
unvoiced problems are brought
up. The
stigma attached to tuberculosis,
fear that
a young daughter may not marry and even
fear of loss of sexual potency are disbussed over a period of time. There was
even an instance when a mother who was
irregular with her child's treatment was so
pressurised by the group that she had to
make a choice as to whether to move from
the spot she occupied on the pavement or
comply with the treatment.
Non Compliance
Inspite of efforts there are always a few
defaulters and this is a problem we have
not been able to overcome. Because of the
belief that injections are all powerful, it
has been noticed that often a patient will
come
regularly until the
streptomycin
course of thirty or sixty injections is
over.
After that drug taking
becomes
irregular. By this time the symptoms of the
illness are already disappearing and it is
difficult to believe one is still
ill and
must continue with pills for another six
months. Oral drugs are considered second
class and the motivation to continue is
weak.
whose roots remain in the villages.
During
marriages, deaths and harvest time the
family will disappear for a month or two
without prior notice and of course drop out
of treatment. Over several group meetings
we have been able to explain that for such
contingencies medicine will be provided for
a longer period, but often decisions to
leave are made on the spot and informing
the medical clinic has very ‘low priority.
Dependancy
When trust and belief is built round people
rather than the treatment,
it
becomes
difficult to duplicate a system or call a
halt to the dependency. We had decided that
once we started to reach our target of 100
patients and 'their families,
we would
7. But Vithoba remembered then
that his brother who stayed with
them a year ago, used to cough
up a lot of sputum. His brother
had since died. If perhaps his
brother also had tuberculosis
then this was how Vithoba had
caught the disease. The doctor
said again that Vithoba would
get better if he took treatment
for 18 months. It would take 18
months for the medicine to kill
all the germs in his chest.
Vithoba heard what the doctor
said, but he was still thinking
about his brother. He was also
worrying how to pay for such a
long treatment.
...pg 33
Many
of
our
patients
HEALTH FOR THE MILLIONS
are rural migrants
APRIL
1984
27
Mantoux Test
The Mantoux Test is a tuberculin test to find, out whether a person is
already infected or not. A tuberculin test does not give any idea as to whether
the individual is suffering from tuberculosis, since infection does not always
lead to disease.
In the standard Mantoux Test 0.1 c.c. of P.P.D. (Purified Protein Derivative
- the purified form of tuberculin from which the constituents of the medium in
which tubercle bacilli were made to grow have been removed)
is injected
intradermally on the front of the left forearm approximately midway between the
bend of the elbow and the wrist. This particular position is chosen so that
there should be uniformity in the test all over the world and if an illiterate
person has to be questioned as to whether the test has ever been done before or
not, one can ask whether an injection has been given in the left forearm.
The test is read after 72 hours. To read the test before 48 hours and after
96 hours is not reliable. The transverse diameter of the swelling at the site
of the injection is measured. If the diameter of the swelling is 10 mm or more
the test is usually called positive meaning thereby that the person is already
infected with tubercle bacillius. However since the allergy takes about 6 weeks
to appear tuberculin test will be positive only 6 weeks after the infection. If
the test is carried out within 4 to 40 weeks (average 6 weeks) of the infection
the test may be negative but it does not mean that the person has not been
infected.
From the community point of view the tuberculin ’ test gives some idea about the
amount of tuberculosis in a community. Since tubercle bacilli are excreted by
patient suffering from tuberculosis, the number of persons found infected by
tuberculin test will give an idea as whether there are many tuberculosis
patients in that community or few of them. For example, in India nearly 50% of
the children are infected (i.e. give a positive Mantoux test) by the time they
are 14 years old. In America, however, where the number of patients in the
community is very small, less than 3% of the children get infected by the age of
15 years. In our country, practically everybody gets infected by the age-of 25
years or so, at least in the cities.
-------------------------------------------- --------------------------- --------------------------------------------------------------------------------------------------------------------------------------- ------------------------------ --------....
transfer those patients who .were now taking
treatment regularly and for at least six
months,
to the nearest municipal clinic.
This way our personalised service would be
available to ah increasing number of new
patients who require careful handling at
the
initial part of treatment.
Older
patients, once exposed to checks at municii'pal clinics would, we hoped,
lose their
fear of the authorities and
use • the
' services of the municipality independently.
n- n
involved was too cumbersome. They suggested
that we see all our patients treatment
through to completion and only add new
patients to our list when we were ready to
take more. At this point we have not
decided how to deal with the problem.
Some Observations
There is far more tuberculosis in the city
of Bombay than we are currently aware of. A
random mantoux test conducted on our under_ We met with extreme opposition both from. five population showed that out of 145
the
patients and the government.
The cases tested 39 were positive cases and a
-patients were reluctant to transfer and the further 28 cases investigated as contacts
municipality envisaged that the-paper work were also positive. Early diagnosis and.a 7
28
HEALTH FOR THE MILLIONS
APRIL
1984
month drug regimen based on Rifampicin can
control the disease. From a total of 348
cases investigated, 88 were found to be
positive. Since the government provides
free drugs and investigations,
it
is
possible to treat all patients provided a)
an awareness of the problem and the need
for cure is understood, and , b)
voluntary
agencies assist the government to implement
these programmes more efficiently.
Patients drop out of
treatment mainly
because they do not understand the need to
take drugs regularly and because
they
cannot explain their problems adequately. A
personal service with individual attention
can help this a great deal.
It is important that tuberculosis patients
be given nutritional inputs in the form of
vitamins, irons and nourishing food because
the strong drugs taken with a meagre diet
cause severe side effects that can be so
unpleasant that the patient is
drop out of treatment.
forced
Environmental conditions, poor health and
undernutrition are the main causes
of
tuberculosis and unless the social and
economic conditions in our country improve
I am convinced the
disease cannot be
eradicated.
POSTCRIPT: So far there has not been any
problem of drug shortages. But in March
1984 the BMC apparently fell short of funds
and they are now waiting for the new budget
to replenish the coffers. As a result there
has been no money to purchase drugs and
hence a drug shortage. Drugs are purchased
I as follows:
Streptomycin/PAS/paracetazone from private
companies. Rifamycin/Isonex/Ethambutol/ are
produced by the government at Kasturba
Hospital, Bombay from 1984.
NEW REHABILITATION COURSE FOR THIRD WORLD ANNOUNCED
The Tropical Child--Health Unit of the Institute of Child Health, London
University, is setting up a Diploma Course for Trainers and Supervisors of
Community Rehabilitation Workers in Developing Countries under the direction of
Professor David Morley. This Course will run for nine months (October/July) and
an initial Course is planned for October 1984.
The Institute of Child Health already runs a course leading to the degree of
Master of Science (University of London) in Mother- and Child Health. It is hoped
that the new Diploma Course may eventually become a similar MSc Course in
Community Rehabilitation. For the time being a Diploma, recognized world wide,
will be awarded to successful students.
Dr. Pamela Zinkin, who will be in charge of developing the Course has
recently returned to the UK after spending five years as Professor of
Paediatrics, Maputo, Mozambique, said: It is important that Rehabilitation
should be more available to disabled children in remote rural and slum areas of
the Developing World. And it is important that this rehabilitation is tailored
to fit the circumstances and needs to these children. By training those who will
return to their countries to set up training courses and supervise Community
Rehabilitation Workers we plan to achieve a revolution in the management and
rehabilitation of disabled children in what have been up to now the forgotten
corners of the world.
For details write to :
.
HEALTH FOR THE MILLIONS
APRIL
Institute of Child Health
(University of London)
Tropical Child Health Unit
30 Guilford street
London WC IN 1EH
1984
to
Bombay Tuberculosis Statistics -1983
The Bombay Municipal Corporation has calculated that by the end of 1984 a
total of 1 million people (out of a population of 9 million) will be under their
tuberculosis treatment. This excludes patients getting treatment from private
doctors.
These figures are based on statistics gathered during the tuberculosis
campaign year 1983 when 88,000 people were under municipal treatment.
On a 7 month rifamycin and supportive drug therapy (known as second line
treatment and given when the first line treatment fails to give a response or
when a quick therapy is sought) within the campaign year, it was found that 25%
of the patients were completely cured of the disease. 38% are still under
treatment because of the severity of the disease. 30% came in the last quarter
of 1983 and they are expected to complete treatment in early 84.
7% dropped out
of treatment.
An analysis done by the BMC as to the causes of drop out with a
percentage wise break up of the 7% is listed below.
REASONS FOR DROP OUT
PERCENTAGE
26%
Non residents of Bombay who came forward &
have now moved back to rural areas
10%
Investigations done at BMC clinics but chose
to be treated at private clinics
5%
Died of the disease
12%
Moved out of the municipal area where they
were being treated and health visitors are
unable to do adequate follow up.
26%
Refused to take treatment either because of
unpleasant effects of the drug or insuf
ficiently motivated.
13%
Wrong address given
attached to disease.
8%
Miscellaneous reasons.
for
fear
of
stigma
Incidence of tuberculosis in Bombay city is recorded by the BMC as follows.
37,000 cases treated by BMC
50,000 cases treated by BMC
65,000 cases treated by BMC
88,000 cases treated by BMC
1980
1981
1982
1983
There are two ways of interpreting this data. BMC argue that the rise in
figures show that more people are coming forward for treatment because of
effective propoganda. One could also state that TB is on the rise due to rural
migration to the city and because the infection is not being controlled.
COST OF TREATMENT FOR BMC:
30
FIRST LINE TREATMENT:
STREPTOMYCIN/ISONEX/PAS/THIACETAZONE
Rs. 135.00 p.m.
SECOND LINE:
RIFAMYCIN/ETHAMBUTOL/PZA/ISONEX.
Rs. 186.00 p.m.
RIFAMYCIN/ETHAMBUTOL/ISONEX/STREPTOMYCIN
Rs. 276.00 p.m.
.EALTH FOR THE MILL IONS
APRIL
1984
J.S. MAJUMDAR
Production of Anti - TB Drugs
J.S Majumdar is the Secretary of the Federation of Medical
Representatives Association of India and an active member of the Drug
Action Network. The above article is extracted from "A Study on
Prevalent Diseases in India and Production of some Essential Drugs "
which was a paper presented by him in the Drug Workshop organised by
VHAI in August 1982.It is being reproduced here as a case study to
show some of the dynamics of drug-shortages in the case of life
saving and essential drugs.
On 20th April,
1982 Sri Dalbir Singh,
the
Minister
of State for Petroleum,
Chemicals and Fertilizers, made a statement
in the Lok Sabha that PAS and its salts,
and INH production were showing a declining
trend during April, 1981 to February, 1982.
He further stated, "the decline in produc
tion is due to (1) demand constraints or
shifts, (2) Industrial unrest,
(3) Availa
bility of cheaper imported drugs."
From the available data and facts it will
be revealed that the Minister was either
wrongly
informed or was giving
wrong
information.
There are no demand constraints or shifts
.as far as anti-TB drugs like INH and PAS
iare concerned. It was earlier stated that
oof an estimated 10 million patients suffe
ring from active tuberculosis of lungs over
6 lakhs patients
(except In a few States)
were reported under treatment. Vast number
oof other patients have no access to modern
medicines. The talk of demand constraints
or shifts is only to hide this fact. The
projected requirements during the sixth
five year plan does not show that there is
a declining demand of INH & PAS as reported
by the Minister.
The compound' rate of growth, during
this period, of INH is 20%, PAS
and
Thiacetazone 15%, Ethambutol 22% and Rifam
picin 16%.
Source : Report of the "Working Group
on the Drugs and Pharmaceutical Indus
try for the plan period (1978-79 to
1983-84)", Government of India, Minis
try of Petroleum, Chemicals and Ferti
lizer
(Department of Chemicals
and
Fertilizers)
Streptomycin, INH, PAS and Thiacetazone
are well established anti-TB drugs. The
auto-toxicity of Streptomycin
has been
accepted as a hazard of the treatment and
Actual Production and Requirements of Anti-TB Drugs in Tonnes
•
Name of the
Product
Actual
Production
77-78
Requirements
82-83
78-79
Sixth plan
Base year
I N H
PAS
Thiacetazone
Ethambutol
Rifampicin
79
548
26
3
Nil
175
750
35
40
3
—-_____
HEALTH FOR THE MILLIONS
APRIL
1984
375
1300
60
90
6
83-84
Rolling plan
450
1500
70
110
7
sufficient care>is being taken. Similarly,
^hiacetazone is also recommended with cau
tion. But
fact remains that indigenous
technology is availaolG f9r
production
of these drugs and the country can be fully
self reliant with proper planning. .Resis
tance to these drugs are rarely reported
when properly used in combinations. There
fore,
there cannot be any demand const
raints for these reasons nor there are
demand shifts. It is well established now
that poverty, malnutrition and absence of
proper hygiene prepares the ground for
invasion of the tuberculosis. Most of the
T.B. patients cannot purchase medicines of
their own.
If any demand constraints are
there,
it is due to the price factor and
that too, not the total expenditure but the
daily expenses on drugs. Therefore,
there
cannot be shift in general towards Rifam
picin and Ethambutol.
Further, Rifampicin is not indigenously
produced. The drug is totally imported. The
imports of this drug were as follows:
1979-80
1980-81
1981-82
5413.5 kg
8948.5 kg
15785.5 kg
Such a small quantity of imports can
naraly meet t.h.9 actual needs of the T.B.
patients. In addition. Rifampicin is also
used for the treatment of Leprosy
in
combination with Dapsone.
The drug is
costly. The CIF cost per unit during 198182 was Rs. 4130/- per kg. The technology of
manufacturing of Rifampicin is only known
to two companies in the world - one is in
Italy,
the other is in Switzerland., They
have the monopoly in the manufacture of
this drug. The donor for Rifampicin in
India is the Swedish International Develop
ment Agency (SIDA).
It will be evident from these facts
that demand can hardly be shifted towards
Rifampicin, which is costly, wholely impor
ted and for which technological know-how is
not available in India.
As far as Ethambutol
is concerned, the
WAITING FOR THE "SPACE INVADERS"......
.... AND THE ENEMY WITHIN
In the year 1980 the world spent a million
dollars a minute on armaments.
32
HEALTH FOR THE MILLIONS
APRIL
1984
take
various pleas including so-called
labour unrest. In reply to a question in
the Lok Sabha on 18th August,
1981,
the
Minister of State for Petroleum, Chemicals
and Fertilizers, stated,
"Periodical shor
tages of PAS granules manufactured by M/s.
Pfizer Ltd. were reported from Delhi in the
recent past. The matter was taken up with
the manufacturers who reported that as they
had closed down for some time due to labour
unrest and later were affected by go slow,
their production and supplies of the above
formulation was affected."
DEATH WARRANT - MNC STYLE.
Whereas, the factory manager of M/s
Pfizer Ltd. issued a notice on 26th March,
1981 which reads:
TO EMPLOYEES OF PAS SECTION:
actual production in the
country from
imported intermediaries during 1979-80 was
23.53 tonnes.
In addition, 96.19 tonnes
were imported during this period.
From this, it will be evident that more
emphasis is given to be import of the drug
rather than the actual production.
On the one hand deliberate attempts are
made to create shortages of INH & PAS by
cutting down indigenous production, on the
other,
import of costly drugs are encou
raged on the plea of demand shifts. Instead
of a natural demand shift, attempts have
been made to deliberately create conditions
to make room for costly and imported drugs,
and for this millions of poor T.B. patients
have to pay the price.
The production pattern of Pfizer Ltd.
is a classical example of under-production
of essential anti-T.B. drugs and over
production of non-essential products.
Products
Licensed
capacity
Production
1978
1979
(in Tonnes)
INH
PAS and
its salts
Protinex
80
110
45
90
52
94
110
269
290
8. The doctor said that INH
tablets only cost about Rs.
3
per month and INH tablets for TB
were also free at the health
centre. So Vithoba started trea
tment.
Sometimes there were no
free drugs and he had to buy the
medicine in the
bazar.
The
doctor explained that the strep
tomycin injection if needed cost
about Rs.
1 for each injection
for the first month, but that
the injections would be availa
ble free at the health centre.
...pg 35
(Source : From Company reports )
In their attempt to
deliberately
cut
production, the industry and Government
HEALTH FOR THE MILLIONS
APRIL
1984
33
In the Lok Sabha
UNSTARRED QUESTION NO. 1434
TO BE ANSWERED ON THE 6TH MARCH, 1984
Manufacture of anti-tuberculosis drug "Rifampicin"
1434.
(a)
SHRIMATI MADHURI SINGH:
will the Minister of CHEMICALS AND FERTILIZERS
be pleased to state:
the steps to be undertaken
drug "Rifampicin":
for the manufacture of the anti-tuberculosis
(b)
whether it is a fact that the large-scale import at dump prices by multi
nationals has proved to be a disincentive for domestic manufacturing of
this vital drug which is equally effective for the treatment of leprosy;
and
(c)
the quantity of
drug?
Rifampicin
being
imported and estimated demand for the
ANSWER
THE MINISTER OF CHEMICALS AND FERTILIZERS
(SHRI VASANT SATHE)
(a)
Government had issued 7 Industrial approvals for the manufacture of
Rifampicin. Foreign Collaboration proposals were also approved wherever
they conformed to the parameters of Government policy.
(b)
No instance of dumping of Rifampicin has come to the notice of the
Government.
However, it is possible that the fall in CIF prices of
Rifampicin in 1982 and 1983 had an impact on the investment in the
indigenous manufacture of the drug.
(c)
The 6th Plan Working Group had estimated that in the year 1984-85 Annual
Demand of the drug would be 24 MT.
Imports for the last three years had been as follows:-
34
YEAR
IMPORTS (MT's)
1980-81
1981-82
1982-83
i6.07
8.95
36.90
HEALTH FOR THE MILLIONS
APRIL
1984
"It is hereby notified for the informa
tion of Employees of PAS section that due
to the sudden steep increase in the price
of MAP without a corresponding increase in
the price of the finished product,
it has
become • un-economical to produce PAS and,
therefore,
it has become necessary
to
suspend operations in the PAS section of
chemical plant. We are making all efforts
to secure a price revision of the finished
product.
Employees of
PAS
section will be
temporarily transferred to other depart
ments with effect from April 6, 1981,
to
date from which PAS operations will be
suspended."
THANE, DATED MARCH 26, 1981
and Anti-TB dosage forms will be very
uncertain". This conclusively proves that
there was no demand shift from INH and PAS
but an artificial shortage was created of
these drugs.
A survey in the market also revealed
that PAS of Pfizer and Biological Evans
were not available since early 1981.
Similarly, Streptomycin from Pfizer and
Glaxo has not been available for many
years. INH is also in short supply periodi
cally .
The above facts will prove that there
was neitherz a demand shift nor labour
unrest but a deliberately induced declining
trend in production.
for Pfizer Limited
Sd/- B.B. Roy
Factory Manager"
From the above statements it would be
evident that attempts were made by the
company to hide the fact that they stopped
production, of PAS granules as the profit
margin was less compared to products like
Protein Hydrolysates, Tetracyclines, vita
mins etc.
The Government did not care to investi
gate the facts and simply passed on the
false information given by the company.
In reply to another question in the Lok
Sabha on 18th August,
1981, the Minister
informed the House that though Pfizer's PAS
granules were in short supply,an equivalent
brand of PAS granules (Biological Evans)
was available. A study in the
market
revealed that PAS granules of Biological
Evans was not available since December,
1980. The company had stopped supplying PAS
granules from January, 1981. This is only
an example to show the manner in which the
Government machinery functions in finding
out the facts about the supply of essential
drugs.
By a confidential circular dated May
26,
1981, Pfizer Ltd.
informed
their
Regional Managers that they could quote a
special hospital price for their tetracyc
line and some other group of products in a
special rate less than the usual trade
price. But, the circular states,
"The
availability of narrow spectrum injectables
HEALTH FOR THE MILLIONS
APRIL
1984
9. Vithoba did
not want to
spread the disease to his child
ren. So whenever Vithoba coughed
and wanted to spit, he did not
spit on the ground where the
children played. Instead he spat
into an old clay pot and covered
his sputum with ash. Every night
Vithoba emptied the old pot in
the fire for 10 minutes to kill
all the germs. Then he used the
same pot for spitting into, the
next morning.
•••P9
37
35
ANNIE GEORGE
Better Care in Tuberculosis
"Better Care in TB" is the draft version of the latest booklet in the
"Better Care" series published by VHAI. Those of you who have seen
the earlier booklets like Better Care during Diarrhoea, Better Care
in VD,would know that each message or teaching point is accompanied
by an appropriate photograph or visual, with a new page for each
point. The idea is to get across the most crucial points of "Better
Care" in the simplest and most direct manner possible, so that it is
understood even by semi-literate persons. Of course, the booklets are
translated in almost all the regional languages.We would be happy to
have your valuable feedback to enable us to modify the script given
below so that a correct and even better version of 1 Better Care in
TB" is produced.
Can T.B. be cured ?
1.
*
3.
Yes, T.B. is completely curable.
It is never
treatment.
too
late
to
What causes T.B. ?
*
take
They are so small, they cannot be
seen with your eyes.
Early treatment can cure all types
of T.B. completely.
These things do not cause T.B.
If you have any of the signs of
T.B.,-seek medical help immedia
tely.
*
Bad blood
*
curse of the gods
*
a bad horoscope
*
fate
*
evil spirits
*
wrong foods
*
worries and anxieties.
:
What kinds of people get T.B ?
2.
*
Any body can get T.B.
*
Rich people
get T.B.
*
and
Young children
T.B.
poor
and
People in villages
cities can get T.B.
*
*
•'
36
Very small germs cause T.B.
people can
old
can
get
Good and bad people can get T.B.
Men, women
T.B.
and
T.B. can affect many parts of the
body but most people having T.B.
have T.B. of the lungs.
and people in
.children
4.
Can T.B.
another ?
spread from
one
person
to
APRIL
1984
can get
Yes.
HEALTH FOR THE MILLIONS
5.
body in the village who has T.B. A
person who takes treatment regu
larly does not spread T.B.
to
others.
How does T.B. spread ?
T.B. germs are present in the
sputum, pus, urine, faeces of a
person having T.B.
7.
When a healthy person comes in
contact with these germs, that
person may get T.B.
If a person having T.B. does not
cover his mouth when he coughs,
the healthy persons near him may
get T.B. germs in their body.
If a person
with
T.B. spits
anywhere like the road, market
place, or the court yard of his
house,
the healthy people there
may get T.B. germs in their body.
What are the signs of T.B. in adults ?
more than 4
after
just
★
Cough lasting for
weeks,
especially
waking.
★
Chronic weight loss.
★
Mild fever,
evening.
★
There may be chest pain.
*
Blood may
sputum.
especially
be
present
in
the
in
the
Usually when T.B. germs get insider
a healthy person's body, the germs
die. But sometimes the T.B. germs
remain alive in some people and
can cause T.B.
6.
How can we stop the spread of T.B. ?We can stop the spread of T.B. by
observing the following:
Person with T.B. must always cover
his mouth when he coughs.
Person with T.B. should never spit
on the floor or open place.
*
*
Person with T.B. must
coverecI container and
sputum every night.
Person with T.B.
plate and glass
him.
He should
glass.
spit in a
burn the
should have a
separately for
use only that plate and
No one else should use the plate
and glass of a person having T.B.
As long as the person with T.B.
has a cough,
the person should
sleep separately from his family.
10. Vithoba did not want his
children to catch tuberculosis.
So he slept on the verandah
until his cough and sputum went
away. Then the children did not
have to breathe the air when he
coughed.
After
taking
his
tablets every day for 8 weeks
his sputum disappeared and cough
was much less. But doctor said
that he must take treatment for
18 months or the disease would
come again, worse form. If this
happened,
the doctor said that
it would be difficult to cure
him then.
...pg 39
T.B. is very contagious. Know the
symptoms of T.B. and locate everyHEALTH FOR THE MILLIONS
APRIL
1984
In advanced cases:
8.
*
The doctor will know if you really
have T.B.‘ by asking about the
signs and symptoms.
*
Coughing up blood
*
pale, waxy skin
*
Examining you physically.
*
voice grows hoarse (very serious)
*
Asking you
done.
*
Asking you to have an x-ray of the
chest done.
*
Finding out if anybody else in
your family, neighbourhood or work
place has T.B.
*
Asking you
you do.
Children with T.B.
cough or mild fever.
may not have
*
The most important sign in child
ren having T.B. is loss of weight,
even if the child is eating well.
*
If a child who eats well does not
gain weight for two successive
(one after the other)
months,
always suspect T.B.
12.
cure T.B.
It takes at least 12-18 months to
cure T.B. completely.
T.B. is curable. If you have any
of the signs of T.B. seek medical
help.
*
Your symptoms will disappear after
2-3 months of treatment. But, you
are-not completely cured. The T.B.
germs are still inside your body.
The treatment has made the T.B.
germs weaker but has not killed
them completely.
*
To kill the T.B. germs completely,
you will have to take treatment
for 12-18 months.
*
If you take treatment regularly,
T.B. is completely curable.
treatment ensures
complete
T.B. is curable, yet millions die
from T.B. every year. If you know
the signs of T.B. and are on the
lookout for them you will be able
to take early treatment.
13.
where can you get treatment for T.B ?
*
All primary Health Centres and sub
centres treat T.B. patients.
*
All municipal and public hospitals
treat T.B. patients.
*
Most voluntary health centres also
treat T.B. patients.
What will happen if
taken regularly ?
Your CHW will guide
nearest T.B. Clinic.
you
is
not
I
to the
How will the doctor/nurse know that you
really have T.B ?
treatment
If you do not take complete and.
regular treatment, all the T.B.
germs in your body will not die.
So even if your symptoms
(ie
cough,
fever)
have disappeared,
you still have T.B.,
and the
symptoms may reappear.
*
*
38
to
’
Why should you know the signs of T.B ?
*
take
In a small child, T.B.
is very
dangerous and can kill the child.
Early
cure.
11.
a sputum test
about the type of work
How long does it
completely ?
The CHW will advise you on what to
do.
10.
get
What are the signs of T.B in children?
*
9.
to
14.
'
If you stop treatment before you
complete the full course, you may
develop T.B. again.
If a person takes treatment sometime
and does not take treatment other times
■HEALTH FOR THE MILLIONS
APRIL 1984
is it dangerous ?
*
*
Yes. If a person with T.B. takes
treatment sometimes and does not
take treatment other times, the
person can become very ill.
The T.B.. treatment is effective
only when the drugs are taken
continously. If the patient stops
and starts treatment the drugs can
sometimes loose their effect. This
is very serious, then^'only very
costly drugs will be able to cure
T.B.
Always inform your doctor or CHW
before hand if you cannot collect
the drugs for the days you will be.
unable to attend the T.B. clinic.
*
he always
.coughing,
covers
his mouth while
*
he always
snezing,
covers
his
*
if he works in a dusty atmosphere
he should cover his mouth and
nose.
nose while
19, Does a T.B. patient need to take milk,
eggs, fish and meat ?
*
These foods are not necessary for
a T.B. patient.
*
If he can afford it, he should eat
it.
If he cannot
affort it, he should
j.
15.
Is it necessary for a person
T.B. to- stay in a hospital ?
who has
No. A person who has T.B. can be
looked after at home.
16.
What care .should the family members
take if one of them has T.B. ?
See question 6 above : How can we
• stop the spread of T.B. ?
Also :
*
*
17.
Keep the patient in a room where
there is lots of sunlight and
fresh air.
All family members should take a
sputum test (or x-ray) to find out
if they have T.B.
How soon can a person
bak to work ?
who
has T.B. go
He can go back to work as soon as
his symptoms have disappeared and
a sputum test shows that there are
no T.B^ germs in his spit.
18.
Are there any precautions a T.B patient
should take while at work ?
He should-ensure that :
51
he does not spit in a public, open
place,
HEALTH FOR THE MILLIONS
APRIL
1984
11. The doctor did not want the
children to get tuberculosis.
The- doctor asked Rukhmani to
bring the children for checkup.
He found Krishna and Shoba both
‘healthy. To help protect them
I from tuberculosis he gave the
children BCG injections.
These
injections
are given on the
shoulder and do not cause fever.
Vithoba had been off work for
two months. They had very little
money left. Vithoba decided they
could not afford to have another
child.
They were happy with
- their two healthy children. So
Vithoba
decided to ask
the
? doctor about family planning.
• ••pg
41
eat a lot
every day.
of- the foods he
eats
If you get T.B. after you have
taken BCG, usually the TB will be
easier to cure. You must come
early and take treatment regu
larly.
20. Do people die of T.B ?
Yes, many people in our. country
die of T.B. every year. If they
come -for treatment early and take
treatment regularly, they will not
die but become cured.
21.
22.
23.
What should a CHW tell
about treatment ?
the
patient
The CHW should tell the
having T.B. that :
person
What can you do to avoid getting T.B ?
*
if the person starts treatment
right away, the person will be
cured,
*
after a few months of treatment,
the person's symptoms will disap
pear and the person will feel
stronger. Don't stop treatment at
that time.
.. BCG is available at all muncipal
and other public hospitals.
*
Treatment for T.B. takes a long
time, at least 12-18 months.
Your CHW will inform you where BCG
is available.
*
Treatment
regularly
tion .
*
the person should continue to take
treatment till the doctor says to
stop.
*
A BCG vaccination will protect you
from T.B.
*
Anybody
tion .
*
The BCG immunisation are available
at all Primary Health Centres.
*
-
can
take
a BCG vaccina
for
and
T.B. must be taken
without interrup
Does BCG always protect you from T.B ?
*
No,
some people get T.B.
though they have taken BCG.
even
C.G.
B.
B.C.G. stands for Bacillus Calmette Guerin. B C G is a living bacillus but
differs from the tubercle bacillus in its being harmless.
In other words, the
tubercle -bacillus is so changed that in the form of BCG, it loses the power to
produce disease but retains the power to produce anti-bodies. Calmette and
Guerin were the two French scientists whG achieved this by making the bovine
tubercle bacillus grow repeatedly on a special medium containing bile for 13
years, till it was unable to produce disease even in a guinea-pig.
Iii order to remove some of the difficulties of storage- md transport, freeze
dried vaccine is being now used,
and car. be used within three months of
manufacture.
If BCG is given to an uninfected child, a small nodule appears in 7 to 10
days at the site of vaccination.
It grows bigger, a small pustule forms which
later on breaks and in about 3 to 4 weeks time there is a small ulcer which
heals in about 3 months' time. This is the normal reaction which most children
get after vaccination.
If, however, an infected child is vaccinated, the nodule
and ulcer are formed very quickly (Koch's phenomenon).
It has been found that if uninfected children are given BCG, the chance of
their developing the disease is reduced by about 80%. Millions of children all
over the world have been vaccinated and it has been proved beyond all doubt that
BCG is harmless and can be safely recommended even for new born babies.
40
HEALTH FOR THE MILLIONS
APRIL
1984
News from the States
West Bengal
"Drugs Vs Peoples Health"
A one day seminar on "Drugs vs Peoples
Health" was organised by the WB VHA on 16th
March at Max Muller Bhavan, Calcutta. The
seminar
was attended by Dr. Zafrullah
Chowdhury,
of
Gonosasthya
Kendra,
Bangladesh who was invited as the guest of
honour. Speaking on the occasion,
Dr.
Chowdhury said that India with its large
complement of scientists
and qualified
people was in a better position to formu
late its own drug policy. It was ironic
that the Hathi Committee report which had
inspired Bangladesh’s drug policy, had not
been implemented in India.
voluntary sector in the implementation of
the various programmes initiated by ' the
Government.
Mr. Singh welcomed the proposal of Mr.
D'Souza
to
form a joint consultative
committee. He said that it will be a
positive step towards formalising the coop
eration between the voluntary health sector
Dr. Mira Shiva, Coordinator, Low Cost Drugs
and Rational Therapeutics, VHAI, stressed
the need to safeguard health as a human1
right and pointed out that essential drugs
based on the health needs of the majority
were not being given priority in produc
tion, distribution or even prescribing.
Bihar
The 16th General Body meeting and one
day seminar on the National Health Policy
were the major events of February 1984. Mr.
Averthanus
D'Souza, Executive Director,
Voluntary Health Association of India, who
delivered the keynote address on the theme,
"National Health Policy and its implementa
tion", suggested in his talk that to ensure
better ' participation of the
voluntary
health
sector,
a
joint
consultative
committee should be set up. This committee
would facilitate the planning of operatio
nal strategies and help to remove adminis
trative bottlenecks.
12.
After
a few months of
treatment Vithoba is back to
work,
feeling much stronger. He
I is not so thin. He has gained
several kilos weight. Rukhmani
makes sure that he takes his
tablets regularly. She does not
want this disease to come back
again. She wants Vithoba to take
the tablets for 18 months as the
doctor said.
...pg
45
Mr. Brij Kishore Singh, Minister of
State for Health, in his inaugural address
pleaded for the active cooperation
of
HEAL-TH FOR THE MILLIONS
APRIL
1984
41
and the Government of Bihar. He promised to
examine this proposal favourably.
The National Health Policy was discu
ssed with special consideration being given
to reorientation of Health Education and
training,
low cost drugs and rational
therapeutics,
nutrition and mother
and
child health care.
There was a panel of 5 speakers. Dr.
Ramaiya from Kurji Holy Family Hospital,
Patna,
shared his views on the present
education
and
training
system,
Dr.
Sathyamala and Sr. Lorraine spoke about
Mother-and Child Health Care, Ms.
Sibane
Chakraborthy from Calcutta presented her
research paper on Nutrition,
and
Mr.
Majumdar, General Secretary, Federation of
Medical Representative Association of India
highlighted the drug situation
in India.
Fr. Britto briefly shared his views on the
indigenous system of medicine.
Kerala
Training Programmes:
The second programme in the series on
"Social Security Legislations" was held on
27th January at the Rajagiri College of
Social Sciences, Kalamasserry. Twenty dele
gates from Ernakulam and Alleppey Districts
attended the programme where the legisla
tions dealing with Provident Fund, Grat
uity, Minimum Wages and Maternity Benefit
were discussed. One more programme in the
same series will be arranged at Quilon for
the southern districts, in May 198.4.
The KVHS Secretariat is busy organising
a one day panel programme on the entire
procedures related to import and customs
clearance of equipment and supplies. The
first course will be arranged at Ernakulam
and the faculty will consist of senior
officials from the customs department and
also from non-governmental agencies.
Andhra Pradesh
Directory
The AP VHA Directory is ready to be
released. This is an effort to bring all
the health care institutions and health
related organisations in the
voluntary
sector in Andhra Pradesh, into one compen
dium. It is felt that this directory will
have value for the voluntary organisations
themselves and also prove useful to the
state government.
Office centre :
AP VHA has managed to get a site for an
independent office at Secunderabad. It will
be adjacent to the new CHAI office and is
about 4 km from Secunderabad station. The
new centre would be ready by 1985.
COCONUT WATER USED IN
bfcTfeC’riON OF TUBERCULOSIS
Coconut water which is usually
discarded has now been used in
the Philippines to develop CEM
or Coconut Water Egg Malchite
Green Medium# one of the prim
ary tools in mass detection of
tuberculosis# CEM was found as
efficient as the Lowenstein Jensen medium which is normally
used in a TB bacteriology ser
vices# Using 1976 prices# a
laboratory using LowensteinJensen medium spent US$ 59
while only US$ 7.60 or 1/8 th
of the former is needed for
CEM.
Study
s.
AP VHA is making a study of cultural
•practices of mother and child care to
assist in planning appropriate health care
delivery systems in the rural areas.
42
- The Cocemunlty Newsletter
Vol. II No. 12 June 1981.
HEALTH FOR THE MILLIONS
APRIL
1984
VHAI INFORMATION SERVICE
Further Reading on T.B,
(6)
BOOKS
(1)
.
by Toman K
World Health Organization, Geneva,
Switzerland
1979 ; 239 pg ; Price Rs. 15.00
Diagnosis, Treatment and Prevention
of Pulmonary TB for General Practi
tioners
(7)
The Tuberculosis
India, 3 Red Cross
110001; 18 pg
(2)
(3)
Association of
Road, New Delhi
Handbook of TB
by S P Pamra,
Tuberculosis Association of India,
3 Red Cross Road, New Delhi-110001;
1980 ; 110 pg.
JOURNALS
Introduction to Tuberculin Testing
and BCG Vaccination
(1)
Edinburgh,
Indian Journal of Tuberculosis
Periodicity : Quarterly
Published by : TB Association of
India, Red Cross Road, New Delhi
Annual subscription : Rs. 50.00
Pulmonary Tuberculosis
(2)
by Menon, MPS
National
Book Trust,
Park, New Delhi-110016.
pg; Price Rs. 23.25
(5)
Tuberculosis in Children
by Miller, E J W
Churchill
Livingston,
London, UK
1982 ; 294 pg.
by Shashidhara, A N
IBH Prakashan, Bangalore
1980 ; 119 pg
(4)
Tuberculosis Case-finding & Chemo
therapy Questions and Answers
A-5 Green
1983 : 254
HEALTH FOR THE MILLIONS
APRIL
1984
Review
of
Respiratory
Official journal of the American
Thoracic Society
Periodicity : Monthly
Published from : 1740 Broadway, New
York, N Y 10019
Textbook
of Tuberculosis - The
Tuberculosis Association of India
by Rao K N & others (ed)
2nd Revised.edition
Vikas Publishing House Pvt Ltd,
5 Ansari Road, New Delhi -110002
1980 ; 607 pg ; Price Rs. 30.00
American
Diseases
(3)
Tubercle - 1919
Longman Group Ltd, Journals Divi
sion, Fourth Avenue, Harlow, Essex,
England
COMMUNITY HEALTH CELL
47/1, (First FloorlSt. Mark-Koa4
BANGaiqbe .5UJQ01
43
Periodicity : Quarterly
Published by : International Union
Against Tuberculosis, 3 rue Georges
Ville, 375116 Paris France
Tuberculosis
book 1978
11 nos
English
Audio Visual Unit, CMC Hospital,
Vellore - 632 004, Tamil Nadu
(2)
'Tuberculosis
Madras
Prevention
Trial,
Indian Journal of Medical Research
(special issue)
Vol 72 (suppl) July 1980
ICMR, New Delhi
(4)
(5)
(1)
10 nos
Hindi
TB Association of India,
3,
Cross Road, New Delhi 110001
(1)
Natural History of childhood tuber
culosis - the characteristics of
Childhood TB”
(TbNH)
Rs 24/- (colour slides)
(2)
Pathology of Tuberculosis in Child
hood - Macroscopic and Microscopic
TB - A New Thrust (article)
(bp)
Rs 24/- (colour slides)
Principles of Internal Medicine
Tuberculosis
of 15 slides
George W & Thorn (edited)
1977 : 900 pg
(D-81)
Rs 15/- (Black and White)
(3)
44
Red
SLIDES
INDIA TODAY
November 30, 1982 : pg no 49
(7)
Tuberculosis Control
Problems of TB in Indian Children
by Gopal Sharan
Tropical Doctor, July 1979,
pg 104-5
(6)
FLIP CHARTS
Domiciliary. Tuberculosis Chemothe
rapy
Indian Journal of Medical Research
(special issue)
Vol 73
(suppl)
April 1981
ICMR, New Delhi
Tuberculosis is Curable
15 nos
English & Hindi
VHAI, C-14 Community Center, SDA,
New Delhi - 110016
OR Foundation for Research in Comm
unity Health, 84 A, R G Thadani
Marg, Bombay 400018
Research Centre Hand
Indian Council of Medical Research
Spur Tank Road,
Chetput,
Madras
600031
(3)
Control of TB
of National TB Institute
Volume One July 1976 and Volume One
July 1977 (Yearly abstracts)
Published by : National TB Insti
tute,
DGHS,
8
Bellary
Road
Bangalore 560003
(2)
Dia
Journal of Indian Medical Associa
tion
January 1983
(1)
Summaries
Studies
Genital
FLASH CARDS
ARTICLES AND RESEARCH REPORTS
(1)
Male
Tuberculosis,
gnosis
(8)
<4) Tuberculosis 1963-1977
is
-
a set
APRIL
1984
curable
HEALTH FOR THE MILLIONS
AGENDA FOR THE NATION - THE NEW 20 POINT PROGRAM
ITEM 14 - Control of TB, Leprosy and Blindness.
During the Sixth Plan oeriod the scheme for establishment of TB
centers and TB beds has been included in the state sector .Under
the centrally sponsored sector, material and equipment and anti
TB drugs are being supplied to the district TB centers
located
in states ona 50:50 sharing basis and to the TB centers located
in Union Territories as 100% sponsored. Anti-TB drugs run by vo
luntary bodies are being supplied as a 100% centrally sponsored
scheme.
Booklet,20 point Program
I
I
13.
18 months go by. Vithoba
visits the doctor for a final
checkup. The doctor is pleased
and says that Vithoba is comple
tely cured. This doctor says is
because he has taken his tablets
every day for 18 months. He has
no cough or sputum. He has no
fever.
His appetite is good. He
can work all day without getting
tired. Vithoba
knows
he is
cured.
HEALTH FOR THE MILLIONS
APRIL
1984
14. Vithoba is glad. The child
ren are not going to get TB.
He
is glad they did not have more
than two children.
Vithoba's
doctor had told him the truth.
Vithoba knew that he was alive
and well now because he had
taken his tablets daily for 18
months. The TB would not come
back. He was happy to be able to
work. The whole family is happy
and healthy again.
45
VHAI INFORMATION SERVICE
Facts on File
TABLE
I
TARGETS AND ACHIEVEMENTS
OF BCG VACCINATION.DONE DURING
1
(in Lakhs)
1982- 83
1
Age-wise Performance (Years)
i
I
46
■
feu
SI.
No.
State/UT
Target
Achieve
ment (%)
1
2
3
1.
Andhra Pradesh
2.
Below
year
1-4
5+
Total
Round
4
5
6
7
8
13.0
130.6
3.50
86.9
3.
Bihar
5.00
142.9
4.
Gujarat
12.00
99.75
5.
Haryana
5.00
83.8
6.
Himachal Pradesl1 2.00
30.4
7.
Jammu & Kashmir
2.00
87.5.
8.
Karnataka
10.00
31.4
9.
Kerala
6. CO
96.7
10. Madhya Pradesh
9.00
34.6
11. Maharashtra
17.00
199.6
12. Manipur
0.30
40.0
13. Meghalaya
0.20
114.8
14. Nagaland
0.10
280.0
15. Orissa
5.00
101.0
16. Punjab
*
6.00
73.1
17. Rajasthan
8.00
54.5
18. Sikkim
*
0.07
169.3
9.22
(54.63)
1.15
(37.80)
2.14
(30.17)
2.56
(21.39)
1.32
(31.50)
0.30
(49.67)
0.53
(30.29)
0.66
(21.04)
0.76
(13.10)
1.06
'34.03)
7.92
(33.08)
0.05
(41.67)
0.08
(33.12)
0.08
(29.69)
1.48
(29.37)
1.95
(44.40)
1.30
(29.90)
0.02
(18.90)
4.81
(28.52)
1.66
(54.56)
4.32
(60.83)
2.09
(17.46)
1.69
(40.34)
0.02
(3.78)
0.72
(41.14)
1.27
(40.48)
3.30
(56.90)
1.31
(42.17)
0.82
(3.41)
0.05
(41.67)
0.12
(51.35)
0.14
(50.87)
3.24
(64.12)
0.68
(15.45)
2.37
(54.44)
0.04
(32.19)
16.88
Assam
2.84
(16.85)
0.24
(7.74)
0.64
(9.0)
7.32
(61.15)
1.18
(28.16)
0.28
(46.55)
0.50
(28.57)
1.21
(38.48)
1,74
(30.00)
0.74
(23.80)
15.20
(63.51)
0.02
(16.66)
0.04
(15.53)
0.05
(19.44)
0.33
(6.51)
1.73
(39.51)
0.68
(15.66)
0.01
(9.93)
#
HEALTH FOR THE MILLIONS
3.04
7.10
11.97
4.19
0.61
1.75
3.14
5.80
3.12
23.93
0.12
0.23
0.28
5.05
4,39
4.36
0.12
APRIL
1984
Age-wise Performance (Years)
SI.
No.
State/UT
Target
Achieve
ment (%)
1
2
3
*
19. Tamil Nadu
Below
year
1-4
5+
Total
Round
4
5
6
7
8
13.00
92.35
0.30
66.6
21. Uttar Pradesh
18.00
131.1
22. West Bengal
12.00
34.0
23. A & N Islands
0.02
163.5
24. Arunachal Pradesh 0.05
131.6
25. Chandigarh
0.15
126.6
26. D & N Haveli
0.02
132.6
27. Delhi
1.8
138.3
28. Goa Daman & Diu
0.20
109.0
*
29. Lakshadweep
0.01
200.0
30. Mizoram
0.14
61.01
31. Pondicherry
0.14
116.1
2.61
(21.73)
0.05
(24.18)
3.33
(14.09)
0.92
(22.50)
0.01
(30.08)
0.03
(51.86)
0.03
(15.0)
0.02
(55.86)
0.33
(13.30)
0.04
(20.22)
0.003
(15.00)
0.04
(39.22)
0.04
(28.64)
6.44
(53.62)
0.13
(65.50)
18.44
(78.14)
2.86
(69.80)
0.005
(15.53)
0.02
(32.72)
0.07
(38.23)
0.001
(5.92)
0.36
'(14.49)
0.01
(5.54)
0.007
(35.00)
0.03
(35.38)
0.01
(5.04)
12.10
20. Tripura
2.09
(17.39)
0.02
(10.32)
"1.83
(7.77)
0.31
(7.61)
.0.02
(54.39'
0.01
(15.42)
0.09
(46.77)
0.01
(38.22)
1.71
(68.66)
0.16
(74.14)
0.002
(10.00)
0.02
(25.40)
0.11
(66.32)
Total : 1982-83
150.0
92.84
41.16
(29..58)
40.03
(28.76)
57.04
(41.66)
139.26
1981-82
150.00
90.49
29.35
(21.56)
31.86
(23.62)
74.27 135.74
(54.82)
1980-81
150.00
86.89
15.25
(11.70)
24.89
(19.10)
90.20
(69.20)
C.20
23.60
4.09
0.03
0.06
0.19
0.03
2.49
0.22
0.02
0.10
0.16
130.34
#
=
Data from 4/82 to 8/82 only.
*
=
Age wise break up not available for 2814 vaccination for Punjab 4618
for Sikkim, 862 34 for Tamil ' Nadu, 8836 fdr Delhi and 1174 for
Lakshadweep figures in bracket indicate
% population to total
population.
HEALTH FOR THE MILLIONS
APRIL
1984
TABLE
II
Statement showing State/UT - wise estimated number of
T.B patents'.
SI.
NO.
Name of State/U.T.
1
2
1.
2.
3.
4.
5.
6.
7.
8.
9.
16.
,11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Himachal Pradesh
Jammu & Kashmir
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Nagaland
Orissa
Punjab
Rajasthan
Sikkim
Tamil Nadu
Tripura
Uttar Pradesh
West Bengal
Estimated
X-ray cases
(in lacs)
Estimated
Sputum cases
(in lacs)
3
4
8.05
3.0
10.50
5.10
1.95
0.60
0.90
5.55
3.80
7.80
9.45
0.25
0.25
0.15
4.00
2.55
5.10
0.10
7.25
0.30
16.65
8.20
2.00
0.75
2.60
1.25
0.50
0.15
0.25
1.40
0.95
1.95
2.35
0.05
0.05
0.05
1.00
0.65
1.25
0.05
1.80
0.10
4.15
2.05
A & N Islands
Arunachal Pradesh
Chandigarh
D & N Haveli
Delhi
Goa Daman & Diu
Lakshadweep
Mizoram
Pondicherry
0.03
0.09
0.08
0.02
0.90
0.15
0.01
0.08
0.08
0.01
0.02
0.02
0.005
0.22
0.04
0.005
0.02
0.02
Total
102.94
25.71
UNION TERRITORIES
23.
24.
25.
26.
27.
28.
29.
30.
31.
Source : Lok Sabha Question - Answer Deowifcb. 1£83 no 1442
48
HEALTH FOR THE MILLIONS
APRIL
1984
TABLE
III
TREATMENT FACILITIES AVAILABLE FOR TREATMENT OF TB PATIENTS 1982
SI.
No.
Name of State
Union Territories
2
1
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
T.B Demon
stration
Centres
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Himachal Pradesh
Jammu & Kashmir
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Nagaland
Orissa
Punjab
Rajasthan
Sikkim
Tamil Nadu
Tripura
Uttar Pradesh
West Bengal
Total No.
of other
TB Clinics
District - Number of
T.B
T.B. Beds
Centres
3
4
5
6
1
1
2
1
1
1
1
1
1
—
1
1
1
1
1
1
27
8
18
6
6
10
5
5
12
2
27
1
—
2
2
6
2
4
41
—
20
102
22
10
25
•19
9
8
9
19
10
45
26
2
2
1
13
10
26
1
15
2
56
16
2699
799.
1799
3388
275
643
705
3445
2199
1699
7149
110
304
100
801
921
2018
90
3609
50
3437
5948
-
1
1
67
1
—
4
—
10
3
—
2
3
1
1
—
1
1
—
1
1
182
10
—
1539
276
—
62
178
17
329
353
UNION TERRITORIES
23. Andaman & Nicobar
Islands
24. Arunachal Pradesh
25. Chandigarh
26. Dadra & Nagar Haveli
27. Delhi
28. Goa Daman & Diu
29. Lakshadweep
30. Mizoram
31. Pondicherry
Total
44502
Source : Health Statistics of India, CBHI, DGHS, 1983.
HEALTH FOR THE MILLIONS
APRIL
1984
49
TABLE
IV
Recommended dosages of Anti-Tuberculous Drugs (I.U.A.T 1982)
DOSE
Action
Drug
Daily
Phase
io isdmuK
1. I.hT.TT (tfV *
d
Bactericidal 5-8 mg/kg
maximum
300mg
-do-
Xll \ IN /
• t\X X
.eev
eev i
i
i
3. Pyraz^inamide (Z) -*do-
f fcd
■' i 5 •'
4. Streptomycin(S) -do-
G •V
Intermittent
Phase
Adverse
Reactions
12-15 mg/kg
maximum
700mg
Polyneuritis
Rarely hepatitis
9-12 *
mg/kg
maximum
600mg
in daily
phase
30 mg/kg
maximum
2 gm
50 mg/kg
maximum
3 gm
Arthralgia
20 mg/kg
maximum
1 gm
Same as in
daily phase
Giddiness/
deafness
40 mg/kg
25 mg/kg
for 6 weeks maximum
15 mg/kg
2 gm
thereafter
5. Ethambutol (E) Bacterio
static
U’ *A
•
Optic
neuropathy
i >
J it?
c■ • L
6. Thiacetazone(T)
-do-
.150 mg **
-
Skin reaction
and hepatitis
Rarely, exfolia
tive Dermatitis
7. PAS (P)
-do-
5 gm B.D
**
-
Anorexia
vomiting
Diarrhoea, etc.
250 mg
**
Anorexia,
nausea,
vomiting,
Diarrhoea, etc.
250 mg BD **
Epileptiform
convulsions,
Psychosis.
8. Ethionamide/
-doProthionamide (N)
erei
9. Cycloserine (C)
-do-
c
Usual daily use
for
*
adults is "450 mg if-the patient's weight is less than 50
kg, and 600 mg if the weight is 50 kg or above. Dose for children is adjusted
suitably; In intermittent phase, usual dose for adults is 600 mg.
Maximum adult dose.
proportionately.
50
For
children
and
under-weight
adults,
reduce
HEALTH FOR THE MILLIONS
dose
APRIL 1984
TABLE
V
Suitable Regimens for Treatment of Pulmonary Tuberculosis,
'(I.U.A.T 1982)
‘
‘ n <
:>'4 niuJuqs -C
Conventional
•oG res p.puTiG__ &bsS
HT daily for
10 months Total Duration
. cZ
SHT daily for 2 months plus
12 months
f
: in trios I
£
it
ii
H
H
it
HP daily for
10 months Total' Duration ;
SHP
12 months
ii
ii
SHT
ti
ii
it
10 months
SH biweekly
Total Duration
is
Short -course
ni
SHRZ for 2 months plus
,vSHRZ H
ii
EHRZ
io
\ jG £•'
RH daily for
4 months
I \ u ev.c
Total Duration
6 months'; -c
II
If
RH biweekly for
4 months
Total Duration
6 months
If
ff
RH daily for
4 months,
Total’Duration
6 months
EHRZ ii
ii
If
II
RH biweekly for
4 months
Total Duration
6 months
SHRZ H
ii
II
ff
SHZ daily for.
4 months
Total Duration
6 months
SHRZ H
ii
II
If
HT daily for
6 months
Total Duration
8 months
RHZE
Thrice weekly
for 6 months
Total Duration
6 months•
RHZS
Thrice weekly
for 6 months
Total Duration
6 months
N.B
:
Intermittent chemotherapy should
of every dose.
only
be given under full supervision
Source : Lectures on TB for General Practitioners - Tuberculosis
India.
HEALTH FOR THE MILLIONS
APRIL
1984
Association of
51
TABLE
VI
DRUG REGIMENS
Recommended in National Tuberculosis Programme
a) For sputum positive TB patients
Code
No.
Drugs and Dosage
Mode and Rhythm of
administration
Instructions
R
Isoniazid 300 mg +
Thioacetazone 150 mg
Both drugs in a
single dose 'or in
two divided doses
orally, daily
Self-administered
at home after meal.
Collected monthly
from DTC/PHI
In.j Streptomycin
0.75 g / 1 g- +
Intramuscularly
Isoniazid 600 to
700 mg (15 mg/kg
body weight) with
Pyridoxine 10 mg
Orally
Both drugs given in
the same time under
supervision at DTC/
PHI twice weekly at
intervals of 3 and
4 days.
Isoniazid 300 mg +
PAS 10 g.
In a single dose.
In two divide doses
Both drugs orally
daily
Self-administered at
home after meal.
Collected monthly
from DTC/PHI
Isoniazed 300 mg +
Ethambutol 20 mg/kg
body weight,i.e
800 mg for pts.
weighing
50 kg
and 1200 mg for
50 kg
Both drugs in a
single dose, daily,
orally
Self-administered at
home after meal.
Collected monthly
from DTC/PHI
1
BI WEEKLY REGIMEN
R
2
R
3
R
4
BIPHASIC REGIMEN
R
5
a. Intensive phase
First two months
Inj. Streptomycin
0.75 g/1 g +
Isoniazid 300 mg +
Thioacetazone 150. mg
or Ethambuto 20 mg
per kg body weight
i.e.800 mg for pts. .
weighing 50 kg and
1200 mg for those
50 kg or PAS 10 g.
Intramuscularly.
daily
b. Continuation phase
In a single dose
orally, daily.
(PAS and Thioaceta
zone may be given
in two divided
doses)
Injection given
under supervision
and the rest to be
self-administered at
home.
Remaining period
With Rl, R2, R3, or R4 As for each,regimen As for each regimen
Cont'd on next page
HEALTH FOR THE MILLIONS
APRIL 1984
b)
For the sputum negative TB patients (Suspect cases)
TB patients in whose sputum AFB are not seen, are prescribed Regimen R1 i.e.
Isoniazid 300 mgm +
Thioacetazone 150 mgm
Single dose orally
daily for 1 to lj years
Patients, allergic to Thioacetazone can be treated with R4
Duration of Treatment
All patients should be treated for a minimum of 1 year or optimum of 14 years
duration irrespective of their disease status. By duration of treatment for 1
year to 14 years is meant that intensive efforts should be made to keep the
patient on regular treatment for atleast one year. Even if patients at the
end of one year are regular, treatment should be continued upto 18 months in
order to prevent relapses.
Treatment can be continued upto 2 years after review at the end of 18 months
but continuation beyond two years has no added advantage.
From:
National TB Institute, BANGALORE-560 003
TABLE VII
COUNTRY’S REQUIREMENTS OF TB DRUGS (METRIC TONS )
Increase %
SI.NO.
Name of the Drug
79-80
80-81
81-82
82-83
83-84
84-85
1.
STREPTOMYCIN
300
330
363
400
440
485
10
2.
RIFAMPICIN
5.4
7.3
9.8
13.3
18.0
24.0
5
3.
I N H
200
240
290
300
415
500
20
4.
PAS
600
630
660
700
730
770
5
5.
THIACETAZONE
40
42
44
46
48
50
5
6.
ETHAMBUTOL
60
78
101
132
170
225
30
7.
PYRAZINAMIDE
8
8.4
8.8
9.3
9.7
10.2
5
HEALTH FOR THE MILLIONS
APRIL
1984
TABLE VIII
PRICES OF IMPORTS
(Rs. in lakhs)
78-79
79-80
80-81
1.
Streptomycin
280.12
274.20
123.69
2.
INH
12.43
11.90
3.06
3.
Rifampicin
95.26
311.11
448.2
4.
Ethambutol
223.7
322.17
92.50
SOURCE
:
Mr.
B.R. Verma,
Senior Investigator, E & S Section (Drug
Sector),
Ministry of Chemicals and Fertilizer, Government of
India, New Delhi.
TABLE IX
PRODUCTION OF TB DRUGS
a.
b.
c.
Imports
(Metric Tons)
79-80
80-81
1. Streptomycin
*
76.12
72.82
44.01
2. INH
23.8
26.2
6.8
3. Rifampicin
1.7
5.4
8.9
4. Ethambutol
66.2
96.1
29.1
Local (Metric tons - larger companies like HAL, CADILLA)
1. Streptomycin
220.7
220.1
227.3
2. INH
81.72
112.53
129.20
3. Ethambutol
10.18
23.58
24.87
Small scale sector (see NOTE Below)
1. Streptomycin
...
not produced ....
2. INH
-
41.8
150.5
3. Ethambutol
-
0.7
10.1
SOURCE s
54
78-79
Mr. B.R. Verma,
Sector)
Ministry
India, New Delhi.
Senior Investigator, E & S Section (Drug
of Chemicals and Fertilizer, Government of
. HEALTH FOR THE MILLIONS
APRIL
1984
3.
Dr. H.P. Basu,
Honorary General Secretary,
Bengal TB Association (P.O. Entally)
24, Dr. Sundari Mohan Avenue,
CALCUTTA - 700014
4.
Dr. A.A. Mallick,
General Secretary,
Bihar TB Association,
Abedin Building, 1st Floor,
North. Wing, Frazer Road,
PATNA - 800001
5.
Dr. M.M Singh,
Honorary General Secretary,
Delhi TB Association,
Rajan Babu TB Hospital,
Kingsway Camp,
DELHI - 110009
LIST OF RESEARCH CENTRES
and associations of tuberculosis
1.
Tuberculosis Research Centre
Spur Tank Road
Chetput
Madras - 600031
TAMIL NADU
Tel. 665425 (5 lines)
2.
National Tuberculosis Institute
Director General of Health Services
No. 8, Bellary Road
Bangalore - 560003
KARNATAKA
3.
Tuberculosis Association of India
No. 3, Red Cross Road
NEW DELHI - 110001
4.
Dr. S.P. Gupta
Assistant Director General
of Health Services (Tuberculosis)
Room No. 350, 'A' Wing
Nirman Bhavan
NEW DELHI - 110011
Tel. 385993
*
5.
Dr. Aneja
New Delhi TB Centre
Jawahar Lal Nehru Marg
NEW DELHI - 110002
6.
Dr. Damodar Bhounsule,
Honorary Secretary,
Goa, Daman & Diu TB Association,
18th June Road,
PANAJI, (GOA)
7.
Dr. S.H. Patel,
Honorary Secretary,
Gujarat State TB Association,
F/6, Saraswati Apartments,
Opp. Gandhigram, Rly. Station,
Ellis Bridges,
AHMEDABAD - 380006
8.
Dr. O.P. Dehar,
Honorary Secretary,
TB Association of Haryana,
36, Madhya Marg, Sector 7-C,
CHANDIGARH - 160017
9.
Dr. Tahir Mirza,
Honorary Secretary,
TB Association of Jammu & Kashmir,
Opposite Chest Disease Hospital,
Dalgate,
SRINAGAR (KASHMIR)
10.
Honorary Secretary,
Himachal Pradesh TB Association,
Kennedy House,
SIMLA - 4. (H.P.)
LIST OF STATE TUBERCULOSIS ASSOCIATIONS
1.
Dr. D. Umapathy Rao,
Honorary General Secretary,
TB Association of Andhra Pradesh,
3-4-760, Barkatpura,
HYDERABAD - 500027 (A.P.)
Dr. L.N. Chintey,
Honorary Secretary,
TB Association of Meghalaya,
Police Bazar,
SHILLONG - 793001
(Meghalaya)
Z r 'I 3
* *.
•
2.
HEALTH FOR THE MILLIONS
APRIL
11. Dr. T. Manickam,
x Honorary Secretary,
Karnataka State TB Association,
No. 3, Union Street,
BANGALORE - 560001
1984
55
12.
Dr. N. Siv^anandan Pillai,
Honorary Secretary,
TB Association of Kerala,
TB Centre,
Red Cross Road,
TRIVANDRUM - 1. (KERALA)
13.
Dr. D.P. Verma,
Honorary Secretary,
Madhya Pradesh State TB Association,
TB Hospital,
Idgah Hills,
BHOPAL (MADHYA PRADESH)
14.
Dr. K.C. Mohanty,
Honorary Secretary,
Maharashtra State Anti-TB Association,
O.H.T. Clinic,
Jarbai Wadia Road,
Sewree,
BOMBAY - 400015
15.
Prof. Harihar Das,
Honorary Secretary and Treasurer,
TB Association of Orissa,
Health Directorate,
BHUBANESWAR - 751001
(ORISSA)
16.
Dr. V.K. Padmanabhan,
Honorary Secretary,
TB Association of Pondicherry,
TB Chest Clinic,
PONDICHERRY - 605001
17.
Dr. K.K. Gambhir,
Honorary Secretary,
TB Association of Punjab,
Red Cross Bhavan,
Sector 16-A,
CHANDIGARH - 160017
18.
Dr. T.N. Sharma,
Honorary Secretary,
Rajasthan State TB Association,
Hospital for Chest Diseases,
Bani Park,
JAIPUR - 302006
(RAJASTHAN)
19.
Dr. L. Venkata Vittal,
Honorary Secretary,
Anti TB Association of TAmil Nadu,
259-61, Anna Salai,
MADRAS - 600006
20.
Sh. B. Ganesan,
Organising Secretary,
Anti-TB Association of TmII Nadu,
259-61, Anna Salai,
MADRAS - 600006
56
Dr. N. Deb Barman,
Honorary Secretary,
TB Association of Tripura,
AGARTALA - 799001
22. Dr. M.M.S. Siddhu, M.P.,
Honorary Secretary,
Uttar Pradesh TB Association,
A.P.
1Sen Road,
LUCKNOW (UTTAR PRADESH)
21.
•
23.
Dr. J.N. Bhuyan,
Honorary Secretary,
TB Association of Assam,
G.B.
L.
Chest Hospital,
GAUHATI
(ASSAM)
'
24.
Shri R. Narayanan,
Development Commissioner, & Secretary,
Sikkim Anti-TB Association,
G.M.C. Building,
GANGTOK (SIKKIM)
25. Dr. M.S. Agnihotri,
Hony. Jt. Secretary,
Uttar Pradesh TB Association,
1-A.P. Sen Road,
LUCKNOW (UTTAR PRADESH)
26.
Shri S.S. Sangal,
Deputy Secretary,
Uttar Pradesh TB Association,
1-A.P. Sen Road,
LUCKNOW (UTTAR PRADESH)
TB SEAL ORGANISATIONS
1.
The Administrative Officer,
Andaman & Nicobar Administration,
Directorate of Medical & Health
Services,
PORT-BLAIR - 744104
(A & N ISLANDS)
2.
Dr. M.C. Murry,
Assistant Director of Health Services,
(BCG),
Government of Nagaland,
KOHIMA.
3.
Dr. N. Kaia Singh,
Secretary,
Manipur TB Association,
Lamphelpat,
IMPHAL - 795004
(MANIPUR)
4.
Dr. D.D. Nimawat,
Organising Secretary,
Medical & Health Services,
JAIPUR (RAJASTHAN)
' .
■
'
HEALTH FOR THE MILLIONS
i
' P*
APRIL
1984
’
Milestones in Tuberculosis
TB lesions found on 3000 year old Egyptian mummies
Hippocrates (460-370 B C) Father of Medicine First described TB
1865 Jean-Antoine Villemin, French Militry Vet. Surgeon experimented transmission of TB to animals
by inoculation.
1882 German Physician Robert Koch discovered TB Bacilli on April 24.
1890 Robert Koch produced Tuberculin
1895 Roentgen—X-ray of chest
1905 Koch was awarded Nobel Prize
1910 Koch died
1921 French scientists A Calmette and C Guerin discovered BCG
1944 Selman A Waksman and colleagues (USA) discovered streptomycin; Waksman received Nobel
Prize in 1 952
1945 PAS, INH, highly effective and cheap drugs appeared
1948 First mass vaccination campaign by Scandinavian Red Gross Society
1956
1964
Domiciliary treatment of TB proved effective
Twice weekly chemo-therapy treatment introduced
1966
Rifampicin proved excellent against TB
SOURCE: World Health, WHO, January 1982
Landmarks : National Tuberculosis Programme
1951 Mass BCG Vaccination Campaign intro
The first TB Hospital in India—in Tilaunia
(near Ajmer) Rajasthan, founded by a Chrisduced in India.
tion Mission.
1955 National Tuberculosis Sample Survey.
1917 First Tuberculosis Clinic in Madras by Dr
1956 Establishment of Tuberculosis Chemo
Chandrasekhara Aiyer.
therapy Centre, Madras.
1928 First Intracutaneous BCG vaccination
1959 Establishment of National Tuberculosis
India by Dr A. C. Ukil—West Bengal.
Institute (NTI), Bangalore.
1929 King George Thanks-giving Anti-TB Fund
1962 Evolvemert of District Tuberculosis Progra
staited.
mme at NTI and its acceptance on country
1939 Tuberculosis Association of India was esta
wide basis.
blished.
1975 Constitution of Expert Committee for
1940 Establishment of New Delhi TB Centre (as
evaluation of TB Programme.
a Medel TB Clinic)
1977 Involvement of Multi-purpose Health Work
1948 Establishment of BCG Laboratory, Guir.dy,
ers in case-finding, treatment and BCG
Madras BCG vaccination introduced in
vaccination activities.
India.
SOURCE : Swasth Hind, June 1982.
1906
600, 000 people die annually of TB
4,000,000 people are infectious
12,000,000 people suffer from TB
Nearly 50% of the children are infected by the age of 14
Nearly 90% of the population is infected by the age of 24
Nearly 60% of all Indian TB patients drop out of treatment
An untreated case has an average survival time of 2 years:
During this time he/she infects 20-25 more individuals
The central government has allotted Rs. 2 crores to fight TB
The Sixth Plan outlay is Rs. 7 crores
Actually, Rs. 55 crores is needed for the National TB Programme
The number of TB cases is increasing.
For Private Circulation Only
HEALTH FOR THE MILLIONS
Vol X No. 3
Backing Up Frontliners
June 1984
In this issue:
1,97,000 Vacancies
1
Nursing as Metaphor
15
News from the States
18
Books
21
New Slides fron
Project Piaxtla
22
This issue of HFM was put to
gether and produced by Augus
tine Veliath (Editor), Aspi B.
Mistry, Ruth Hamar, P. George
and P.T. Thomas.
Owned and published by the
Voluntary Health Association
of India, C-14 Community Cen
tre, S.D.A New Delhi-110 016
and printed at J.K. Offset
Printers, Jama Masjid, New
Delhi
This issue of Health for the Millions focusses on the female
health workers who are variously described as the “key factors”,
“the frontliners” and “the interface” in primary health care. All
accept that well trained, highly motivated cadre of nursing perso
nnel working at the’ village level is critical to the achievement of
health for all
It is estimated that India would require about 1,97,000 Female
Health Workers by 1991. As against this requirement, we train
about 6,000 nurses a year. There is a serious shortage of trained
nurses The institutions charged with training nurses lack both
physical and human resources to do so.
The exhaustive study done by Ruth Hamar and Betsy Lehman
summarised in this issue argues for strengthening of our capacity
to train more nurses and revise the existing training system. While
noting that ‘the lion’s share of the activities are assigned to the
female health worker, the report states “the workload of the
ANM/HW(F) is often not reasonable in terms of population area,
geographical distribution and health needs of the people.” What is
more—theory and practice in how to teach and supervise village
level workers is lacking.
In view of these, a number of both short and long term measures
nave been suggested. Also included is a proposal for an expert
mental female health worker school
—Editor
NURSING IS AN ATTITUDE
Nursing is an attitude—
A way you don’t forsake;
A part of you that never dies
Though painfully you ache
Nursing is an attitude—
Technique is only part.
Communication, empathy, and
Listening—it’s art.
You look at life a different way
Than others seem to do.
For after all this game of life
Is often played by you.
The dreams that we as students dream;
Are they so really wrong?
Someone must start to change this world
And ease this massive throng.
Little girls often dream.
Of caps and capes and such.
They dream of making people well,
But only by their touch.
* Yes, nursing is an attitude—
Though lofty it may be.
At least ive have a goal, a dream,
A way that we can see.
Jerri Fogteman, Louisiana State Unioer^ity School of Nursing, New Orleans, La.
AMERICAN JOURNAL OF NURSING
RUTH HARNAR
BETSY LEHMANN
1,97,000 VACANCIES
India's success in accomplishing her acce
pted goal of "Health for all by the year
2000 A.D." as defined by radical improve
ment in the vital health indicators, is
largely dependent on the Female Health
Worker (Auxiliary Nurse Midwife)
who has
been termed the "vital key"
to
the
lowering of fertility rates and child
mortality reduction. Improvement of these
two measures is basic to all o-f the other
vital indicators. The Female Health Wor
ker is in the strategic position at the
sub-centre, the "inter-face" between Gove
rnment Health Services and the Community
with its chosen Health Guides (or Commu
nity Health Volunteers) and Trajihed Dais
(Traditional Birth Attendents). Her cru
cial
role mandates the provision
of
relevant training specific to tasks which
the Female Health Worker must perform and
an adequate support system,
including the
Male Health Workers as well as other
nursing personnel required for teaching
and supportive supervision.
This is the inescapable conclusion of a
study of the relevance of nurse eduction
to India's requirement for Primary Health
Care, commissioned by USAID in 1983 as a
part of the Health Sector analysis. The
purpose of the study was to examine how
well the various categories of nursing
personnel are prepared to provide and
manage child mortality reduction (CMR)
services in rural areas of India.
This paper summarizes the major findings,
problems and some important corrective
actions, which are described
in more
detail in the full report of the study.
The Government of India has set targets
for the establishment of adequate numbers
of health centres and sub-centres
to
provide opportunity for every citizen of
the country to obtain basic or Primary
Health Care. The Female Health Worker is
the KEY HEALTH FUNCTIONARY directly sup
ported by the Male Health Worker and the
Female Health Assistant
(or Lady Health
Visitor).
If we look at the requirements
for the female health worker,
the follow
ing facts emerge:
Projected
Requirement
for 2000 AD
Effective
Stock
available 1981
Additional
Number
Required
FEMALE HEALTH WORKER
Government Centres only
122,000
81,588
40,412
Both Government & Private
197,290
81,588
115,702
FEMALE HEALTH ASSISTANTS/
LHW (1/4 of 122,000)
30,500
10,230
20,270
HEALTH FOR THE MILLIONS
JUNE 1984
Since the Female Health Assistants (FHAs)
are now drawn from the FHW/ANMs who are
upgraded by a six months training pro
gramme, the number of FHAs needed must be
added to the additional number of FHWs
required
(115,702) making a total of
133,000 FHWs to be trained to reach the
2000 AD target.
Although fewer than 6000 FHW/ANMs have
qualified annually in recent years,
it
does not seem too difficult to raise the
number to a little over 6000 a year to
accomplish this total, especially since
the stated admission capacity is 14,289.
However,
because
the
actual
number
recruited was 12,730, the failure rate is
high (29% in one state), many students
take more than the minimum time to pass,
and the attrition rate during training has
been found to be about 23% an accurate
estimate of those who will be available
for employment is difficult to make. This
has become a serious problem. Added to
this is the fact that there is a high drop
out
of
FHWs from employment
posts:
retention of Female Health Workers in
service in places which might be termed
hardship posts, is another factor to be
considered.
- lack of opportunities for participa
tion in continuing eduction program
mes.
- lack of reward system from authori
ties .
2.
Lack
of
educationally qualified,
suitable local candidates for posting
in the rural areas. The practice of
appointing young, unmarried FHWs (F)
to work in "remote, unprotected sub
centres is a deterrent to recruitment
of the needed workers.
3.
The inferior status accorded to the
nursing profession by society nega
tively influences self-concept and is
due to:
a)
constraints imposed by society on a
profession largely populated by women;
(as evidenced by reluctance of parents
to
send
daughters to become FHW
because sexual harassment is common).
b)
performance of nursing duties which
break with many traditionally accepted
behaviour norms, resulting in loss of
respect;
c)
low priority accorded to meeting the
personal
and
professional
needs
expressed by nurses. This results in
loss of motivation and interest in the
profession, with a deterimental effect
on recruitment;
d)
reluctance of medical colleagues and
society to allow the nurse authority
and a decision-making role, resulting
in low job satisfaction. This
is
another deterrent to recruitment and
influences the profession itself.
PROBLEMS
Why is it “easier said than done” to train
the greater numbers of Female
Health
Workers required for the primary Health
Services of the country?
Problems related to the setting and social influences
Problems in recruitment and retention oi
all categories of nurses, and especially
those in rural areas are due to:
1.
Hardships encountered because of
- inadequate living arrangements, with
lack of safety from harrassment,
- lack of respect, appreciation, andsocial support,
- lack of schooling for children,
- lack of contact with colleagues,
2
Relationship of job responsibilities, crucial
nursing tasks and training
Other studies have identified
12 Key
Health Problems which must be overcome for
lowering fertility and child mortality.
These can be grouped together as problems
related to a)
fertility, b) antenatal
care, c) delivery (or midwifery),
d)
postnatal period and care of the infant
and
e)
care of children 0-5
years.
Nursing tasks or competencies required to
manage each of these key health problems
HEALTH FOR THE MILLIONS
JUNE 1984
have been listed and compared to the job
descriptions of the nursing personnel and
other health workers in rural areas.
The competencies listed include a high
percentage of skills in educating and
motivating; teaching, training and suppor
ting dais, Village Health Guides (or CHWs)
and the public. To teach others requires
competencies in recognition and management
of many common disorders and nutritional
needs which the nurse must know well
herself.
A
comparison
of
all these required
competencies
with
the
official
job
descriptions for the various government
health functionaries in rural
service
makes it clear that the"lion's share" of
the activities are assigned to the Female
Health Worker. It is true that her work
is largely concerned with the care of
women and children, who constitute three
fourths of the population. However, it is
also apparent that the job description of
the FHW requires revision to make it
realistic and manageable.
The Male and Female Health Assistants
foster teamwork and provide
necessary
assistance and guidance to the Health
Workers (Male and Female), Health Guides
and Dais. They are further supported by
the District Public Health Nurse,
if she
exists. But supervision of Health Workers
(F)
in service is inadequate and not
supportive because of inadequate supervi
sor training and facilities:
Assistant (F) are often lacking.
Whether it is really feasible for the
Female Health Worker to carry out her
responsibilities for all the record keep
ing and accurate statistics which must
then be checked by the FHA, is questiona
ble. These include an extensive baseline
survey, household/family records
which
must be updated every 3 years, an MCH
register with nine sections. Child care
register with three’ sections and a monthly
report with twelve major sections. But in
addition there are seven more registers
with a total of 209 spearate columns to be
filled in. These records
need to be
assessed for^their utility and value in
relation to the time spent on keeping
them.
Curricula for preparation of nursing personnel
for relevant nursing tasl^s
Analysis of the curricula and manuals for
Health Workers and Health Assistants indi
cate that the manuals and job responsibi
lities are directly related
for each
category, including fertility and child
mortality reduction-related nursing tasks.
The Health Worker (F)
course curriculum
has more theory than the minimum required
for the performance of assigned tasks in
- Lady Health Visitors
(Health Supervi
sors) are no longer being trained,
- experienced ANMs given the 6 month "Pro
motional" Health Assistant (F) course tc
become supervisors have a lower basic
education background than the present
FHW students,
- the "Promotional course" content does
not match the Health Assistants’ manual
and job description and includes inade
quate content on teaching supervisory
skills and communication,
- the Health Assistants are not adequately
trained for teaching roles,
- facilities for housing and travel for
supervisory/support personnel
(Health
HEALTH FOR THE MILLIONS
JUNE 1984
3
certain areas, e.g. anatomy and physio1 ^y. However, theory and practice in how
to teach and supervise village
level
workers is lacking.
Incorporating princi
ples of applied psychology with group
dynamics,
interpersonal relation-ships,
and the development of counselling skills
is needed.
The ultimate success of India’s health
sare delivery system at the grass-roots
level
depends on the motivation
and
ability of the learners and on the quality
of teaching and skill of the teachers. In
order to train the cadre of rural health
nursing personnel for their responsibili
ties, it is necessary to:
The Health Assistant curriculum
lacks
content on supervisory skills and record
keeping. Both curricula require revision.
1)
develop
and
incorporate
community
Health concepts in the curricula,
2)
provide suitable training sites,
3)
implement relevent instruction, incor
porating problem oriented/competencybased training methodology.
The learning needs assessment study of
rural health workers has shown areas of
training deficiency. These point out the
crucial importance of apppropriate and
relevant teaching-learning experiences in
the initial training programmes of the
workers, and the need for manuals to be
made available for each student/worker in
local languages.
Inservice education pro
grammes must be provided to:
1)
make up deficiences and up-grade know
ledge and skills,
2)
provide opportunities for feedback, and
3)
to keep those in the field in touch
with new technologies.
NVESE J)OCTO£ RATIO
Preparation of Instructors
The Indian Nursing Council regulations
determine faculty requirements for Health
Worker and Health Assistant training pro
grammes, and instructors are prepared in
various ways. A review of general nursing
(diploma) and BSc nursing curricula indi
cates that these courses of study prepare
students for first level nursing posi
tions, but not tutoring positions. Addi
tional
schooling
on teaching/learning
methodologies and public/community health
nursing is needed to prepare faculty for
HWs(F) and HAs(F).
A study of current curricula shows that
diploma nurses (RN, RM’s) with a postbasic BSc two year nursing degree course,
or
with
a 10 month/one year
post
certificate Tutor or Public Health Nursing
course are more adequately prepared as
faculty than are BSc nursing graduates.
This is because of the greater emphasis on
teaching and community nursing in the
post-basic programmes. General
nursing
and post basic nursing curricula need on
going monitoring and revision to insure
appropriate preparation of
Tutors and
Public Health Nurses.
Implementation of Nurse Training Programmes
Even an adequate, relevant curriculum and
academically qualified teachers do not
necessarily guarantee capable and knowled
geable graduates. A literature review of
actual implementation of curricula and
regulatory policies for nursing and Health
Worker education programmes have shown
4
HEALTH FOR THE MILLIONS
JUNE 1984
EVALUATION OF HEALTH WORKERS’
inadequacies in many aspects.
PERFORMANCE IN SERVICE
These findings were confirmed by field’
visits to 46 different training program
mes,
including each type’ of- nursing
school, and interviews with 3.2 Principals/
Chief Tutors, 91 faculty and 34£. students.
The reality in the majority of Health
Worker schools is very different from the
prescribed
requirements. Lacunae. . and
weaknesses are,
in many aspects, quite
alarming. Problems which -made the Train
ing of Female Health Workers inappropriate.
and inadequate were the following:
- lack of enough
(Tutors/PHNs),
qualified teaching staff
- training sites inappropriately based in
urban hospitals,
- lack of rural field practice areas with
adequate facilities,
- lack of physical facilities and transpo
rtation,
...
- content of curriculum too traditional
and partially irrelevent,
- teaching/learning methodologies'not pro
blem-oriented, or competency based,
It is not surprising, given the situation
described above, that the evaluation of
HW/ANMs performance and utilization is not
satisfactory. Findings of several inves
tigations of Health Worker performance and
utilization of services/impact
on the
population served have helped clarify role
expectations and skil-ls needed to meet
health needs of the consumer, and have
influenced changes in training programmes.
For
example, it bacame apparent that
training was needed to develop the HW(F)
role as teacher, supporter, and supervisor
of the dais in her area
(instead of
expecting her to conduct 50%
of all
.deliveries.)
The workload of the ANM/HW(F) is often not
reasonable in terms of population, area,
geographical distribution and health needs
of the people. Some problems encountered
by HWs (F) in accomplishing their tasks
are:
1)
lengthy travel, distance to be covered
usually by foot, to reach the assigned
population,
- training time insufficient to ^implement
curriculum and teach the knowledges and
skills needed for job responsibilities
Teaching staff lack effectiveness
of:
because
NWSfc DOCTOR RATIO
OUK. goal P0£ H7I
WAS
- inadequate teacher preparation,
- heavy work load due
numbers of teachers,
to
insufficient
- lack of knowledge about how to u^e
effective,
innovative teaching-learning
methodologies,
- inadequate
teaching
facilities
and
learning resources, and unsatisfactory
evaluation of students,
- lack of community health field experien
ces, inservice education, and refresher
courses on new trends in health care,
communication skills and group dynamics.
HEALTH FOR THE MILLIONS
JUNE 198^
2
2)OCVOE-
5
2)
immense worK scope, including mainta
ining
a voluminous, record keeping
system,
3)
sexual harrassment faced by young sin
gle
women
assigned
to work
in
villages.
In addition to improvement in training,
the development of cooperation
and a
supportive network among all health care
team members including human and material
resources. The
recruitment,
training,
supervision, and retention of the Female
Health Worker in service are also vital
issues.
The
Training
Needs Assessment
study
conducted in the Integrated Rural Health
and Population Projects clearly identify
training lacks and retraining needs among
Health Workers. All nursing service units
and training programmes would benefit from
this type of analysis, particularly if
resources could be channelled toward areas
showing need.
Nurse Education
Improvements required in important areas
in
FHW and in all nursing education
programmes are briefly summarised below:
1)
Curriculum - Community Healtn oriented
-curriculum with inputs
required
for
adequate
implementation
2)
Management - Posting of qualified nurof Schools
ses as Principal/ Chief
Tutor with decision mak
ing powers; support ser
vices;
and
continuing
education opportunities
3)
Faculty
and Staff
Central
to
this discussion
is
the
recognition that the Female Health Workers
play a crucial role in Primary Health Care
and the lowering of fertility and child
mortality rates.
4)
Teaching
- Appropriate teaching facfacilities
ilities and adequate equ
ipment, appropriate for
competency based learning
experiences
In summary,
conclusions:
important
5)
Student
accomodations
There is a critical need for more and
better trained nurses, especially for
FHWs, their teachers and supervisors,
to ensure Primary Health Care goals;
6)
Teaching
- Problem-oriented teaching
methods/
competency based learning
learning
with selected, well supeexperiences rvised practice, relevant
to the nursing
skills
required;
and learning
needs given priority over
service needs.
7)
Community - Rural field experiences
Health
directly related to job
experience
description
with safe
adequate
accommodation
and provision of trans
portation.
Inservice or continuing education courses
are
required for those presently
in
service. But
in
addition,
existing
management and administration
problems
relating to training and performance of
field staff must be given
attention.
There is not likely to be much improvement
without
an active support system
by
concerned and committed officers in the
rural health services.
SUMMARY OF PROBLEMS AND
RECOMMENDATIONS
1)
there
are
three
20
There is an inadequate institutional
capability, both in terms of human and
physical resources to nrfeet the demand
for more hnd better trained nurses;
and
3)
The professional, financial and social
incentives necessary to attract and
retain
qualified
individuals
in.
nursing,
particularly
for
rural
services, are virtually non-existent.
6
- Adequate numbers of qualified faculty and staff,
appointed and posted in
staff vacancies available
- Safe, hygienic, and well
maintained
facilities
HEALTH FOR THE. MILLIONS
JUNE 1984
8)
Student
- Relevant and objective,
learning
competency based evaluaevaluation
tion.
Recruitment and retention of nursing personnel
especially in rural areas.
The following factors
appear
to
be
influential in recruiting, training and
retaining
healtn personnel tor
rural
services:
L)
Being reared in the rural area influr
ences rural job preference. Such girls
should be selected for training.
2)
Living in rural areas during training,
for experience in community health.
3)
Living conditions including home and
friendship
of
local
people
are
important.
4)
Socio-economic factors such as safety,
work
for
husband,
schooling for
children should be arranged.
5)
Opportunities for personal and profes
sional
growth
through
continuing
education opportunities encourage re
maining in the job
One recommendation of the study which
takes account of many of these factors in
recruiting and training of FHW is the
proposal for an Experimental FHW school
described in the next section.
SOME IMMEDIATE STEPS TO INCREASE FHW
AVAILABILITY FOR POSTING IN SUB CENTRES
Other alternatives can be considered in
addition to increasing the number of HW(F)
schools and student intake (which will
require
as an esential pre-requisite,
adequate preparation of sufficient Tutors
and Public Health Nurses to conduct the
training.)
Some possibilities
come to
mind.
One possible alternative would be for the
Government to transfer ANMs working in
hospitals to sub-centres for a Limited
number of years, giving short refresher
HEALTH FOR THE MILLIONS
JUNE 1984
courses on knowledge/attitudes/skills nee
in
the community. These
health
ded
workers may be happy to move to a sub
centre if it is in their own villages.
(Surveys indicate many
of
them
are
originally from rural areas). If this is
done, the impact on hospital service must
be considered.
The government can actively recruit for
rural postings the Health Workers being
trained
in
private
sector
schools,
especially if the students
are giver.
financial support/stipends by the govern
ment while in school.
If possible, provide private schools with
finances to enable increases in student
capacity. Many of these schools maintain
high
quality education standard,
are
already located in rural areas, could
quite easily expand, and probably would be
very willing to assist the government by
increasing their usually small intake of
students,
particularly
if they
have
financial assistance.
Recruit ANMS who, far family reasons, have
dropped out of nursing after completing
the course, and might be willing to return
if a refresher course, were
offered.
Perhaps the Regional Health and Family
Welfare Training Centres could plan and
offer refresher courses to assist
in
reinstating women who have not worked for
some years.
PROPOSAL FOR AN EXPERIMENTAL FHW SCHOOL
To overcome many of the problems described
in this paper it is necessary to implement
several pilot projects to try out new
ideas. These would help make the FHW’s
training relevant, based on skills ' or
competencies required for work at the sub
centres .
The course planned and described below
includes the subjects required by the
Indian Nursing Council in the. revised
ANM/HW course. The content, however, has
been
reorganized
into
6
integrated
subjects to be ^earned in.3 semesters
(18
months)
plus a 6 months "practicum" or
internship. The subjects specially rela
ted to the duties of the FHW in the
subcehtre are covered in the first year.
The clinical^ nursing
and institutional
midwifery subjects are planned for the 3rd
semester as shown below:
Curriculum organisation and content
First Year
1st Semester
Hours
2nd Semester
Hours
•• -
I.
II.
V.
III.
Community Health (1)
& Development
(Chapters 1-4
from Revised
Textbook for HWs.
Chalkley)
135
Keeping the
Family Heathy (1)
60
Keeping the Family
Healthy (2)
45
Midwifery and Family
Welfare (1)
Domiciliary Mid
wifery
Maintaining a
Healthy Body and
Mind (1)
Community Health &
Development (2)
(Chapters 5-8)
110
140
90
150
Maintaining a Healthy
Body and Mind (2)
50
Second Year
IV.
3rd Semester
Hours
Restoration to Health
(Clinical Nursing)
250
4th Semester
INTERNSHIP
V.
Midwifery and Family
Welfare (2)
55
-
8
HFAith for THE millions
JUNE 1984
sub-centre
villages;
Experimental factors in this school
Experimental
would be;
factors
in
these
Rather than in district hospitals, the
location of these schools would be in
small
rural
hospitals and health
centres, with practice in a sub-centre
/village.
A prerequisite for location of sites
for field practice in villages is the
cooperation of and acceptance by the
community.
b.
Problem-oriented learning would begin
with practical experience:
The experience would begin with accom
panying the health team members to
field locations, and move to learning
the theory necessary, based on what
the student needs to know.
It would
be competency based learning, partici
pative, and utilizing problem solving
techniques.
d.
near
their
own
e.
Length of course:
In addition to 18 months, Xth class
pass
students will have 6 months
internship for experience and take
high school subjects for Xllth class
examinations.
Content Organization:
All the subjects related to community
health,
especially
knowledge
and
skills related to the 12 Key Health
Problems would be taught ih the first
2 semesters, at the village site. The
restoration to health (curative care
nursing)
and institutional midwifery
courses would be taught in the third
semester at the school headquarters,
located in a rural hospital.
c.
or
- "Special Students" - women with less
than Xth class pass, (e.g. VII or
VIII class pass); married
women
whose children are preferably school
age.
(Private
arrangements
for
passing Matric examinations could be
arranged before completing the third
semester of the HW(F) course).
schools
Site:
a.
in
Recruitment of students:
Students would be selected from among
the following:
- local girls and women,- candidates "sponsored" by their home
villages;
- married couples living in the commu
nity;
(preferably "sponsored"
by
their home villages)
- candidates assured of posting in the
HEALTH FOR THE MILLIONS
JUNE 1984
States
where FHW are
very
urgently
required
are
considering a "Sandwich
Course", referring to the posting
of
students who have completed the 1st year,
to work in sub centre posts for a year or
more before they return to complete the
semester. The division
of
time
3rd
suggested for the first year is Theory (4
months)
+ practice (2 months in PHC,
3
months in a sub-centre), theory to review
for exams (2 months).
The experimental Health
Worker School
described above could also be considered a
Sandwich course, with
opportunity for
service posting in sub-centres (not at PHC
or hospitals) between the 2nd and 3rd
semesters. However,
the
"experimental
factors"
listed above are
based
on
education and learning principles which
would contribute to its successes
in
preparing, in one year's time a person who
could:
(1) work effectively
with the
community, the Village Health Guides, the
Dais and with other health team members
(2) contribute to creating a higher level
of health for the people of her community
and (3) after returning to the school to
complete the 3rd semester and practicum,
give more understanding and intelligent
nursing care to patients in homes and
rural hospitals.
An additional advantage of this plan for u
new way of implementing the FHW course
would be the opportunity it offers for tt
participation of community members in th
following:
- selecting of me bites tor training,
- developing plans for the building and
other facilities,
goal of increasing the numbers ot hHWs and
improve the quality of their service in
the sub-centres. The implementation of
other recommendations included in the full
report of the Study would:
- preparing of learning resources,
- gathering
age
1)
contribute substantially to overcom
ing
the
problem and difficulties
described in this report;
2)
help upgrade the quality of nursing
services relevant to the needs of the
country through more appropriate and
higher quality education;
3)
contribute to the improvement of.the
status of the nursing profession and
the
self-image of nurses, thereby
increasing their job satisfaction and
willingness to work in rural areas, as
well as develop the resources within
the profession.
information about the vill
- recruiting students, and
- sharing knowledge and expertise
augment the training programme.
to
LONG TERM RECOMMENDATIONS
The implementation, alter testing in pilot
projects, of FHW schools as described
above, would assist with the immediate
NURSING TASKS RELATED TO KEY HEALTH PROBLEMS
Nursing Tasks
Key Health Problems
A. Related to FERTILITY
INFORM AND MOTIVATE PARENTS to:
Early age of first
legal pregnancy
delay
marriage of girls till after the
age (18), and if possible, after 20.
encourage newly
contraceptives.
Short birth intervals
couples
married
to
use
- use temporary contraceptives.
- request MTP if necessary.
- request sterilization.
Large completed family
size
MAKE AVAILABLE various contraceptive methods.
- through depot holders.
- through self.
-
by assisting in planning
with surgical procedures.
Family
camps
and
- by IUD insertion.
10
HEALTH FOR THE MILLIONS
JUNE 1984
B. Related to ANTENATAL CARE
EDUCATE AND MOTIVATE families
and mothers for:
Low birth weight
- appropriate diet for pregnant women.
Malnutrition (in
mothers)
- low cost supplements for mothers^
- taking iron & folic acid to prevent anemia.
- developing kitchen gardens.
recognizing
possible
abnormalities
in
pregnant women and obtaining appropriate aid.
acceptance of ante-natal care
and examinations so need for referral can oe
recc iiixzeu.
Neonatal
Tetanus
and
Maternal
acceptance
immunization
PLAN AND CARRY
visits and care.
of
tetanus toxoid
during pregnancy.
ante-natal clinics, home
OUT
IDENTIFY HIGH RISK PREGNANCY
priate action.
and
take
and
family mem
appro
- prepare for home deliveries.
C. Related to MIDWIFERY
High incidence of birth
injury and asphyxia
EDUCATE AND MOTIVATE
bers to:
obtain a trained
delivery.
mothers
person
for
management of
Septicemia
CARRY
OUT
skillful/and
safe delivery,
RECOGNIZE complications in mother
and take appropriate action,
and
child,
TRAIN AND SUPPORT dais in doing deliveries,
recognizing need for referral or assistance.
D.
Related to POST-NATAL
mother period and CARE OF
THE INFANT
Septicemia
DEMONSTRATE AND TEACH
family
members
how to
- do a safe cord dressing for the infant,
give hygienic perineal care to the mother.
Low Birth Weight
HEALTH FOR THE MILLIONS
recognize weakness or abnormalities in the
newborn and take appropriate action,
JUNE‘1984
11
on
its
side
and chilling
by
keeping the
- keep the newborn turned
lying down,
- prevent colds
child warm,
- put the infant to breast
for feeding.
when
soon after delivery
ADVISE
mother and family
on
appropriate
measures to prevent, an un-wanted, or too
early, pregnancy.
E. Related to CARE OF
CHILDREN. 0-3 years
Respiratory Infections
DEMONSTRATE AND TEACH mothers how to
- prevent colds and chilling,
- prevent
with
pneumonia
steam inhalations,
- give fluids to drink,
- feed the sick child,
- care for a
concerning:
cnild
with
measles, especially I
- adequate nutrition and
- prevention
Diarrhea
of
exposure
to cold.
mothers, families and vill-
TEACH AND MOTIVATE
age leaders to
- carry out home sanitation,
- plan for safe
provide it,
drinking
water
supply, and
- plan and provide for appropriate sanitary
measures in home and village,
- maintain
personal
hygiene for cleanliness,
- avoid use of bottle feedings,
- use Oral Rehydration Solution early in diarrhea to prevent and treat dehydration.
DISTINGUISH
diarrhoea,
GIVE ORS
12
and
between
other
simple
and
dangerous
appropriate management.
HEALTH FOR THE MILLIONS
JUNE 1984
TEACH and MOTIVATE families and
community
about preventive measures for malaria,
Malaria
IDENTIFY malaria patients,
MAKE malaria slides,
GIVE presumptive treatment, and
CARRY OUT
complete treatment for malaria.
TEACH and MOTIVATE mothers about
Malnutrition
- breast feeding immediately
the infant,
after
birth
of
- giving boiled water to infants, if necessary,
- beginning weaning foods from 6th month:
mixed cereal foods, green leafy vegetables,
yellow fruits and vegetables etc.
- diet supplements for lactating mothers and
under - 5 children
(including vitamin A +
anemia prevention),
- how to feed sick children adequately.
TEACH MOTHERS, DAIS, VILLAGE TEACHERS, BALWADI
TEACHERS AND SUPERVISORS about nutrition
needs, and recognition of symptoms
of
malnutrition in children, by use of arm
circumference measurement, etc.
DEMONSTRATE preparation of a
nutritious diet with available
children, and mothers, showing
children of various ages.
IDENTIFY high risk children
care required.
and
foods;
for
how to feed
give
special
TEACH AND ASSIST MOTHERS in beginning a kitchen
garden.
Malnutrition (cntd.)
TAKE AN ACTIVE PART
to plan for
in
women's organisations
- adequate feeding of children,
- income generating schemes, and
- women's literacy.
ASSIST IN PLANNING AND CARRYING OUT nutritional
status surveys
- by taking weights of children
HtALTH FOR THE MILLIONS
JUNE 1984
13
health for THE MILLIONS
JUNE 1984
CLAiRE
FAGIN
DONNA
D1ERS
NURSING AS METAPHOR
For some time now we have been curious
about the reactions of people we meet
socially to being told, "I am a nurse."
First reactions to this statement include
che comment, "I never met a nurse socially
before", stories about the person's latest
hospitalization, surgery, or childbearing
experiences; the question "How can you
bear handling bedpans (vomit, blood)?" We
believe the statements reflect the fact
that nursing evokes disturbing and discom
forting images that many educated, middle
class, upwardly mobile people find diffi
cult to handle in a social situation. As
nurses, we are educated to give comfort,
so it is something of a paradox when we
make ourselves and others uncomfortable
socially.
It is easy to say that some reactions
are based on an underlying attitude toward
nurses that we tend to think of as a
stereotype. But labeling the attitude does
not help us explain it or escape it.
Perhaps we can deal with
the social
perception by examining- the metaphors that
underlie
the
concept of "nurse"
metaphors that influence not only language
but also thought and action. An explora
tion of the metaphorical underpinnings of
nursing must start with the etymology of
the word "nurse," which is derived from
the Latin for "nourish."
Nursing
is a metaphor
tor
class
struggle. Not only does nursing represent
women’s struggles for equality, but its
position in the health world is that of
the classic underdog, struggling to be
heard, approved, and recognized. Nurses
constitute the largest occupational group
in the heaith-care system (1.6 million).
They work predominantly in settings that
are dominated by physicians and in which
physicians represent the upper and contro
lling class. Dominant groups yield ground
reluctantly, especially to those who are
regarded as having simply settled for a
job instead of choosing a more prestigious
profession.
Nursing is a metaphor for equality.
Little social distance separates the nurse
from the patient or the patient from other
Nursing is a metaphor for mothering.
Nursing has links with nurturing, caring,
comforting, the laying on of hands, and
other maternal types of behaviour, all of
which
are
seen
in our society
as
essentially
mundane and hardly.
worth
noticing. Even
the thoughts
of
the
vertical nurse over the horizontal patient
evokes regressed feelings in a woman or
man who is told, "I am a nurse." Adults
do not like to be reminded, especially in
an adult, socially competitive setting, of
the child who remains inside all of us.
HEALTH FOR THE MILLIONS
JUNE 1984
15
patients in the nursing-care setting, no
matter what the social class of each.
Nurses themselves make little distinction
in rank among persons with widely varying
amounts of education. Nurses are percei
ved as members of the working class, and
although this perception is valuable to
the patient when he or she is ill and
wants to be comforted, it may be awkward
to encounter one’s nurses at a black-tie
reception, where working-class people do
not belong.
Among physicians, nursing may be a
metaphor for conscience. Nurses see all
that happens in the nature of health care-the neglect as well as the cures, the
reasons for failure as well as those for
success. The anxiety, not to mention the
guilt, engendered by what nurses may know
can be considerable. Nurses
recognize
that many of the physician's attempts to
conquer death do not work. They are an
uncomfortable reminder of fallibility.
Nursing is a metaphor for intimacy.
Nurses are involved in the most private
aspects of people's lives and they cannot
hide behind technology or a
veil of
omniscience as other practitioners
or
technicians in hospitals may do. Nurses
do
for others publicly what
healthy
persons do for themselves behind closed
doors. Nurses as trusted peers, are there
to hear secrets, especially the ones born
of vulnerability. Nurses are treasured
when these interchanges are successful,
but most often people do not wish to
remember their vulnerability or loss of
control, and nurses are indelibly identi
fied with those terribly personal times.
Thanks to the worst of this kind of
thinking, nursing is a metaphor for sex.
Having seen and touched the bodies of
strangers, nurses are perceived as willing
and able sexual partners. Knowing and ex
perienced, they unlike prostitutes, are
thought, to be safe—a quality suggested
by the cleanliness of their white uniforms
and their professional aplomb.
Something like the sum of these images
makes up the psychological milieu in which
nurses live and work. Little
wonder,
then,
that some of us have been badgered
(at least in our earlier days)
about our
choice of career. Little wonder,
then,
that nurses have had to develop a resili
16
ence required of few other professionals.
Little wonder, too, that it is so diffi
cult for us to reply to our detractors.
One may wonder why any self-respecting,
reasonably intellectual man,' or woman
chooses nursing as a lifelong career. Our
students are regularly asked questions
like this by family, friends, and acquain
tances: "Why on earth are you becoming a
nurse? You have the brains
to be a
(doctor,
lawyer, other)." All of them,
long before entering schools such as ours,
must answer this question for themselves
and their questioners in a way that per
mits them to begin and to continue nur
sing. Their responses and ours frequently
focus on the role of the nurse, the
variety and mobility possible in a nursing
career, or the changing nature of the
profession. T.iat kind of answer doesn't
get to the he rt of the problem in the
mind of the questioner. Although it may
elicit an "Oh,‘I didn't realize that," it
doesn't make any permanent points for any
one. The right answer has to address the
metaphors, since these are the reasons for
the concern. The answer must convey the
feeling of satisfaction derived from the
caring role; indifference to power for its
own sake; the recognition that one is a
doer who enjoys doing for and with others;
out most of all, the pleasure associated
with helping others from the position of a
peer rather than from the assumed super
ordinate position of some other profes
sions .
The metaphors,
if we turn them around,
can easily work to explain our position.
Intimacy—why shrink from the word, even
while we educate our listeners about its
finer meaning—equality, conscience, and
the many qualities of motherhood
(another
word that can usefully be separated from
its stereotype)
are exactly what draw
people into nursing and keep them there.
If we could manage to be wistfully
amused by the reactions we evoke at social
events rather than defensive, life would be
easier. Educated, middle-class, upwardly
mobile—we are indeed the peers of others
at these social gatherings. We are peers
informed about disease prevention, the
promotion of health, and rehabilitation.
We are not disinterested
experts but
advocates, even for those who misinterpret
us. Others may be only dimly aware of our
role, but it is rooted deep in our historv
HEALTH FOR THE MILLIONS
JUNE 1984
and exemplified by the great
nursing
leaders who have moved society forward:
Lavinia Dock, so active
in
pursuing
women's rights; Lillian Wald (a nurse whom
society has preferred to disguise as a
social worker), who developed the Henry
Street Settlement and educated all of us
in understanding and approaching health
and social problems; Margaret Sanger, who
faced disdain, ignominy, and imprisonment
in her struggle to educate the public
about birth control; and Sister Kenny, who
was once the only hope for polio victims.
so mucn ror the metaphors of others.
For ourselves? We think of ourselves as
Florence Nightingale— tough, canny, po
werful, autonomous, and heroic.
Source:
CLAIRE FAGIN, PH.D. R.N.
DONNA DIERS, M.S.N., R.N.
in the New England Journal of Medicine
Vol 309, No.2, July 14, 1983.
ANNOUNCEMENT
Over the past year, VHAI has collaborated with Ms Madhu Sarin in
Chandigarh on a pilot training programme for the dissemination
of improved Nada Chulha.
The Nada Chulha, smokeless and fuel efficient, is designed to
make a substantial impact on the quality of women's lives and
ensure better health and child care.
In this project we have been involved in development of suitable
organization structure, training methodologies, and educational
materials for large scale dissemination of improved chulhas.
This we have done in collaboration with three voluntary organi
zations: one each in Himachal Pradesh, Haryana and Rajasthan
and (two) state governments of Punjab and Haryana.
The chulha is now in use in thousands of rural homes in different
parts of Haryana, Punjab, U.P., H.P., Gujarat and Rajasthan.
We now propose to publish a revised and improved version of the
following materials, developed and tested at our training sessions.
1.
Nada Chulha Handbook:
For Trainers/Coordinators/Supervisors
Nada Chulha Construction Manual
3.
Users Information Sheet
4.
Promotional Poster
For Mis tris
For
Users
For General Public
This is to invite you to let us know at your earliest how many
copies of the above publication you will required.
Please do not send any money - now, only just let us know the approxi
mate number of copies you require.
The pricing will be strictly on no profit no loss basis.
We shall get back to you when we have worked out the actual prices
and a definite release date.
HEALTH FOR THE MILLIONS
JUNE 1984
NEWS FROM THE STATES
Doctors, Defaulters and Disease
There are one and a half million people
with TB knocking on the doors of our
institutions seeking help. The majority
of them are being turned away with cough
medicines,
Prof
Dr
D. Bannerji
of
Jawaharlal Nehru University told the VHAI
annual general body meeting.
The two day meeting was inaugurated at
Udhagamandalam, Tamil Nadu on April 26,
1984.
People are aware of the
symptoms of
illness and when to seek assistance.
It
is not necessary to chase people up (as it
was previously supposed). The vital need,
stressed by Prof. Banerjee, is to develop
people oriented health technology based bn
the knowledge of people. Directly oppos
ing this approach, was the plan in the
late 1950's and early 1960's, to provide
3,500 mobile X-ray units to India, to
cover mass screening of the people. This
approach presumed that rural people are
primitive and ignorant.
In fact this met
■the needs of the radiograph industry.
It
has been proved that X-ray gives consider
able over-diagnosis. Only 10% of people
who are positive TB by X-ray are positive
sputum cases!
The aim should be, he
continued, to
provide domiciliary treatment of TB in
rural areas, as an integral part
of
general health care; with adequate, facili
ties at least at easily accessible centres
for sputum testing. The National Tubercu
losis programme was set up in 1962, to
implement this aim, free of cost, to the
patients.
A defaulter must be defined as a person
whose action causes suffering to himself
or to the community, not merely the one
who does not comply with a doctor's wish.
18
With this definition, many health profess
ionals including doctors who prescribe
cough
mixtures instead of
diagnosing
carefully are guilty of defaulting. Often
organisations
commit
gross and
more
unpardonable faults, than individuals.
Prof. Banerjee stressed
that
primary
health care should act as a threat to the
establishment technology oriented hospital
approach, but now we are too disorganised
to do it, so it has become selective. Who
selects? Some one behind PHC. We simply
can not accept this selectivity. Access
to health should be a serious weapon
against oppression.
"You cannot have a
just health care system in an unjust
society."
Dr Bannerjee's address was followed by a
presentation by Ms Seetha of the National
Tuberculosis Institute and a panel discu
ssion in which Mr Joseph Vazhakala, Shanti
TB Central Society, West Bengal, Dr Edwin
Arthur from Padhar Hospital, Betul, MP and
Dr
Grewal from CMC Ludhiana
(Punjab)
participated.
Dr Mira Shiva of VHAI coordinated the
educational session and the exhibition of
posters.
Dr
(Mrs)
reelected
Board.
Harbans Dhillon
has
been
President of VHAI Executive
Dr Daleep Mukarji has taken over as
new treasurer.
the
the new boara members are Mr Korah
JGuj*rat)'
John
Noronha
(W.Bengal) and Sr Lucy Panikulam (Delhi).
Among
The Board also recorded its deep
appreciatiion for all those staff who left
VHAI ir
1983-84. The Board in particular
recallei
the
services of Ruth Harnar
in
the
following
words! .
"she was
able
to
HEALTH I-OR THE MILLIONS
JUNE Ivs.
DR. BANNERJI SAID. . .
Tuberculosis specialists all over the
world now insist that a case can be
diagnosed only when the presence of the
germ is demonstrated: cases
diagnosed
through x-ray alone are called suspected
cases".
An element of success (can be found)
in
the failure of NTP: by its failure, it has
pointed out the failures within the entire
system of the health services of the
country.
A definition of a defaulter
can
"one
whose behaviour causes suffering to him or
her or to the community, both at a point
of time as well as in a time perspective.
"From this definition it is obvious who is
by far the biggest defaulter: it is the
organization. The organization is respon
sible for enormous suffering among people
because, more than two decades
after
launching of the NTP, it is still turning
away hundreds of thousands of infectious
cases
in
various health institutions
without even a diagnosis.
It should also
be held responsible for causing enormous
suffering to the masses because it has so
often failed to supply the vitally needed
drugs. It has- failed to give
proper
information to patients and motivate them
adequately. The organization must also be
held responsible for not having adequate
transfer system when a patient changes his
place of residence. The organization must
also be held accountable when they wrongly
diagnose a tuberculosis case on the basis
of x-ray alone (many of the "defaulters"
belong to this category)
and when the
"defaulter" is resistant to the treatment
offered.
A voluntary agency can also make use of
the basic tenets of NTP to organize a
people oriented tuberculosis service to
alleviate the suffering due to the disease
and
thus
help
them to fight
more
effectively
for
their
rights.. Smear
examination of sputum and
domiciliary
treatment can be developed under most
"primitive" conditions. That has been a
lasting contribution of NTP.
First, selective Primary Health Care is a
contradiction
in itself - PHC calls for a
holistic approach dealing with suffering
of people as a whole; it cannot
be
selective, paternalistic, patronizing and
technocentric.
It appears that this concept has also
created some degree of ambivalence within
JNICEF
and
there are murmurs
about
confining health services to GOBI (Growth
monitoring, oral rehydration, breastfeed
ing and immunization). There are some who
want to add an FF (Food supplements and
family planning) to GOBI ! Even if GOBI-FF
is visualised as selected elements which
are to be emphasised within an integrated
health service system which is committed
ultimately
to universal coverage,
|t
leaves wide open the entire- question of
operationalisation of the concept under
conditions actually prevailing
in the
Third World. Where are the data from
operational research (as was done for NTP)
to justify feasibility of GOBI-FF? And, if
GOBI-FF is conceived as the only approach
selected,
it
is vulnerable to
some
criticism as the selective PHC.
Nurse Anaesthesia
Two seats, available in September 1984
Nurse Anaesthesia Course
to begin at
Bethesda Hospital, P.O.Ambur, North Arcot
Dist, Tamil Nadu 635802
on
the 5th
September.
"It would help the patient if you tried to look
more cheerful."
HEALTH FOR THE MILLIONS
JUNE 1984
19
perceive potential in people and help it
to grow and express itself creatively.
She touched the core of leadership of the
VHAI movement as well as the Nursing
profession in India, enabling it to come
into its own. She is an educationalist
par excellance. Ruth was born in India
and a good part of her education took
place in this country. She has a deep
understanding
of the people and
the
culture of the land where she has spent
the major portion of her life. She is a
good daughter of India, of whom we feel
proud."
Of Simone Liegeois, the Board said, she
"travelled widely throghout the country
meeting people at all levels, and had the
particular gift of forming rapport with
the health workers at "grass root level".
Her deep commitment to the philosophy and
goals of VHAI, her dependability
and
competence made her a valuable member of
the VHAI team. In spite of a recent major
illness, Simone returned to
India to
continue her postive contribution to he
VHAI programmes".
essential drugs by the public sector as
well as by private pharmaceutical firms
and to direct them to concentrate on
production of about 320 essential drugs in
accordance with the WHO’s recommendations.
An association source regretted in Calcu
tta
on Tuesday that a recent survey
revealed that like private sector the
public sector also had been relying more
and more on the sales of non essential
medicines,
like tonics, vitamins
and
nutritive supplements ignoring the objec
tives set in the Planning Commission’s
report as well as National Health Policy
statement.
Mr D.P.Poddar, Executive Secretary of the
WB VHA said that it had organized a health
education campaign to prevent the spread
of dysentery and had sent 32 volunteers to
16 districts of West Bengal.
The organi
zation had circulated 150,000 leaflets on
prevention
of diarrhoea and dysentery
among the people in the villages.
It had
also distributed preventive drugs.
- The Statesman May 31 1984
(FOR READERS IN WEST BENGAL-
Plea to produce essential drugs
rhe West Bengal Voluntary Health Associa
tion has urged the Union Government to
stop
production of over 11,000
non
If any individual or group has done any
study on the
’prescribing pratice
of
doctors during the dysentery epidemic'
kindly let us know. We need it for our
Low Cost Drugs and Rational Therapeutics
activities) .
WHY IS THIS NOT A SENSATION? asked Liv Ullman of the Oral Rehydration
Salts which restore the body’s essential fluids and electrolytes to
people critically dehydrated by diarrhoea. Speaking on behalf of UNICEF
the actress said, ”0RS is simple.
It is cheap and can save thousand of
lives each day. Why is it not on all the front pages? Why are all the
people involved in this not Nobel Laureates? If this had been a cure
for cancer, for something rich people suffer from, my God, there wnnia
be nothing else on TV.”
J
ucre wouxa
WHAT DOES PETER THE GREAT OF RUSSIA have in common with parents
in the
Third World? Answer: A grim______
record_____
of infant mortality
_
A footnote
in the biography of an early eighteenth centu
century Russian Czar notes the
births and deaths of Peter's children: ]
170k
1707); paul
(b.1705, d. 1707); Catherine (b.1707, d. 1708); Anne (b
1708,
i728)
Elizabeth (b. 1709, d. 1762); Natalya (b. 1713, d.
1
'15)
;
Margarita
(b. 1714, d. 1715); Peter (b. 1715, d. 1719); Paul (b. and d
1717);
Natalya (b. 1718, d. 1725); Peter (b. and d. 1723); Paul (b
1724)
kD* and d.
20
HEALTH FOR THE MILLIONS
JUNE 1984
BOOKS
Referral Directorv on Mental Healt
and Related Services in Delhi
Rs. 15
Pages 240
Produced by New Delhi's unique voluntary
organization Sanjivni, this is an attempt
to identify for the sake of variety of
disturbed people all possible . sources
available to them in the community both
professional
and voluntary. The
book
lists among others counselling centres,
consultant psychiatrists
and
clinical
psychologists and centres for the mentally
retarded. There is also a section on
services for women and children including
legal aid services. The last section is
devoted to community welfare services.
Available from Voluntary Health Associa
tion of India, C-14 Community Centre,
Safdarjung Development Area, New Delhi
110016, India.
Indian Womanhood: Then and Now
Situations. Efforts. Profiles
by Jessie B. Tellis-Navak
Published by Satprakashan Sanchar Kendra
•Rs 35 Hard cover
Rs 25 Paperoack
Pages 302
This book in five parts aims at creating
an awareness of the situation of women and
girls in India. The first traces their
story then and now. The second treats of
some
problems - purdah, dowry,
wife
beating and others - that are peculiar to
her sex.
The third part describes and analyses some
efforts made by women to improve themsel
ves economically and socially. The. fourth
part presents profiles of women, great and
small who have struggled and overcome
difficulties
to achieve their
goals.
Finally in the fifth part, a few selected
cartoons, poems and songs are included
that give women's voice to new ideas,
feelings and visions.
HEALTH FOR THE MILLIONS
JUNE 1984
available from Voluntary Health Associa
tion of India, C-14 Community Centre,
Safdarjung Development Area, New Delhi
110016.
Rural Development: Putting the Last First
Robert Chambers, Ford Foundation, 55 Lodi
Estate, New Delhi 110003
Longman Group,
2JE, UK.
Rs 32/60
Burnt
Mill, Harlow, CM20
246 Pp.
The main aim of this book is to show that
those who are last - the rural poor, are
often unseen or misperceived by outsiders
- those concerned with rural development
who are themselves neither rural nor poor.
It argues for reversals in outsiders'
values and behaviour, and presents practi
cal proposals to strenghthen
the new
professionalism which puts the last first.
This book is about outsiders - those
concerned with rural development in the
third world who are themsleves neither
rural nor poor, and about the rural poor
whom
they
do not see or whom they
misperceive.
It argues that outsiders'
views are biased and their methods of
learning about rural poverty frequently
crude and inefficient.
Rural people's
knowledge is often ticn and valid, but is
usually discounted and ignored by outsi
ders. Rural deprivation is more interloc
ked than outsiders realise,
combining
poverty with physical weakness, isolation,
vulnerability and powerlessness.- Clearer
thinking is needed to see what to do,
including practical political
economy,
working out who will gain and who will
lose. Reversals are required in profes
sional values , to emphasise what matters
for poorer rural people- and to enable them
to demand and control more resources.
Outsiders are conditioned to put last the
needs, interests and resources of the
poorer rural people. Practical action is
outlined to enable outsiders to reverse
these biases, and to put more of the last
first.
21
BOOKS
Referral Directorv on Mental Healt
and Related Services in Delhi
^s. 15
Pages 240
Produced by New Delhi's unique voluntary
organization Sanjivni, this is an attempt
to identify for the sake of variety of
disturbed people all possible. sources
available to them in the community both
professional
and voluntary. The
book
lists among others counselling centres,
consultant psychiatrists
and
clinical
psychologists and centres for the mentally
retarded. There is also a section on
services for women and children including
legal aid services. The last section is
devoted to community welfare services.
Available from Voluntary Health Associa
tion of India, C-14 Community Centre,
Safdarjung Development Area, New Delhi
110016, India.
Indian Womanhood: Then and Now
Situations. Efforts. Profiles
by Jessie B. Tellis-Navak
Published by Satprakashan Sanchar Kendra
-Rs 35 Hard cover
Rs 25 Paperoack
Pages 302
This book in five parts aims at creating
an awareness of the situation of women and
girls in India. The first traces their
story then and now. The second treats of
some
problems - purdah, dowry,
wife
beating and others - that are peculiar to
her sex.
The third part describes and analyses some
efforts made by women to improve themsel
ves economically and socially. The. fourth
part presents profiles of women, great and
small who have struggled and overcome
difficulties
to achieve their
goals.
Finally in the fifth part, a few selected
cartoons, poems and songs are included
that give women's voice to new ideas,
feelings and visions.
HEALTH FOR THt MILLIONS
JUNE 1984
available from Voluntary Health Associa
tion of India, C-14 Community Centre,
Safdarjung Development Area, New Delhi
110016.
Rural Development: Putting the Last First
Robert Chambers, Ford Foundation, 55 Lodi
Estate, New Delhi 110003
Longman Group,
2JE, UK.
Rs 32/60
Burnt
Mill, Harlow, CM20
246 Pp.
The main aim of this book is to show that
those who are last - the rural poor, are
often unseen or misperceived by outsiders
- those concerned with rural development
who are themselves neither rural nor poor.
It argues for reversals in outsiders'
values and behaviour, and presents practi
cal proposals to strenghthen
the new
professionalism which puts the last first.
This book is about outsiders - those
concerned with rural development in the
third world who are themsleves neither
rural nor poor, and about the rural poor
whom
they
do not see or whom they
misperceive. It argues that outsiders'
views are biased and their methods of
learning about rural poverty frequently
crude and inefficient.
Rural people's
knowledge is often ricn and valid, but is
usually discounted and ignored by outsi
ders. Rural deprivation is more interloc
ked than outsiders realise,
combining
poverty with physical weakness, isolation,
vulnerability and powerlessness. Clearer
thinking is needed to see what to do,
including practical political
economy,
working out who will gain and who will
lose. Reversals are required in profes
sional values , to emphasise what matters
for poorer rural people- and to enable them
to demand and control more resources.
Outsiders are conditioned to put last the
needs, interests and resources of the
poorer rural people. Practical action is
outlined to enable outsiders to reverse
these biases, and to put more of the last
first.
21
SLIDES AND AUDIO-VISUALS
New Set of Slides from Project Piaxtla, Mexico
1.
7.
Teach new ideas or skills oy comparing
them with familiar objects or activi
ties .
8.
Use teaching aids that call for doing
as well as seeing ■ — aids that students
must handle or put together.
9.
Make them as fascinating or fun as pos
sible, especially teaching aids for
children.
HOMEMADE TEACHING AIDS: Principles and
Examples
Slides 80, colour with, script
Price Rs 200 X
Original
VHA1 Price Rs 120
10.Use teaching aids that do not simply
show or explain something, but that
things
help the students to think
through and discover solutions
for
themselves—teaching aids that exercise
the learners' powers of observation and
reason.
This
set
"Guidelines
Aids".
of slides illustrates
the
for
Appropriate
Teaching
11.Use your imagination, and encourage
students to use theirs. Turn the making
and inventing of ’teaching aids into a
challenge and an adventure.
1.
Make your own teaching aids, using lowcost local materials.
12.Keep teaching aids relatively simple,
so that when health workers return to
their communities, they can make their
own and teach others.
2.
When making teaching aids, use and
build on skills students already have.
2.
3.
PUPPET SHOW: How to Care for the Teeth
Try not to make the aids for students,
but rather involve students or members
of the community in making them for
themselves.
VHAI Price Rs 20
4.
Look for ways to use real objects ins
tead of just drawing things.
A puppet play presented by school children
on prevention of tooth cavities.
5.
Draw human anatomy (and signs of health
problems) on people, not on paper.
3.
6.
Make teaching aids as natural and life
like as yuu can, especially when detail
is important.
22
Slides 12, colour with
Price Rs 120 X
script
Original
FAMILY CARE OF THE DISABLED CHILDREN
Slides 30, colour with
price Rs 75
script
Original
VHAI price Rs 45
HEALTH FOR THE MILLIONS
JUNE 1984
— Help able-bodied children to appreci
ate and play with disabled children.
— Avoid having disabled children sit or
lie in positions that can make their
problems worse.
— Look for simple ways and aids to help
children avoid contractures or other
secondary problems.
— Apply basic principles of therapy to
everyday activities—eating, dressing,
carrying etc.
— Help the disabled child
mind as well as her body.
A handicapped child cannot do everything
as well as other children, but often there
are some things she ran do as well or even
better. Rather than feel sorry for the
handicapped child and look only at her
weakness, it is better for her family to
recognize and encourage her strengths.
This slide show presents a number of
simple ways to help children with physical
handicaps,
like polio or cerebral palsy,
to become as self-reliant as possible.
The therapeutic aids and methods shown
here are examples of the following basic
principles of family care of disabled
children:
— Make orthopedic and therapeutic aids
using
low
cost resources whenever
possible.
— Build on people’s local knowledge and
traditions.
— Provide only the smallest amount of
help needed to help the child do the
most he can for himself.
— Keep aids simple and
local circumstances.
adapt
them to
_
Invent or adapt aids to meet the parti
cular needs of your child.
_
Make therapy fun so the child does it
on her own, as play
— Encourage nrothers and sisters to und
erstand the disabled child's needs and
to help with therapyHEALTH FOR THE MILLIONS
JUNE 1984
develop her
— Include the disabled child in day-today family and social activities.
— Help children become as independent as
possible—especially in daily activi
ties such as eating, dressing, bathing,
and going to the toilet.
— Help disabled children master skills
for helping others and living produc
tive lives
4.
CHILD-to-child ACTIVITIES IN MEXICO
Slides 65, colour with
Price Rs. 200 X
script
Original
VHAI price Rs. 95
In villages and communities in many parts
of the world, much of the care for young
children.is provided by older brothers and
sisters. These young ’child-minders' not
only play with their smaller brothers and
sisters, but carry them about and even
bathe, change, and feed them. It is not
unusual for small children to spend more
time under the care of an older sister or
brother than with their mother or father.
CHILD-to-child is an international program
designed to teach and encourage schoolaged children to concern themselves with
the health of their younger brothers and
sisters. Children learn simple prevention
and curative activities appropriate to the
Local situation,and pass on what they
Learn to other children and to their
families.
23
The activities shown in this series were
led by experienced village health workers,
and by teachers in primary school, Ajoya,
a village of 850 people.
5.
PROJECT PIAXTLA: A Villager Run Health
Program in Mexico
Slides 65, colour with
price Rs 200 X
script
Original
VHAI price Rs 120
Project Piaxtla is a small, community
based health program in the mountains of
Western Mexico. Today
it is run and
controlled
entirely by local
village
health workers.
This slide show explores the ways in which
the Piaxtla health team uses the strengths
and traditions of local people. It shows
how the health team helps poor persons
gain the self-confidence, knowledge, and
skills they need to defend their health
and well-being. Training courses held at
the Project’s Ajoya Clinic stress active
problem-solving, rather then memorization.
New health workers learn to weigh the
benefits and dangers of Western cures
against the benefits and dangers of local
traditional cures. Health workers then
return to their village and encourage
other villagers to actively solve local
health problems. Solutions may involve
curative medicine, preventive medicine,
and social change.
The Piaxtla health team believes that a
health worker's primary job is to help
people gain greater control over their
health
and their lives. The
healthy
person, family, or community is one that
is relatively self-reliant — one that can
relate to others in a helpful,
friendly
way, as an equal.
'
6.
THE IMPORTANCE OF BREAST
NOT BOTTLE FEEDING
Slides 18, colour with
price Rs 45 X
VHAI price Rs 27
24
FEEDING
script,
AND
Original
In Ajoya,
school children conducted a
•diarrhoea survey' in their own homes.
From the survey the children learned that
in their village, diarrhoea
is 5 times
more common in bottle-fed babies than in
breast-fed babies.
They also found tnat
over 70% of the mothers were
bottle
feeding their babies.
Some of the women in Ajoya were very
disturbed by the children’s findings.
A
group of them decided to put on this play,
to make the whole community aware of the
importance of breast feeding.
The health
workers helped the women plan and organize
the play.
7.
LEARNING THROUGH ROLE PLAYING
Slides 41, colour with
price Rs 102.50 X
script,
Original
VHAI price Rs 62.00
Role playing provides a lively, realistic
way of practicing skills that involve
working with poeple.
It is especially
useful for training persons who are more
used to learning from life than from
books.
In role plays, the learning group acts out
real-life situations, with <
each person
playing a particular role. A
role play
allows health workers-in-training to
practice problem-solving skills they
wili n_ 1
as health workers in their own
villages,
Role plays also help a p--person understand
the thoughts of others,
as ,
when,
for
example, a male health worker
Plays a
pregnant women or a farmworker
Plays a
rich landowner.
HEALIH FOR THE MILLIONS
JUNE 1984
This slide show presents many role plays
used in health worker training courses.
The show also • highlights a number of
"props" which can help make role plays
more realistic and fun.
The idea for this street theater presenta
tion in Nicaragua comes from New Delhi,
India, where health education workers in
the slums perform a mime presentation
entitled, "The Malnutrition Monster."
8.
The importance of this kind of theater
depends to a large extent on audience
participation. In this presentation, the
children in the street, especially became
actively and excitedly involved.
TEACHING luEAS USING FLANNEL BOARDS
Slides 50, colour with
price Rs 120.50 X
script,
Original
10.
VHAI price Rs 75.00
TEACHING
HEALTH
ABOUT MOTHERS AND CHILDREN'S
Slides 80, colour with
price Rs 200 X
script,
Original
VHAI price Rs 120
Most health workers agree that activities
with mothers and children are the most
important part of health work
in
a
community. this is because:
— Women and children make up more than
half the people (up to 75%)
— The health needs of mothers and child
ren are especially great.
A flannel-board is a display board on
which vou can easily place and remove
pictures. Il is a hanay teaching aid
which
helps bring learning to
life.
Flannel-boards can be used with illustra
tions, puppet shows, and learning games.
These help students see, think and do.
In all the activities, students analyze
problems, take initiative, and search for
ways
of
doing things to meet their
communities' needs. Flannel-boards should
be used to encourage people to think!
9.
This slide show presents
examples of
learning activities which help
health
workers, mothers, and children learn about
the special needs of mothers and children.
The show includes examples of activities
which teach about four areas of mothers’
and children's health: prenatal
care,
birth, care of young children, and child
spacing.
11.
THE MEASLES MONSTER
Slides 25, colour with
price Rs 87.50 X
— Mothers and older children are the mail
providers whose needs are greatest of
all.
script,
Original
USELESS MEDICINES THAT SOMETIMES KILL
Slides 24, colour with
price Rs 60 X
script,
Original
VHAI price Rs 38.00
VHAI price Rs 36
This
street theater presentation
was
enacted by a group of Nicaraguan health
briaadistas during a training course on
teaching methods for health education in
Mav
1982. The course was conducted at
the
time of the national vaccination
Overuse and misuse of medicines is a
problem in many countries.
Instead of
buying nutritious food, older people who
are weak and anaemic sometimes waste their
money on vitamins, tonics and other wonder
drugs. The play in this slide tries to
show the dangers of this kind of misuse.
campaign.
HEALTH FOR THE MILLIONS
JUNE 1984
12.
LEARNING TO DRAW AND USE PICTURES
Slides 72, colour with
price Rs 180 X
script,
. human proportions right, duplicating with
a silkscreen, and taking photographs.
Origina.1
a
.it
VHAI price Rs 108
13.
TEACHING
TION
ABOUT DIARRHOEA AND DEH
Slide 72,
colour with
price Rs 180 X
scrips,
R
Original
VHAI price Rs 108
This slide show presents many ways that
drawings can be used in health education:
in posters, flip charts, flannel-boards,
learning games, puppet shows, and role
□lays; with stories; to illustrate hand
books and reference materials; and as dis
cussion starters. The show also explores
different methods of producing health edu
cation pictures: copying, drawing on peo
ple, using real objects, using symbols,
using the right amount of detail, getting
Diarrhoea is one of the main causes of
death in small children. However, most of
these children actually die from dehydra
tion — the loss of too much water.
The
most important way to fight death from
diarrhoea is to put liquid back into
children who have diarrhoea. Also,
the
underlying causes of diarrhoea must be
countered -- poor sanitation and poor
nutrition, which is often the result of
unfair distribution of land.
This slide show presents many ways that
nealth workers can help parents, children,
and whole communities to fight death from
diarrhoea. These methods encourage people
to
rely on their own knowledge
and
resources, to pursue social changes that
will lead to a healthier society.
THIRTY MILLION slaves : S lavery was abolished in th© British Empire (which
constituted a large part of the world) 150 years ago, but the
institution persists in a variety of forms,, reports David Sinclair in
World Paper
*
In its most pernicious form it is known as "chattel
slavery" — that is, the absolute ownership of one person by another
*
"In 1983," he writes, "it appears to be limited to the Sahel region of
North Africa where as many as 100,000 people in Mauritania are believed
to be slaves" — despite the fact that the Mauritanian government
abolished the institution in 1980
*
"What most worries the Anti-Slavery Society at present, however continues Sinclair, ’is the apparently growing exploitation of children
and young women, sometimes for factory work, but more often for sexual
*
purposes
In Bangkok, children are sold for between $75 and $100 to
factories and brothels
*
In Pakistan and India, there are thousands
perhaps hundreds of thousands of child prostitutes * * *.Modern forms of
slavery are not exclusive to the Third World," concludes Sinclair
"In the United States last year, three men were jailed for kidnanoincr
migrant workers and holding them by force on a farm in North Carolina
And in wealthy Beverly Hills, California, a police investigation
’*’
revealed a trade in domestic servants from Indonesia, smuaolfvi
U.S. and sold for as much as $3,000 each
"
*
™ggied into the
26
HEALTH FOR THE MILLIONS
JUNE 1984
MATERIAL RESOURCE DEPARTMENT
”P
mor
DEEMED EXPORT PURCHASE SCHEME
'S AUXILIARY FOR SOCIAL ACTION
CASA is registered under the charitable
J Societies Act XXI of 1860. It is the arm
i of the Protestant Churches for Social Action
J* in India. CASA organises Disaster response,
f Social Welfare/Rehabilitation and Development
Programmes.
MATERIAL RESOURCE DEPARTMENT
MRD/CASA is established in CASA head
office at Delhi to organise and handle
the procurement under the deemed export
scheme in cooperation with WEM, Hamburg,
West Germany.
DEEMED EXPORT PURCHASE SCHEME
The Scheme is introduced by the Govt.
of India for National & Multinational Voluntary
Agencies, to procure indegenious equipment
and material on Deemed Export Scheme
on payment of hard currency. It is also
extended
to WEM/CASA for charitable
and non-profit making Organizations working
in the field of Health, Social Welfare,
Education & Rural Development.
BENEFITS OF THE DEEMED EXPORT SCHEME
© 1„ Cost
reduction from 15% to 60%.
2. Refund of Excise duty.
3. Rebate on duty drawback.
4. Benefit of RPL.
© Sales Tax Exemption in Maharashtra and
Haryana.
e Export quality.
o Advantage of foreign exchange.
SYSTEM PROCEDURE
(•Price agreement with
manufacturers
and suppliers by WEM/CASA.
• Institutions raises enquiries with MRD.
• MRD obtains
invoices from suppliers.
•Institution receives invoices,
endorses
and returns it to MRD.
®MRD forwards invoices to WEM, West
Germany.
©WEM places firm order
and arranges
payment.
©Supplier
arranges delivery directly to
the institutions
® MRD co-ordinates delivery/commissioning
and after Sales Service.
RANGE OF ITEMS UNDER THE SCHEME
• Complete Medical system such as X-Ray,
Operation table including Electro-Medical
appliances.
©Hospital Equipment such as
generator
sets,
laundry,
equipment,
sterilizers,
electric fans, furniture, lights etc....
©All types of vehicles i.,e., bus, truck,
jeep, cars etc..
©Agricultural
equipment,
drilling rigs.
pumps etc..
©Scientific & Laboratory equipment
for
educational & research Institutions.
©Vocational
equipment & tools,
sewing
machines, welding machines, lathes etc..
©Audio Visual equipment, projectors, video
sets etc..
©Building
Industry
equipment
material
such as iron & steel, mixtures, complete
electric fittings,
sanitary ware,
floor
tiles etc..
©Electronic equipment & appliances, sound,
audio visual, power, office system & compu
ters.
CHURCH’S AUXILIARY FOR SOCIAL ACTION
Rachna Building, 2 Rajendra Place, Pusa Road, New Delhi 110 008
Telephone : 5715105, 5715498, 5715499-Telex : 31-4612 CASA IN.Telegram : CASARD New Delhi
Available Now
YDRA-
Revised Hindi and English Editions
Where There Is No Doctor
‘J
is more than a book of first aid. It covers a wide range of things that affect the he?'
the villager — from diarrhea to tuberculosis, from helpful and harmful home remedies to
the cautious use of certain modern medicines. Special importance is placed on cleanliness,
a healthy diet, and vaccinations. The book also covers in detail both childbirth and family
planning. Not only does it help the reader realize what he can do for himself, but it helps
him recognize which problems need the attention of an experienced health worker.
This book is for ...
The villager who lives far from medical centers.
It explains in simple words and drawings what he
can do to prevent, recognize, and treat many com
mon sicknesses.
The Teacher in a rural school. The book will
help her give practical advice and care to the sick
and injured. It also gives guidelines for teaching
children and adults in her community about the
problems of health, cleanliness, and nutrition.
Village leaders of all kinds, social workers,
development workers, animators, motivators or any
one who is concerned of the health and well being
of their community.
This English edition has a new introductory
section for the village health worker, discussing
ways to determine needs, share knowledge, and
involve the community in activities that can better
people’s health.
Mothers and Midwives will find useful the clear, easy-to-understand information foi
home birth, care of the mother, and child health.
This book has been revised for India by Voluntary Health Association of India with
the help of several Community Health Programmes from various parts of the country.
Price:
HINDI:
ENGLISH:
Rs.19 + postage
Rs.29 + postage
Voluntary Health Association
of India
C-14, Community
Centre
S. D. A. New Delhi-110016
FOP PRIVATE CIRCULATION ONLY
V'
Vol. X No. 4
A Bimonthly of the Voluntary Health Association of India
AUGUST 1984
326, V Main, I Block
Koramongala
Bangalore-560034
India
MAKING
THE GOOD,
THE BAD
AND
OF
A STATE VHA
THE UGLY
FACE TO FACE
ESSENTIAL
WITH
AN EPIDEMIC
AND
LOCOST
SCHOOL
INDICATORS
HEALTH
OF
MIRROR
HEALTH
MEDICINAL
JOINT
PLANTS
COMMISSION
IN
COMMON USE
A Random Harvest
HEALTH FOR THE MILLIONS
Vol X No. 4
August 1984
In this issue:
Making of a State VHA
1
The Good, the Bad and the Ugly 5
Face to Face with an Epidemic
9
Essential and Locost
11
School Health Mirror
16
Indicators of Health
19
Joint Commission
22,
Medicinal plants in common use 24
This issue of H FM was put together
by Augustine Veliath (Editor), Aspi
B Mistry, Padam Khanna and P.
George. Cover and illustrations are
by Ms. Usha Devrajan.
Owned and published by the
Voluntary Health Association of
India C-14. Community Centre,
S.D.A., New Delhi-110 016 and
printed at J.K. Offset Printers, Jama
Masjid, New Delhi.
This issue is a random haYvest from the communications sent by various
state voluntary health associations.
Two articles, both from people long associated with the VHA movement
in Madhya Pradesh and Kerala respectively do some introspection on
the movement itself. While TN VHA shows that a mechanism to facilitate
the all important dialogue between government and voluntary sector is
possible, the fledgeling Meghalaya VHA explores how the voluntary
sector can back up the national health policy.
Gujarat moots a new initiative in making low cost and essential drugs
available. Bihar goes beyond “the systems” to find home remedies that
work.
From Andhra Pradesh comes good news about school health. West
Bengal shows how an active State VHA can cope with an epidemic.
The purely subjective selection is intended to give an idea of the wide
range of areas in which the State VHAs have been involved.
The inclusion or the absence of material from a particular state VHA
does not in itself signify anything. We have only included material from
eight VHAs. Since this special issue will be an annual feature let us hope
that other VHAs will figure in subsequent years.
—Augustine Veliath
Parents must be like a tree:
They must have branches
Like open arms that welcome all
their children
A bark able to stand rain
Like tears and problems,
Storms and arguments.
Boots making a tree stand, on its
own and nourish itself,
Like the route you need to guide
your child to independence.
Like leaves, you must explain to
your child,
The changes he will go about
during his life.
Parents must be able
To show their child the right path
to the
Stem of a good life.
*from How to Grow a Child: A Child’s Advice to Parents
edited by Bernard Percy
Z
<
Madhya Pradesh
DR. D.W. MATEGAONKAR, B.Sc.. M.B.B.S., M.S., F.I.C.S.,
Making of a State VHA
COMMUNITY HEALTH CELL
326, V Main, I Block
Koramangala
Bangaloro-560034 tadia
It is always good to pause and take a stock of
the whole situation while we are engaged in an
ongoing task. For the M.P. VHA now it is high
time after being in existence for ten year^we
look back not only to count our blessings and
be happy over our achievement but to become
more careful to avoid the mistakes and
shortfalls of the past and become thus,
wiser.
April 14-15 of 1973 was very important
period in the history of MP VHA. Dr
Chowdhary, the then Regional Secretary of
M.P. Christian Medical Association of India
invited
our
sister
voluntary
health
institutions in M.P. to the M.P. regional
conference of C.M.A.I. This was done with
the sole purpose of formation of M.P. VHA.
Prior to this Father Tong, the then Executive
Director of VHAI had suggested at the
National Hospital Convention in Hyderabad
that each State forms its own VHA unit. For
many, this idea was very new. We had our
deliberations and after two days of open
discussion MP VHA took birth here in Padhar
Hospital premises. For many, including me
it was the first experience of meeting with
such a cross section of health workers whose
aims and objectives were very similar. Most
of us had lot of reservations towards
Government
Health
agencies. We
could
suddenly
feel
a
friendly
atmosphere
prevailing among all of us. There was
developing a common bond of real service with
in the group. That is how we could all agree
to form organisation like MP VHA, so that we
can come together more often, discuss our
problems, help one another in the service
field and also talk to the Government Health
Agency with one strong voice.
Since then many people have come and gone but
the MP VHA is still here and I am sure will
continue to prosper and be a means of a
HEALTH FOR THE MILLIONS
AUGUST 1984
Excerpts from a speech at annual meeting of MP VHA
service agency to the reai poor and needy in
the rural area of M.P. We were about 125
delegates representing more than 50 health
institutions of voluntary charitable nature.
The Memorandum of Association, constitution
and rules and regulations of the Association
were throughly gone over. The matter was
made easier as some other States had gone ovei
the exercise before and thus we had something
to go by.
At that meeting itself we all could feel how
Dr Clement Moss the Director of Medical
Services of E.L.C. was guiding the destiny of
the Association in the right direction. I ca.i
say that for the 7-8 years it was Dr Moss who
was the real guiding force behind the working
of our Association. He did a yeoman's service
to the organisation. In spite of being fully
involved in the building up of the Padhar
Hospital he gave his time for the working of
the M.P. VHA. He got our Constitution
Registered under the M.P. Registrar of
Societies. Dr Moss worked very hard to give us
a strong MP VHA. I really enjoyed working with
him. We must thank the Lord for providing such
a willing worker who gave us a strong
foundation to build on.
The initial enthusiasm shown in the first
meeting started dwindling away. The reasons
are many. Whatever traspired during the first
meeting here in Padhar was not fully conveyed
by the delegates
to their respective
institutions.
There was some
lack of
understanding of the philosophy of VHA
movement.
Protestant
health unit were
suspicious of Catholic health units and vice
versa. The other health agencies were
suspicious of both of us.
In spite of all this the work started picking
up. We had our Annual General Body meeting
very regularly and well attended. The
Governming body meetings were also held
1
regularly. Dr Moss worked hard to get more and
more voluntary health units to join the
association so as to strengthen it. Miss
Carol
Carty was
the
first
full
time
Promotional Secretary for this organisation.
She was connected with this association from
July 1974 to July 1976. This gave her an
opportunity to go round and visit the
institutions and thus the membership started
increasing. Then Miss Marjorie Hill joined us
and has been doing a very hard work to carry on
the torch of sincere service till today.
From the beginning we could feel oneness in
our deliberations. We could feel that all our
voluntary health units received a big common
umbrella under which we could regularly come
together. The emphasis on the community
health by the organisation helped us to
exchange ideas. This way this very important
aspect of our service got a boost. Workshops,
seminars in regional groups gave ample
opportunity to grow for various memeber
institutions. Gradually Nursing Services,
hospital
administration
and
accounting
guidance and strategy was coming forward.
There was more and more give and take among
the member institutions. Our membership of
the Voluntary Health Association of India was
a new avenue opened to us to understand and to
know how other States are facing their
problems and how they are progressing.
In the first year we were only 32 institutions
who were on the roll. Today I belive there are
more than 113 institutions big and small on
the roll. The income rose from Rs. 1,600/- in
the first year to Rs 60,000 in 1983. We are
continually growing, continually helping one
another and thus delivering the health goods
to the needy rural population mostly, in a
better way day by day. We have the advantage
of having the help and guidance from the
expert resource people at the VHAI stationed
at Delhi.
This is a very good time to see whether the
aims and objectives which we had set ten years
back have been achieved or not. Some of the
biggest problems which faced us was in the
area of communications with one another and
with our organising secretary. M.P is a big
state geograhically. There are many areas
which are inaccessible even in the best of
weathers. There is still reservations among
the member institutions as regards sharing of
resources and know-how. There is some kind of
selfish interest in this. IF the needy
population whom we are supposed to serve is
kept foremost in our mind then these petty
2.
things will not show up. We are existing for
others who are in need. If we had two more
persons like Miss Hill I feel the progress
would, have been fourfold. MP VHA needs
dynamic'people like Miss’frill who can act like
**
catalysts.
18‘
v ”
There are still m^Ay-ih'ekl’th' institutions in
M.P. who should ftSveM’beWf,w>tivated to join
us. They feel that thd^/^ate self sufficient
and so do not need organisations like MPVHA. I
hope good sense will prevail on them soon so
that they can join the main stream for thier
own betterment and also for others who can get
help from them.
There is another delicate point I would like
to tread on. When we came together under VHA
in MP and then at all India level lot of
promises were made by the then Government
officials connected with the Ministry of
Health at state and central level. At least I
thought after formation of MP VHA it would
give us a very good and powerful platform to
negotiate with Govt, for getting cooperation
and help in our field of service. I feel many
of my ambitions remained only sweet dreams.
My experience of woking for 26 years in a
rural MP Hospital was full of bitterness and
frustration. Others may be little fortunate
and must have had a smooth sailing. The
problem
of
securing
concession
on
electricity tax for member institutions was
an unsurmountable task. I do not know how many
times Dr Moss and Dr Choudhary went to
Jabalpur and Bhopal for the same. I think
still there is no progress in that.
Compared to other progressive states MP
government is unfortunately very reluctant
to share their resources with voluntary
health organisations. The immense resources
available with the voluntary organisations
like MP VHA have not fully been tapped for the
good of common man especially poor and needy
of the villages. Time and again we hear of the
shabby treatment given by the government
health officials of genuine voluntary and
charitable agencies.
Most of our member institutions are involved
in community health works. We all know that
for a real community health programme,
dishing out health teaching, distribution of
pills or even training village level health
workers is only scratching the tip of the
iceberg.
Unless there is some way of
improving the socio economic status of the
people, our community health work is a wasted
exercise no matter how much we have spent
money wise. For this we need help of the Govt.
HEALTH FOR THE MILLIONS
AUGUST 1984
agencies
at
various
level.
Even
the
permission to start a small scale village
based industry becomes a great hindrance.
Power connection for poultry project which
helps the villagers does not come. Anything
with which we try to augment the income of the
villagers is resented and obstacles are
created.
Instead of supporting village
development schemes by social agencies,
social workers were falsely implicated in
civil and few criminal proceedings in the
court of law.
Local
government
officials
with
the
connivance of the political leaders with
vested interests will go ahead and nip in the
bud any genuine upliftment of the down
trodden.
The downtrodden and tne outcasts are made to
live at the level they were born in the world.
Are we going to sit quiet and say this is none
of our business? Shall we continue to work in
the area which suits us and where we do not
have to involve in confrontation with such
people and situations ?
I
know
instances
where
small
health
institutions who are members of MP VHA face
tremendous difficulty in getting licenses
for duty free spirit and permits
for
procuring narcotics. They have to go from
pillar to post. All the things depend on the
whims of the local government officers. If
we are fortunate, we may come across a kind
Samaritan
who
may help in the time of
need. But this is very rare.
Going beyond the hospital wall to the community, we need help from the gouemment
HEALTH FOR THE MILLIONS
AUGUST 1984
how many times have district level officials
given a cold shoulder to the applications to
process grants for A.N.M. Schools, vehicle
from UNICEF etc. I know specific instances
where the local DMO did not grant permission
to hold free eye camp by a hospital which was
doing the service to the poor in rural areas
tor many years before the government thought
of running eye camps with all the resources
available with them. Hew many times family
planning grant is not granted. Permission to
do family planning operations by some good
surgical units were not granted in order that
the patients may be reimbursed. Mother and
Child Health antenatal, well baby and under
five clinics suffer because of non supply of
medicines and free immunising facilities.
Leprosy
work
along
with
tubercolosis
eradication programmes cannot be carried on
inspite of all facilities and expertise
available with the government. So many times
we cannot move unless we compromise on our
stand. What is the answer to these problems?
Some members are not affected but there are
many who are frustrated and get discourag
ed to carry on the work.
hands together in some definite projects
covering large blocks of area, the Government
will have to listen to us. We will have to
forget our individual differences. We will
have to stop competing among ourselves. We
will have to pool together our meagre
resources available and approach the Health
Ministry for their cooperation. This may
still not be so easy as it sounds.
Any honest and sacrificial service to the
poor and needy will always raise obstacles.
That is the way of the world. Powers of
darkness will always come in the way of powers
of light which are represented by truth,
honesty and fear of God. The world will never
allow us to walk in light and take care of the
poor, neglected, down trodden and castaways.
But inspite of the opposition we face if we
are true to our calling there is joy and
happiness and contentment in whatever we do.
COMMUNITY HEALTH PROGRAMME
Question now arises why this state of
affairs. After ten years of existence as MP
VHA why was it not possible to win over
government health agency so that the purpose
for which we came into existance could be
fulfilled. We just had a proposal and we are
at the same stage for ten years. Engagement
between MP VHA and MP Health Department has
not yet taken place. It is high time that we
get engaged to one another so that we can get
married and bear fruits of a better physical,
mental and spiritual children in the way of
Health for All by 2000 A.D. What should be our
strategy? We of the yester generation have,
it seems, failed in bringing about engagement
fol lowed by marriage. Somebody has to take up
the baton and carry it forward.
10-week courses are available in Community
Health and . Development
for medical,
paramedical and social workers, involved in
community health and interested in training
community/village health workers. Registra
tion fee Rs. 200/-per participant. All other
training costs will be met by INSA.
1st Course
5.2.1985 to 12.4.1985
Last date for receipt of
applications 30th Novermber
1984
If we had banded together more closely I think
our impact might have been little more
effective. We should collectively bargain
with government. For that let us have
definite projects made out and ask for the
cooperation in finance and expertise which
goes begging most of the time. We must get our
house
in
order
first.
As
individual
institutions or in that way as members of our
separate organisations we will not be very
effective in having any bargaining power with
the government. But on the other hand if we
forget our individual entity and joining
2nd Course
6.5.1985 to 12.7.1985
Last date for receipt of
applications 28th February
1985
Contact
Programme Director
INSA/INDIA
Rural Health and Development
Trainers Programme, No. 2,
Benson Road, Benson Town
Bangalore 560 046
4
1985 courses
HEALTH FOR THE MILLIONS
AUGUST 1984
P.O. GEORGE
Kerala
The good, the bad and the ugly
Excerpts from a speech at the annual meeting of Kerala VHS
. The voluntary agencies have been active in
the field of health care in Kerala for the
last half a century-We can be.legitimately
proud of the fact that our contribution in the
field has also been commendable in according
the state of achievement Kerala has reached
in the area of health care. Of late, there has
been a persistent demand for a change in the
style
of
providing
health
facilities.
Besides the government of India has recently
defined
its
health
policy. At
this
juncture, it is only reasonable that we
review our contribution and decide as to the
nature of services to be provided in future.
I perceive my task as of one to raise issues
and help you to do a realistic stock-taking.
I limit myself to this stock-taking alone.
I
only intend to visualise the future of health
services, without going into the details.
Please let me warn you that I have depended
heavily on my observation within my limited
experience with voluntary agencies in the
health field and my discussion with health
personnel at various levels.
Hence these
observations can be personal and may I invite
you to correct them if faulty, or supplement
them, it inadequate in details.
In Kerala health facilities are being
provided by the government, private agencies
and
the
voluntary
agencies.
Limited
statistics are available with regard to the
first and last category of facilities.
While in the case of the second no such effort
has ever been made so far.
state.
It works out to be 1:783 bed
population ratio.
As a result of this we
have achieved a crude death rate of 7.2 %
per 1000 population as against the national
target of 9 per cent by 2000 A.D.
The decadal
growth rate of population is 19 per cent as
against a national average of 24.75%.
The health services of the government has
been planned according to a definite design
and hence they cover every village of the
state.
There
is
no
duplication
of
facilities.
These facilities have been
catering to the needs of the common man
generally.
The very commendable achieve
ments in the field of population control is
noteworthy.
The government health services
have been able to provide for medical
education and research in a well organized
way.
There are on the other hand, serious draw
backs to the health services provided by the
state.
Some of them are:
a)
rampant
corruption and inefficiency
prevalent at^all levels of the department
b)
Thorough politicization of the staff
c)
Undue enthusiasm of the medical practi
tioners for private practice
d)
Concentration of specialist
in the urban areas
e)
the very unsatisfactory way of mainta
ining inventories and equipments; and
f)
Lack of responsibility
in
handling
public
finances. These are several
drawbacks as a result of which the poor
people do not receive the help as and when
required; the facilities are enjoyed by
those for whom they are not meant.
Government run health Services:
It has been reported that the government
health services department runs 5 medical
colleges, 13 district hospitals, 55 taluk
hospitals, 165 primary health centres, 1810
sub-centres and 595 rural dispensaries.
In
all it provides for 32,447 beds in the whole
HEALTH FOR THE MILLIONS
AUGUST 1984
facilities
5
Private initiatives:
In the over all picture of the health
delivery system in Kerala, the private
practitioners have played a very significant
role.
So far no effort has been made to make
a comprehensive survey of the facilities
provided by them.
Going by one’s own
observation, we can say that the private
practitioner operates in every nook and
corner of the state.
They offer OPD clinics
for a couple of hours a day, or small nursing
home with 10-20 beds manned by a medical
graduate and his qualified or unqualified
assistants,
or well equipped hospitals
placed in urban centres, of late, several
individuals have been joining together to
register themselves as companies, charitable
societies, co-operative or small industries,
to build hospitals.
Even large industrial
and business houses have started to comeforward to establish health care institutions.
The private practitioners have to be
complimented for taking health facilities to
the remote areas of the high ranges.
They
often provide medical care with the minimum
cost and show the willingness to be at the
call of the people in need.
However, one can point out very serious
problem in this area, such as (a) through
commercialisation of the health care ins
titutions ; (b) provides ample opportunity
for qualified or under qualified men to
operate in the field of health care, (c) they
became party to numerous unethical practice
in medical care,
including unnecessary
surgeries and investigations; (d) they are
instrumental in pushing up the cost of
medical personnel in Kerala; (e) it helps to
generate
and
circulate
lots
of
black
money; (f) they retain the patients until such
time as they become unmanagable causing
avoidable emergencies; and
(g) provides
incentives to staff to shift loyalities at a
price.
One can safely state that the private
practitioners have made a definite contri
bution in the field of health care.
But one
has to guard against the excessive enthusiasm
of a
large percentage of the medical
personnel for private practices.
There is
a need for restraint in establishment of
medical facilities.
One can only wish that
this restraint comes from the concerned
agencies.
But if it is not forthcoming,
6
whether the Government provide
restraint is a debatable point.
for
such
The voluntary agencies:
The voluntary agencies comprising of the
various
religious
organisation,
church
medical boards,
religious congregation,
charitable registered societies conduct
nearly 350 hospitals in Kerala, according to
a survey being conducted by KVHS.
They
provide for nearly 20,000 beds.
These
institutions have the resources of nearly
1500 doctors and 3000 qualified nurses; the
ratio for beds to doctors and nurses being
1:13 and 1:7 of the doctors 60% are post
graduates. The districts of Ernakulam,
Trichur, Kottayam and Pathanamthitta account
for
nearly
65%
of
all the available
facilities.
Crowding of hospitals:
This means the health services provided by
the voluntary agencies demonstrate a dis
tinct concentration in the central Kerala, it
also means that the voluntary agencies have
been relatively shy of starting health
facilities in the coastal areas and high
ranges.
It may be worthwhile to look for the reasons
for this concentration. I consider the
following as valid reasons:
The availability of adequate communication
system;
Presence of a dominant church - the syro Malabar church which has large number of
religious congregations and sisters placed
in these areas; and
Reasonably high density of population which
will guarantee a sizeable client for the
hospitals.
This crowding of facilities creates a number
of problems. Most of these institutions are
not
fully
utilizing
their
capacity.
Hospitals with very low occupancy rates or
poor utilization of costly
equipment
and personnel pushes upward the
overnead expenses of the institution. In such
cases, these institutions hardly ever show
the realism to close down facility which is
not viable. Instead they resort to one or more
of the following strategies: (a) Attract a
more successful doctor in the neighbouring
institution
offering
him
additional
incentives; (b) Install costly equipment and
HEALTH FOR THE MILLIONS
AUGUST 1984
add super specialities with the objectives of
wooing the clientele (c) when the institution
is financially weak offer the low class
employees poor service conditions as an
economy
measure.
There
are
several
institutions in Kerala which do
not pay
these employees the minimum wagesprovide
for leave, provident fund, gratuity etc. The
gap between the highest paid and lowest paid
employees continue to get wider day by day,
and (d) pass on to the consumer what could not
be made up or received as aid from outside
agencies. Further the relationship between
these institutions is hardly ever cordial as
a result of which collaboration between them
may not be possible.
The positive characteristics:
lowest paid staff is very wide. *(d) voluntary
agencies are forced to help doctors and
medical personnel to generate and maintain
black money, (e) Hospital facilities are
planned without adequate consideration of
the requirements of the people and the
facilities available in the region. This
leads to duplication of facilities and
wastage of resources.
The motivation for health services:
Now that we have considered the extent and
quality of the health facilities provided by
the voluntary agencies. It may be worthwhile
to examine the motivation behind entering the
field in a concerted way. One can see that the
religiously motivated people entered the
field of health care as it is a quasi
spiritual activity. This personal commitment
was further strengthened by the dire need
existing in the community, particularly the
poorer sections. This attitude has a telling
effect on the quality of services provided.
The voluntary hospitals generally demons
trate greater commitment to the quality of
patient care. This is more so in institutions
where
people
with religious commitment
work. They add the much needed spiritual
dimension to the art of healing.
The
voluntary hospitals are known for their
cleanliness and tenderness with which the
patients are looked after. They have placed,
specialists
away
from the urban centres
which is
commendable
indeed .. The
voluntary hospitals are usually very well
equipped; and the equipment maintained in
good condition. The contribution of the
voluntary agencies in the area of training
nurses and para-medical staff is indeed
great.
Times have changed and several other agencies
have entered the field of health care, the
motivation of the above mentioned people also
have undergone changes. Over and above the
one mentioned above one can formulate the
motivating factors as below:
The voluntary hospitals, or mission hospi
tals as they are often referred to have been
doing a great deal of help to the poor and are
often channels of free medicines and food
materials from abroad.
(b) enthusiasm of the leaders of the various
religious communities, churches, religious
congregations etc to compete with each other
In competition one aims not only at ones own
victory, but also tne other's losing.
Besides these achievements, the voluntary
agencies have pioneered community health in
Kerala. In addition to the hospitals a number
of agencies have gone into the area of
community development.
(c) Sometimes
hospitals
are
built
establish monuments for persons.
(a) desire of the policy makers to gainfully
engage
their
professionally
trained
personnel and to meaningfully utilize the
equipment obtained from elsewhere.
to
(d) in certain cases health facilities are
planned with a view to invest the funds
available from various foreign agencies.
The weak spots:
The health services provided by the voluntary
agencies have serveral drawbacks too. They
are :
(a) Most of the mission hospitals are costly
for the common man. (b) most of these are
managed by people without adequate training
in management and as such are managed badly.
(c) the gap between the highest paid and
HEALTH FOR THE MILLIONS
AUGUST 1984
One can state with much confidence that as
reasons
mentioned
above
influence
the
decision, the quality of patient care moves
downward. Further, when the survival becomes
crucial, the institution resorts to the
strategies mentioned above.
National Health Policv Promises:
Now that we have analysed the extent, nature
7
and
motivating
factors
behind
the
establishment of voluntary health care
institutions, the pertinent issue at this
juncture is: ’what should be our approach to
health
care
for
the
future?
This
is
particularly relevant as the National health
policy states: "There are a large number of
private, voluntary organisations active in
the health field all over the country. Their
services and support would require to be
utilized
and
intermeshed
with
the
Governmental
efforts
in
an
integrated
manner" (National health policy No.8(1) . The
government
is
inviting
the
voluntary
agencies to associate themselves with the
governmental effort and promising to provide
"organized
logistical,
financial
and
technical support to voluntary agencies
active in the health field" NNHP-No.8 (7))
with a view to enlarge its health services. In
articles No.8(12), policy states" efforts
should be made to fully utilize and assist in
the enlargement of the services being
provided by private voluntary organisations
active in the health field. In this context,
planning, encouragement and support would
also require to be afforded to fresh
voluntary efforts, especially those which
seek to serve the needs of the rural areas and
the urban slums."
Response of the voluntary agencies
The most relevant question at this juncture
is "How do we respond to the call of the
government in order to attain the objective
of health for all by 2000 A.D ?" Let us rem.ind
ourselves that the turn of the century is just
16 years away and we have miles to go, before
we can reach our goal.
'Health1 in 2000 A.D. should be seen in the
total perspective. I believe that it should
go beyond the provision of universal,
comprehensive primary health services. It
should be seen in the over all development of
the community.
Sr. Carol Huss addressing a
convention of health personnel in Trivandrum
"I See a peaceful quie tcountryside, a kind of
green revolution.
Families are not only on
the land, but own the land: the large mass of
bonded labourers, or daily wage workers are
gone.
The villages are clean, well cared
for, healthy places to live.
The water is
safe to drink, a well planned drainage system
prevents
stagnant
pools
where
disease
carrying files and mosquitoes breed, every
house has latrine and bathroom and none uses
8
the field. And see there the village council
is ready to begin their monthly meeting.
Ten
men and women elected for two years terms,
taking
up matters of
socio-political,
economic, religious, health and education
concerning the village. The village is
almost self-contained. Certain items go to
the District market and a few things are
brought in.
But the gas and light are
produced locally by bio-gas plants.
People
are healthy because they take a total
approach
to
health".
(Huss
Carrol:
Health services and utilities system in
India in the 21st century.
Health
care
Administration Manual, KVHS, 1977, P.23)
Our
response
to
the
government's
invitation and our own quest for a healthy
village to live as visualized above can be,
(a) to collaborate with the governments
efforts in this area. The modalities for
such collaboration will be worked out in the
group sessions,
(b)
to reorganize the
services being provided by the volunatary
agencies in such a way as to make health for
all by the turn of the century a vibrant
reality.
In this context we have to consider
the advisiability of shifting our focus from
central Kerala to the coastal areas and high
ranges. But then we have to scientifically
assess the viability of such establishments
vis-a-vis the real needs of the area.
Further we hould consider the advisability of
enlarging the hospitals with such system.
Here we need to work out adequate modals which
may be followed in the special situation
prevailing in our state. That will be the task
in the 2nd working group. The third group
will focus their attention on the hospital
system as provided by us today and identify
their strengths and weaknesses and suggest
corrective measures to be effective.
We have briefly outlined the various
agencies and their contribution in the field
of health care in Kerala, with greater
emphsis on the contribution of the voluntary
agencies. With regard to the future of
health
services,
we
recognize
the
responsibility placed on the voluntary
sector and hope to work out the modalities in
the working groups.
Hunger today is largely a natural and man
made phenomenon: human error or neglect
creates it
*
human complacency perpetuates
it and human resolve can eradicate it.
HEALTH FOR THE MILLIONS
AUGUST 1984
D.P. PODDAR
West Bengal
Face to Face with an Epidemic
Reproduced from a communication sent by West Bengal VHA
Following newspaper reports, letters from
members of the WBVHA from rural Bengal and
telephone messages from different offices in
and around Calcutta, WB VHA called an
emergency meeting of representatives of
government, medical colleges and voluntary
organizations on 3rd May having persons from
government offices, medical colleges and
voluntary organizations.
It was reported to this meeting that
over
56,000
cases
of
bacillary
dysentery had been recorded and the
death
roll
had
mounted
to
a
staggering 1758 in two months.
At
this
time of epidemic and crisis
to
strengthen the effort of government health
services the
following actions were taken
which have been aprecia'ted by people in
general.
1.
necessary.
The volunteers were asked to
work for 5 days in cooperation with the
Government district level authorities and
voluntary
organizations
to
create
awareness among people for the prevention
of dysentery and to conduct group meet
ings. Volunteers will submit a report on
their work with recommendations which is
to be discussed in the meeting to be held
by end of May.
4.
By
the
second
week
of May,
Halazone tablets|supplied to
voluntary organisations
and rural areas
5,00,000
Oxal Rehydration Salt(ORS)
20,000
iFurazolidine Suspension
1,600
A one page leaflet was prepared within
two days. 2,00,000 copies of these were
circulated to:Voluntary organizations 1,50,000
Government organizations 50,000
Also the above leaflet message was given
as insertion in newspapers like Aaj Kaal,
Basumati, Ganashakti, Asre Jadid (Urdu) and
the Statesman.
2.
Effort was made to
popularise the
message of the above leaflet through radio
and television.
3.
32 volunteers
(students of medical
colleges) were selected and given two
hours training and were sent to the
different districts of West Bengal,
equipping them with sufficient leaflets,
posters,
halazone
tablets , ORS
and
Furazolidin^
Suspension
wherever
health for the millions
AUGUST 1984
THE PRICE OF HEALTH
Providing primary health care — including water and
sanitation, trained workers, communicable disease
control and basic drugs — would cost an extra $50
billion a year for the next 20 years. That is $12.50
per person per year:
2
O
of world
-jr- spending on
cigarettes
2
of world
spending on
alcohol
U
15 spending
of world
—— military
9
cooked food and see that flies do not sit
on it.
Prevent Bacillary Dysentery
* Be
careful
about
polluted
water,
unwholesome food and flies. Never take
uncovered or stale food. Take freshly
Wash raw fruits and vegetables thoroughly in clear water before use. Wash your
hands with soap and water and then touch
or eat your meals.
*
Boil your drinking water. It may also be
purified by using 2 halozone tablets in 1
litre of water or 2 teaspoonfuls of
bleaching powder in 12 litres of water
which can be taken after half an hour.
*
Don’t stop normal diet and breast milk
the child in spite of loose motions.
*
Washing the soiled clothes of the patient
in a tank or passing stool or urine near a
tank or a tubewell should be strictly
prohibited. Clothes of the patient are to
be boiled. Excreta must be disposed of
very carefully in the water-closet or
covered with earth in a deep pit. Wash
your hands with soap after the movement
of bowels.
*
The moment the disease starts, give the
patient a large glass of boiled and
cooled water mixed with 6 teaspoonfuls of
sugar (or a handful of ’gur’), 1/2
teaspoon of salt and 1/2 teaspoonful of
baking soda. Give the patient this
solution repeatedly. Oral rehydration
powder in boiled and cooled water can
also be used.
*
Contact the local health workers or the
hospital for advice and guidance. Don’t
get frightened, nor create a panic.
Essential and Locost
Gujarat
Reproduced from a communication sent by Locost, Gujarat
The History of LOCOST
In the last few years, voluntary agencies
have been sensing an urgent need for a
rational drug therapy structure. Two main
reasons led to this sense of urgency. One,
there were widespread irrational prescrip
tion practices with no social accountabi
lity. Two, there was no formal setup for low
cost and quality drugs distribution.
Commissions went unheeded, seminars and
workshops
posed
the
problem
with
no
alternative strategies, research studies and
journalistic exposes focussed the problem
acutely but that seemed to be all. Pioneers in
the field of community health in Gujarat like
Dr. R.R. Doshi, Dr. Ashwin Patel, Fr. M.A.
Urrutia, S.J. discussed and sowed the first
seeds of LOCOST in a nebulous form.
In 1982, a team of experienced doctors and
scientists in the field of community health
got together and drew up a list of the
essential drugs based on the Hathi Commission
and the W.H.O recommendations. A search for
dedicated and competent personnel finally
led to a nucleus infrastructure for LOCOST.
cines. LOCOST is a response to a growing
demand and challenge of the voluntary health
sector for low cost standard generic drugs
based on a scientific rigour for quality
control.
LOCOST is governed and managed by
*
*
*
*
a board of trustees
an executive committee
a member secretary
a coordinator and his team.
The Board of Trustees and Executive
Committee frame policies and procedures,
adopt methods and strategies to promote
the objectivesof LOCOST
The Member Secretary who is a member of
the Executive Committee, supervises and
ensures that the LOCOST ideology and
framework is implemented in the action
wing.
THE BARE ESSENTIALS
In August 1983, LOCOST was finally registered
in Baroda.
Availing of the
facilities
afforded by AMIL Pvt Ltd., LOCOST procured
its first orders, tested them and despatched
them in late 1983. LOCOST is now well on its
way to establishing a small step, but in the
right direction, in the field of social
justice in health.
The LOCOST Organization
LOCOST (LowCost Standard Therapeutics) is a
collective voluntary enterprise for rational
therapeutics through promotion of low cost,
scientifically tested, generic based medi
HEALTH FOR THE MILLIONS
AUGUST 1984
11
The Coordinator looks after the day to
day
administration,
arranging
the
procurement, testing and despatch of
quality drugs to the various partners of
LOCOST.
2.
On the basis of firm orders these
manufacturers will be supplying the
specific drugs to LOCOST.
3.
Quality Testing & Control : LOCOST's
responsibility is to ensure a rigorous
quality testing and control of these
drugs before despatch to its partners.
4.
The drugs distributed by LOCOST adhere to
the principles of rational drug therapy
as chartered by the Hathi Commission,
World Health Organization, etc.
5.
Delivery and Despatch to Partners will
then be undertaken by LOCOST
6.
Consumer Cost Benefits : By eliminating
the intermediary, LOCOST provides a
wholesales price discount of 5-20% for
drugs on its price list.
Why LOCOST ?
Several independent studies have revealed
the following facts
There are approximately 30,000 formula
tions in the market going under various
brand names.
1.
Most of these formulations can be
simplified in their composition and
constitution thus ensuring their scien
tific base.
2.
Marketing them under generic name can
further reduce their costs to the
consumer.
AN INVITATION
4.
Granting a reasonable profit margin, the
present on-going rate of profits can be
lowered considerably.
These are, in short, some of the aims,
objective, methodologies and strategy to
evolve and ensure a more "just order" in the
field of health in general, and rational
therapeutics in particular.
5.
It is possible to ensure a high quality of
drugs at low costs.
3.
LOCOST1s Methodology
1.
Procurement : LOCOST has contacted a
number
of
reliable
low cost
drug
manufacturers in the Bombay-Thane and
Ahmedabad-Baroda-Surat regions whose
integrity and credibility have been
established.
If your Institution agrees with this basic
orientation, philosophy and values, and
would like to collaborate in the collective
effort, please write to us at the address
given below:
The Coordinator
Project LOCOST
c/o AMIL
G.P.O Box No. 7
Vadodara 390 001
Phone 58481
FORTHCOMING ISSUES OF
HEALTH FOR THE MILLIONS
OCTOBER
The Hospitals Bill What you need to know
December
Medicines as if people
Mattered II (AN UPDATE)
To ensure copies renew your subscription
Write to:
Health For The Millions
VHAI
C-14, S.D.A. Community Centre
New Delhi 110 016.
12
HEALTH FOR THE MILLIONS
AUGUST 1984
LOCOST
(Low Cost Standard Therapeutics)
GPO Box No.134
Baroda 390 001
(Gujarat)
Tel.No. 58481
June 11, 1984.
N.B:
Please indicate your requirements below. We would welcome bulk orders or orders atleast
for a quarter. Orders will be completely - despatched by July 1, 1984. Please return
this form to :
The Coordinator, LOCOST, GPO Box No. 134, Baroda 390 001.
Purchaser
(Name in block letters)
Address
ORDER FORM
Sr
No .
1.
2.
3.
4.
5.
6.
7.
8.
9.
10 .
11 .
Name of the
drug
Drug
strength
Aspirin IP
Ampicillin
Aluminium Hydroxide,
Magnesium Trisilicate
Ampicillin
Atrophine sulphate
CPM
Chloremphenicol
Chlorpromazine
Chlorpromazine
Calcium lactate
Cotrimexazole IP
HEALTH FOR THE MILLIONS
AUGUST 1984
Form
(Tab/
Cap/
syp)
300 mg
Tab
Cap
250 mg
125 mg + Tab
250 mg
125 mg
syp
5 ml
25 mg
Tab
4 mg
Tab
250 mg
Cap
10 mg
Tab
25 mg
Tab
300 mg
Tab
80 mg + Tab
400 mg
Price
per
1000
batch
Rs.
Total amount
Qty.
ordered
Rs.
20.00
590.00
32.00
29.00
(per 450 ml)
6.00
6.50
295.00
19.00
40.00
13.00
300.00
13
14
HEALTH FOR THE MILLIONS
AUGUST 1984
NOTES
Syp = Syrup.
1.
Form
:
Cap = Capsules,
2.
Prices
:
Prices are given in Indian Rupees and are likely to increase or
decrease depending on the price of the raw material actually purchased.
3.
Delivery, despatch and terms of payment :
3.1
3.2
3.3
3.4
3.5
3.6
3.7
Tab = Tablets.
Goods will be despatched against payment through bank or cash. If
through bank, please make demand draft.
Please indicate preferred mode of transport and nearest station for
collection of goods.
Prices are inclusive of sales tax, etc. for orders within Gujarat.
Octroi and local taxes extra.
The sales tax for orders outside Gujarat State will be 11% without 'C'
form ad 4.4% with ’C' form and 4.4% in Gujarat State with or without 'C
*
form.
While every effort will be made by LOCOST to ensure safe delivery, the
goods are despatched at the purchaser's risk, unless insurance is
specified by the part in which case insurance charges will be extra.
Please arrange to order for 3 to 6 months atleast.
Guarantee : Products are guaranteed for their quality of production and
the quality of the material. You can demand a photostat copy of the
quality test certificate for a particular drug. Quote batch number
while asking and also enclose Re. 1/- per certificate for xeroxing and
postage charges.
GLOBAL FAMILIES ; On average, 3.9 children are born to each woman in the world, but
there are wide regional variations. In Africa, on average, the number is 6.5, in Latin
America 4.4, in Asia 4.2, in the USSR 2.3 and in Europe and North America 1.9, (From the
United Nations Fund for Population Activities)
ENVIRONMENTAL IMPERIALISM -"Some companies in the industrialized world are exporting
chemical waste to poor nations as a way of getting around t‘ough new domestic laws
regulating disposal," reports the Inter Dependent. UN Environment Program head Mostafa
K. Tolba urged the developing countries to resist this "form of environmental
imperialism. "
CRUEL FOOD PARADOX : The global food situation in 1983, reports the World Food
Council, can be characterized by the paradox of exceptionally large reserves' in the
major food-producing countries while, at the same time, production in many food
deficient countries of the Third World is either stagnating or deteriorating in the
face of current adverse international economic trends. The brutal effect of this
paradox is that more people than ever before face the threat of undernutrition even
though international prices for food grains and coarse grains have plummeted to their
lowest levels (in real terms) in 30 years.
HEALTH FOR THE MILLIONS
AUGUST 1984
15
Andhra Pradesh
School Health Mirror
Reproduced from School Health Mirror
Published by AP VHA
I
The School is the Eyes of the Community
The School is the Lab of the Community
The School is the Model House of the
Community
The School is the Sign post of the
Community
established during the formative years have a
direct effect on adult health.
Educating the school age child about
health can benefit not only the individual,
but his/her family and community. As a
parent one influences the health and health
EXPERIMENTATION
(LAB)
OBSERVATION
(EYES)
SCHOOL
HEALTH
PROGRAMME
ORIENTATION
(SIGN POST)
DEMONSTRATION
(MODEL HOUSE)
Health can be studied and learnt from
observation, from what they see.
It is not
learning by
heart or being told.
Children make experiments, they question,
thus they learn by trial and error f from
discovery and innovation.
School is a model house where the children
are able to demonstrate what they learnt by
observation and what they have experimented
upon.
They reach a level at which they
demonstrate.
Eg: Yoga, nutrition etc.
i
It is also an occasion, an opportunity for
orientation to new, helpful, healthy habits
and
attitudes.
eg:
personal
hygiene,
environmental hygiene etc.
awareness of his/her children and must know
how and when to use health care services and
personnel. As a citizen, the individual
influences others by personal behaviour and
will participate in decisions affecting the
environment and health care system.
Components of SHP
1.
2.
3.
HEALTH
Thus the health of our school age child
will determine to a great extent the quality
of life each will have during the growing and
developing years and on throughout the life
cycle.
Lifestyle and behaviour patterns
16
Health Education
Environment
Health Services
: A state of complete physical,
mental, and social well-being
and not merely the absence of
disease or infirmity (WHO).
A
quality
of
life
involving
dynamic interaction and inter
HEALTH FOR THE MILLIONS
AUGUST 1984
and psychologically of sick children
and their followup.
dependence
among
the
indi
vidual's physical well-being,
his
mental
and
emotional
reactions,
and
the
school
complex in which he exists.
HEALTH
: A process with intellectual,
EDUCATION
psychological,
and
social
dimensions relating to acti
vities
which
increase
the
abilities of people to make
informed decisions affecting
their personal,
family,
and
community well-being.
1.
-
Prevention and control of communi
cable diseases.
Provision of emergency services for
injury or sudden illness.
Nutritional services.
Health records keeping.
3. SCHOOL ENVIRONMENT: Third Component of
SHP:
SCHOOL HEALTH EDUCATION:
Provision of
environment
The first component of a comprehensive
school health programme
Planned by both school and community
With scope,
sequence,
progression
and continuity
- For grades I to X.
Taught
by
teachers
trained
and
prepared in health education.
Designed to develop critical thinking
.and individual responsibility for
one's health.
Structured to incorporate current
and emerging health problems.
Focussed on the dynamic relationship
between physical, mental, emotional
and social well-being.
- Strengthened by integrating avail
able community resources into class
room teaching.
Health
knowledge-learning
oppor
tunities .
Health attitudes-feelings,
emo
tions .
Health practices-behaviour.
2. HEALTH SERVICES:
Second component of
SHP:
Appraisal of health status of pupils
and school personnel.
Counselling of
pupils, parents, others concerning
health problems
Organisation
school day
AUGUST 1984
a
adequate
healthful
Meeting standards for sanitation,
safety, lighting and ventilation.
Proper school maintenance.
Phases in starting School Health
Programme:
1.
Orientation of school administrations,
teachers, parents, and local leaders.
2.
Setting
Team.
3.
Setting up of a School Health Council
Committee at the school level.
4.
Selection and training of Teachers.
up of a School Health Training
5. Selection and training of student health
guides.
6.
Involvement of students in community
activities and care of their brethren
through Child-to-Child programme.
Why the Teacher is effective in
School Health Programme:
1.
HEALTH FOR THE MILLIONS
of
and
Establishment of friendly staff and
pupil relationships
Observation and identification
and encouragement in the correction of
remedial defects if any.
Assistance in the identification and
education of scholastically backward
or handicapped-physically, mentally
safe
Teachers are where the schools are, and
they are a rich local resource.
They are
available in large numbers, present even
in remotest areas.
17
2.
They are best equipped to undertake the
task
of
health
education,
their
educational background and skills befit
them for this work.
3.
Considerable acceptibility - personal
as well as of what they teach with pupils
and their parents and through them the
community.
Most teachers specially are
natives of the region ad know the beliefs
and customs.
Convincing them to change
those
affecting
will
be
something
exemplary for the community.
4.
Social status in the community and
faith of the people, good support with
voluntary
agencies
and
Govt.
and
community.
5.
Involvement
cf teachers in health pro
gramme
is
consistent
with
overall
philosophy of developing nations to
maximally
utilize
locally
available
resources.
Teacher knows the customary
behaviour;
tnerefore
can
picK
any
deviations.
A good teacher understands
students’ physical, social and emotional
needs more than an outside health person.
6.
Teacher
can observe pupils' eating,
study, health and play habits, their
attendence,
their
growth
and
their
scholastic record and any discrepancy
between capacity and performance.
Health education helps the teacher in
developing and maintaining his/her own
health;
objective
consideration
of
existing prejudices and superstitions
about health are made.
7
©t
d'® ^o<e.
s
accv
. ^C'\oJ -v
VO ** voo cXoS
'o'00'""'- <c3‘
o\
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4
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-
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4o
s
6
• C/M
- cV''ateevcS
■
fxte
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co
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V
oo^
Fi'0,n
s'.o'’cS
•-
AS **
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* “
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v>'Vo
A*
- ?
Dr E. LYNGDOH
Meghalaya
Indicators of Health
Excerpts from a speech made at the Meghalaya State VHA meeting
There is need for laying down indicators for
monitoring and evaluating the progress of our
country towards the goal of Health For All by
the year 2000 A.D. There are already global
indicators for this purpose. A general review
of the progress in terms of the indicators
will help us to realise where we
stand. Health For All by the year 2000 A.D.
has been endorsed at the highest official
level by the Parliament. Troubles begin in
respect of the indicator number three which
callsupon the nation to spend atleast 5% of
the gross national product on health. It is
unfortunate that the social service sector in
general and the health sector in particular
has not been given the importance in the plan
outlay, although it has been realised in all
quarters that human welfare has to be the
supreme consideration of all development
plans and programmes. If we are going to
achieve Health For All by 2000 A.D. there is
need to increase the plan outlay for health
sector.
Indicator number four which requires
that reasonable amount of National Health
expenditure is devoted to the local health
care is not yet satisfactory. Undoubtedly
India
including
Meghalaya
has
made
efforts through Community
considerable
Health Guide Scheme, Multi-purpose Workers
Shceme, Dai Training Scheme and orientation
of Medical Education Scheme to extend medical
aid and primary health care facilities to our
vast rural population. However, it is a
matter of concernthat in our enthusiasm for
expansion of
the
health care service
not much attention has been paid
towards the quality of service to be
rendered.
The first priority should be to consolidate
the existing infrastructure by making up the
deficiencies in respect of equipment and
trained man-power, an advanced plan should be
done to ensure that the required equipments,
HEALTH FOR THE MILLIONS
AUGUST 1984
trained
personnel and
other
facilities
are
available for
infrastructure to be created.
physical
the
new
The most important indicator set by the World
Health
Organisation
for
monitoring
a
programme and strategy of Health For All by
2000 A.D. is that the Primary Health Centres
should be available for the whole population.
The specific achievement on which stress has
been laid by the indicators are :
1)
Availability of safe water in the home or
within walking distance;
2)
Adequate sanitary facilities;
3)
Immunization
diseases;
4)
Availability of at least 20 essential
drugs within one hour's walk or travel;
5)
Availability of trained personnel for
attending pregnancy and child birth and
care for children upto atleast one year of
age.
against
communicable
Above
361
millions
of
India's
rural
population do not have adequate drinking
water facilities.
Sanitation facilities
even in our cities and municipal towns are
still very inadequate.
Despite the various
schemes for improving the situation, the
coverage in the sanitation field for the
urban and rural population is 27% and 2%
respectively.
In respect of drugs, the indicator insists on
the availability of atleast 20 essential
drugs within one hour's walk.
In India,
besides periodic shortage of essential and
lifesaving drugs, paradoxically there are
thousands of brands available though only few
essential drugs are needed.
The effort of
.19
Primary Health Care
In the game of life and death many people in the world
are playing against the odds:
• 1 in 2 never see a trained health worker
• 1 in 3 are without clean drinking water
• 1 in 4 have an inadequate diet
Every year diarrhoea kills 5 million under-fives; malaria kills one million people in
Africa alone. These and other killer diseases are preventable. Doctors and
hospitals offer cures for some. But what can really change the survival odds is a
package known as Primary Health Care (PHC).
DISEASE
CONTROL
FOOD
AND
NUTR'.TION
WATER AND
SANITATION
• Around two-thirds of
under-fives in the poor
world are malnourished.
PHC means ensuring an
adequate, affordable food
supply and a balanced
diet.
• 80% of the world's
disease is related to lack
of safe water and
sanitation.
PHC means providing
everyone with clean
water and basic
sanitation.
/C
* Over half
7Ot^rs X
)
/
childbirth e n
/
'
of babies
/
hPHC^anstr
blrth attenw
• Up to 50% of health
budgets are spent on
drugs.
*
vjxa--
.n-ing
workers
PHC
® Traditional birth
attendants deliver 60% —
80% of babies in the
developing world.
PHC means enlisting
traditional healers,
giving additional
training and using tradi
tional medicines.
peases and
\
t0
\
\
corri’Tton «
Injuries
y
/
a,n«d
I
hea''h.
li
HEALTH
EDUCATION
x \ CUR^Wt
„ Z; cMt
) s chil°
/
/
TRADITIONAL
MEDICINE
ESSENTIAL
DRUGS
PHC means restricting
drugs to 200 essentials,
preferably locally manu
factured, and made
available to everyone at
a cost they can afford.
• Some 5 million
children die and another
5 million are disabled
yearly from 6 common
childhood diseases.
PHC means
immunisation against
childhood diseases
and combatting
others like malaria.
i
0 Preventing ill
health depends on
changing personal
and social habits.
PHC means
educating people in
understanding the
causes of ill health
and promoting their
own health needs.
THE WINNING HAND
The eight elements of Primary Health Care give
everyone - young children and poor people
especially — the best chance of winning the fight
for life.
The cost of putting PHC into practice world
wide is an extra $50 billion a year: less than twothirds of what the world spends on cigarettes,
and only one-fifteenth of world military
expenditure.
20
*4*
FOOD & MUTRlTIQNj
HEALTH FOR THE MILLIONS
AUGUST 1984
the Government to bring down the number of
drugs
and
replace
brand
names
for
pharmaceutical names are yet to bear fruits.
Unless this is done, it will not be possible
to have a standard list of drugs and
equipments reduced to minimum, that takes
into account the epidemiological situation
as well as resources available. This is the
greatest problem which requires urgent
attention to achieve Health For All by 2000
A.D.
India's child population is 266 millions and
about 50% of the children, more than half of
them below 6 years, live in conditionsof
poverty, deprivation and malnutrition.
Programmes for the welfare of the children
and mothers have been launched and the most
successful programme is the Integrated Child
Development
Services
Scheme
as
this
Programme has linkages with other important
interlinked programmes like safe drinking
water, health care services, environmental
sanitation,
community
education
and
immunisation.
If proper range of services
can be provided, particularly to the weaker
and vulnerable section of the community, the
wastages arising from infant mortality,
physically
handicapped,
malnutrition,
stagnation in school and poor development of
mental
capacities
can be
considerably
minimised and this will lead to positive
contribution to the social and economic
development of the country.
HEALTH FOR THE MILLIONS
AUGUST 1984
In our effort to achieve Health For All by
2000 A.D.,
the community participation
should be ensured in all these development
schemes. The community participation assumes
special importance for the point of view of
programme effectiveness and the satisfaction
of the community about services rendered by
the Programme. The community should become
the agents of their own development instead
of passive beneficiaries of development aid.
Unfortunately, the community participation
in this country is still poor and the
voluntary organisation can play a greater
role.
The way in which the com.aunity can
participate includes the acceptance of
individuals of high degree or responsibility
for their own health care by adopting healthy
life-style by applying principles of good
nutrition and hygiene, and by making use of
immunisation services.
Another problem which requires urgent att
ention is the health management information
system.
At present, the health information
system is for all purposes non-existant.
What we have at present is only service
stastics and morbidity and mortality in
respect of priority health problems are based
on
sample
surveys
and
studies.
The
development and implementation of the health
information
system should
receive
the
highest priority if we want to achieve health
for all by 2000 A.D.
because no proper
planning and programme implementation can be
done unless the health information system is
improved.
21
Tamil Nadu
Joint Commission
Rewritten from a communication sent by TN VHA
VHAI has often sought a top level joint
commission
of
the
government
and
the
voluntary sector both at the national and
state level.
Now there is good news from
Tamil Nadu.
At least one such meeting took
place early in 1984.
Present at the meeting were the Commissioner
and Secretary to Government, Health and
Family
Welfare
Department,
Thiru
R.
Shanmugham; the Director of Public Health and
Preventive Medicine, Dr. V. Kapali; and the
Deputy Director of Primary Health Dr K.V.
Shanta.
Representing the voluntary sector were Drs
Sanjeevi, Rajasekaran Reddi and Rajaratham.
A number of questions regarding the ratio of
the funding by centre,
state and the
voluntary sector came in for discussion.
The government also clarified its guidelines.
on opening health centres.
The dearth of qualified auxiliary nurse
midwives, unqualified female workers and
male workers also figured in the discussion.
The government agreed that the voluntary
organizations continue to employ those
trained at
1.
Voluntary Health Services, Adayar
2.
Christian
Vellore
3.
Christian Fellowship ’ Community
Centre, Ambilikair and
4.
Institute of Rural Health
Planning, Gandhigram
Medical College and Hospital
At the meeting the government also agreed to
issue instructions to all referral ins
titutions to pay special attention and
priority to those who bring referral cards
from mini health centres.
Hitherto, the expenditure on the running of
each mini health centre was shared as
follows:
Voluntary organization
State government
Central government
and Family
Rs.
Rs .
Rs.
9,000
4,500
4,500
Rs . 18,000
The Government of India have agreed to the
following revised pattern of assistance
Voluntary organization
State government
Central government
Rs.
Rs.
Rs.
9,000
9,000
9,000
Rs. 27,000
Health
It was brought to notice that the voluntary
organizations had difficulty at times, in
securing Immunization Drugs from the PHCs.
22
It
was
decided
that
the
voluntary
organizations should draw up a definite plan
of action or programme, for the next year
(1984-85) and based on this, place indents
with the District Health Officer concerned,
by February 1984 indicating the source from
which they would like to draw the supplies.
The District health Officer should give
apriority to the Mini Health Centres in the
matter of supply of these drugs and he would
ensure timely supply.
The expenditure of Rs. 27,000 per Mini Helath
Centre, per annum represents the ceiling for
purpose of sharing the expenditure by the
voluntary organization, the State Government
and the Central Government in the ration of
1:1:1.
It is open to voluntary organiza
HEALTH FOR THE MILLIONS
AUGUST 1984
tions to spend more but the State and Central
Government's share of assistance will be
restricted to Rs. 18,000/- (9000+9000 on the
sharing pattern of 1:1:1).
On behalf of the voluntary organizations, it
was represented that they have not yet
received grants due to some minor objection
or other, by the audit parties.
In the light
of the general decisions, taken and the
clarifications
given
at
the
meeting
(enumerated
in
the
paragraphs
above)
secretary instructed that the arrears of
grants due to the voluntary organization
should be released immediately and in any
case before 31.3.84.
The next meeting is scheduled for July.
These meetings will be held at least once in
six months.
THE BOTTLE INVASION CONTINUES
Kanthy Venkat reports:
unhealthy practice carried on in hospitals.
The use of commercial milk foods is by no
means an urban elitist phenomenon. Rural
environs have not escaped the onslaught.
22% to 30% of all infants in the villages
around metropolitan cities were receiving
commercial milk foods, according to a study
by the Nutrition Foundation of India.
Health personnel should be trained to give
advice
having
regard
to
realistic
situations, local conditions and dietary
habits,
instead
of
blindly
advocating
commercial milk — an advice which is not time
consuming and which is in consonance with
what the affluent practice.
A good proportion of the families were
spending more than 10% of their meagre
incomes on commercial infant foods.
Most of
the poor were over diluting commercial milk
and feeding it in unhygienic ways and this was
reflected in a higher prevalence of severe
grades of undernutrition in such children
than in those exclusively on breastmilk.
The report notes that the code recently
adopted by the government should be observed
and implemented in spirit and not by the
letters.
The way should be paved by the
indigenous
baby-food
maufacturers
by
avoiding
unethical
promotion of
their
products.
Further, it was found that a very high
proportion of infants born in hospitals both government and private are introduced to
commercial milk foods even before they are
put to the breast. The health personnel play
an important part in advising commercial milk
food which is accepted and used by most young
mothers.
The report feared that "commercial milks
have
established
for
themselves
a
substantial beach head" in the dietary
patterns of the poorest infants in the rural
environs of the metropolitan centres.
With
increased income generation they could make
further inroads and progressively erode the
breast feeding practice.
The report suggests that in the interest
of child health, nutritionists, neonatologists and paediatricians must take the lead
in spearheading movements for fostering and
promoting breastfeeding and eradicate the
HEALTH FOR THE MILLIONS
AUGUST 1984
It calls
for strict observance and
implementation of the code to be taken up by
consumer protection societies, voluntary
agencies, media and the public apart from
Government agencies.
The report also suggests other ways like
providing necessary nutrition, to expectant
and nursing mothers, subsidised food for poor
nursing mothers, provision of facilities for
breast feeding to working mothers, educating
the public regarding the superiority of
breast milk over commercial supplements and
promoting the use of supplements other than
commercial infant foods like fresh milk,
wheat, rice, dal, vegetables etc.
The report emphasises that at best
commercial milk should be viewed as just one
of the several possible supplements to breast
milk in late infancy and any impression that
they are unique or essential should be
totally 'weaned away' from the minds of the
people.
23
Bihar
SR. BERNICE M.M.S.
Medicinal Plants in Common Use
Reproduced from a paper circulated by Bihar VHA
1.
COUGH SYRUP:
2.
Ingredients -
GARLIC (ALLIUM SATIVUM)
Chemicals: Have a broad spectrum of
anti-bacterial, anti-fungal,
Tamarind leaves
- 3 handfuls
Chopped ginger
- 3 tablespoons
Water
- 2 glasses
Sugar or Jaggery
- 1/2 glass
Lime juice
- to taste
anti-protozeal
Contains
sulfur,
oil, allicin.
Ingredients:
a)
Tamarind leaves - volatile
oil;
in
fruit and leaves - cit
ric, acetic, tartaric,
oxalic acids,
butyric
(refrigerant,
patient
perspires).
It
inhi
bits growth of two gram
positive organisms.
Dosage
Avoid use for children below 2
years
internal
use
of
garlic.
b)
For wounds, dog bites,
etc. - Apply fresh cru
shed garlic on wound
after cleaning well, and
bandage. Can mix with
(haldi) paste.
c)
For skin diseases - like Scabies, Ringworm
Boil one tablespoon of crushed garlic in
1/2 cup of coconut oil.
Apply to affected
parts twice daily after bath.
3.
24
- 1 to 2
tablespoon
every 4 to 6 hours daily.
4
Adults
- one tablespoon 4
times daily.
- Children - 1 to 2 teaspoon every 4
to 6 hours daily.
Adults
For cough, dysentry - make a garlic
syrup.
Dosage: Children - one
teaspoon
times daily.
- Volatile oil, anti
fungal
&
anti-bacte
rial .
Procedure - Boil the tamarind leaves and
the chopped ginger in 2 glasses of water until
the mixture is reduced to one glass. Strain
out the juice, then add the half glass of
sugar or jaggery, and boil again over slow
fire, until the mixture becomes syrup-like.
Remove from fire and cool.
Add the stained
lime juice.
Place in clean bottle and use.
Will remain at least for 2 weeks.
For
preservation - add 1/2 teaspoon of Sodium
Benzoate for every litre (8 cups) of syrup.
Use freshgarlic only.
Mix one glass of water with 4 table
spoons of sugar and boil.
Then add 3
pods of crushed garlic, and stir until
syrup is formed. Cool and use.
Chemicals found in -
Ginger
activity.
volatile
COLEUS AMBOINICUS LOUR
Chemicals - Volatile
oil,
HEALTH FOR THE MILLIONS
glucesides.
AUGUST 1984
a)
For cough. Gas pains - Wash
fresh
leaves and crush them to
get
the
juice.
Add
sugar or honey to taste.
Dosage: Children
- 1 teaspoon
times daily.
Adults
3
3
tablespoon
- 1
times OD.
If leaves are less, boil 5 leaves in 1
cup of water and take as above.
4.
b)
Headache - Crush few leaves and apply on
forehead.
c)
Insect bites and stings - Crush leaves
and apply to affected parts.
MINT NENTHA ARVENIS L. OPIZ) Podina
Chemicals
Chemicals:
a)
'
Volatile oil - mainly pulgenone, piperitone, limonane.
PAIN
WITH GAS
Make a decoction of leaves, using 1
tablespoon of leaves to one glass of
water and boil till it becomes 1/2
glass. Divide and give for -
Children - 1 teaspoon
b)
6.
BUTTONHOLE (EUPHORBIA HIRTA L.)
Chemicals : Contains different sterols,
glucosiaes, alkaloids.
a)
- 1 tablespoon
daily.
4 times daily
four
b)
Externally, the decoction is
for wounds as wash and for
diseases.
c)
Dried leaves can be burned and used as
inhalation for asthma or rolled into
cigarette and smoked.
Chemical act
ion - of plant is to dilate the
bronchioles and ease breathing.
used
skin
7. SENSITIVE PLANT (MIMOSA PUDICA)
Touch
me not
Chemicals - Saponin,
tannins,
resins,
alkaloids, glucosides: known
to
depress
the
Central
Nervous system.
Precaution - large doses could be poi
sonous and prolonged use
known to cause nausea.
times
a)
For ASTHMA, DYSENTRY, URINARY COMP
LAINS -
For ITCHING, INSECT BITES:-
Boil one whole plant (small) in 2
glasses of water till it becomes one
glass.
Take before sleeping.
Boil one handful of leaves in 3 glasses
of water.
Use this for skin wash
daily.
b)
c)
For ASTHMA, WHOOPING COUGH -
Boil 1 whole plant (15-30 gms.) or 10
flowers (violet) in 2 glasses of water,
until the water becomes tea like in
color.
Divide into 3 parts and take
orally 3 times daily.
For children
lessen the dosage.
Volatile oil - mainly palgenone, piperitone, limenane.
For COUGH, ABDOMINAL
PAIN:-
Adults
Boil 3 leaves in 3 cups of water for 25-30
mins.
Then devide 4 into equal parts and
take daily 4 times.
For children lessen
the dosage.
For SEDATION -
For PINWORM INFECTION:An enema using 7 tablespoons of crushed
fresh plant, boiled in 1 litre of water
for 5 mins, can be used.
Use one whole plant (small) and boil in
one glass of water till it becomes 1/2
glass. Drink before sleeping.
8. ALOE BARBADENIS (CACTUS-LIKE PLANT)
5.
BOAT LILY
For COUGH WITH BLOOD: BLOOD IN STOOLS -
HEALTH FOR THE MILLIONS
AUGUST 1984
Chemicals - various antharaquinone glycesides; slight traces of
volatile
oil,
alkaloids.
25
a)
calcium and chlorides.
For BURNS, BRUISES, LOCALIZED SWELL
ING, SKIN ULCERS -
Chemicals - Alkaloids, glycosides.
a)
Wash one leaf well, then split the leaf
and squeeze out the juice on affected
area.
b)
For Baldness and Falling hair - the
sap from the leaves is rubbed directly
on the scalp either after washing hair
or use as a shampoo.
9. COLEUS SCUTELLARIOIDES (I) - A
garden ornamental.
common
A decoction of leaves of whole plant
can be used; 9-15 gms fresh or 5-9 gms
dried material.
3-5 leaves in a cup x
3
2times daily
b)
Also has ANTI-DIABETIC & ANTI-CANCER
action.
12.PAPAYA
Chemicals - tannin, pectic substances,
phytesterial, calcium exalate, fats.
Chemicals - Enzyme papain with action
similar
to
Pepsin.
Has
glycosides, alkaloids, cal
cium exalate.
a)
a)
b)
HEADACHES,
BRUISES,
WOUNDS,
GAS
PAINS - poulties with leaves is used
over area.
b)
For COUGH, OTHER RESPIRATORY DISEASES,
TUBERCULOSIS, INDIGESTION, GAS PAIN -
c)
Dosage: For 12 years and above - use 2
* to 4 teaspoons of latex in one
cup of water.
Add sugar to
taste and drink early in the
morning on an empty stomach,
can repeat for 2 to 3 days.
HEADACHE, MUSCLE & JOINT PAINS Place thin slices of ginger in oil and
heat over fire.
After it becomes
warm, apply the oil to painful areas.
c)
NAUSEA, VOMITING,
GESTION -
For children - one to eleven years Decrease the quantity
SORETHROAT, INDI
A slice of fresh ginger can be chewed or
sucked.
d)
ROSEUS)
As ANTI-INFLAMMATORY Use fresh latex and apply direct on the
wound, skin ulcers, bed sores.
Strips
of green papaya can also be applied
instead of latex.
Precaution - not good for cases with
ulcer stomach.
11.PINK PERIWINKLE (GATHARWANTHUS
Cemetry flowers
AS DEWORMER (ROUND WORM / WHIP WORM)
Take white sap (latex) from unripe
papaya by piercing the fruit.
Boil 3 tablespoons of chopped ginger in
2 cups of water.
Drink the decoction
while little warm for 3 or 4 times
daily.
b)
For INDIGESTION Use 3 to 4 teaspoon of latex (white sap
from unripe fruit) dilute it in one cup
of water and drink, after adding sugar
to taste.
Chemicals - Volatile oil, tannin, fats,
iron,
peroxidase,
pectic,
substaneos.
a)
For CONSTIPATION -
Take ripe fruit and mild laxative or
eat 2-3 seeds of ripe papaya daily at
night till complaint is better - for
Adults.
For DESPEPSIA (Indigestion) - a de
coction of the plant taken orally.
10.GINGER (ZINGIBER OFFICINALE)
26
AS A MILD TRANQUILLIZER, DIURETIC,
HYPOTENSIVE -
e)
For SWELLING DUE TO INJURY OR FALL -
HEALTH FOR THE MILLIONS
AUGUST 1984
f)
Apply fresh papaya leaf on affected
areas and bandage it.
Change every 68 hours till swelling has
subsided.
c)
For FEVER, RHEUMATIC PAINS, PARALYSIS
- Boil leaves and branches in water.
Use it warm for both except in fever use
it when cool.
Latex from fruit peelings or crushed
fresh leaves - can be applied freckless
for skin problems.
d)
For FAINTING,
DIZZINESS
fresh leaves and smell.
e)
INSECT BITES,
RINGWORM, SKIN PROB
LEMS - Apply fresh juice from crushed
leaves to affected parts.
f)
AS INSECT REFELIANT - Burn
leaves and twigs at night.
Precaution: Latex papaya should not
be given to patients with
stomach ulcers.
I3.CHRYSANTHEMUM (Yellow flowers)
Chemicals - Volatile oil,
glycosides,
vit. A & Bl, lactones.
Found to have antibacte
rial & hypotensive pro
perties .
a)
For BRONCHITIS, WHOOPING COUGH, RHE
UMATISM, ARTHRITIS, SWELLINGS, BOILS,
ABCESSES, GAS PAINS -
b)
a)
.TULSI
(OCIMUM SANCTUM L.)
Chemicals - Tannin,
sulfur, fats, cal
cium exalate,
peroxidase,
formic acid, volatile oil,
alkaloids.
a)
For ABDOMINAL PAIN, COUGH,
BRONCHITIS, DIARRHEA -
b)
- Dried peel or rind of guava can be
powdered and diluted with water for
children - 1 teaspoon of powder in
1/2 cup of boiled water given 3 times
daily.
Add sugar & pinch of salt.
Root decoction
MALARIAL FEVER
HEALTH FOR THE MILLIONS
as - DIAPHORETIC in
AUGUST 1984
16.BALSAM INACEAE
Chemicals - Sulfar,
pectic substances,
phenolic compounds,
fixed
oil, peroxidase.
a)
For FUNGAL SKIN DISEASES, RINGWORM,
ECZEMA - Use fresh flowers or tender,
small leaves.
Pound well and apply on
affected areas once or twice daily.
b)
For PAINFUL MENSTRUATION (DYSMENORR
HEA) - Boil 5 leaves in 1 cup of water
and drink.
c)
For DIFFICULT LABOR - Pound 10 seeds and
boil in 1 cup of water.
Drink the
decoction.
d)
For BOILS LUMBAGO,
SNAKE & INSECT
BITES - Crush fresh flowers or tender
leaves and apply over area.
It has a
mucilagenous & cooling affect.
CATARRH,
Make a decoction with one handful of
leaves and twings in 2 glasses of
water. Boil until one glass.
Divide
into 4 parts and taxe daily.
INDIGESTION, DIARRHEA -
- Boil 3 medium size
leaves (fresh
or dried) in one glass of water add
pinch of salt and 1 teaspoon of
sugar.
Drink
after
each
loose
stool.
For HYPERTENSION -
Check blood pressure and discontinue
accordingly.
dried
Chemicals - Tannin & astringent, pectin,
sapenin, glucosides, volatile oil, anti
bacterial properties.
leaves in 1 cup of
Use 2 flowers in a cup of water and make
a tea infusion.
Divide into 3 equal
parts and drink daily.
Crush
15.GUAVA (PSIDIUM GUAVAJA L.)
Use 20 leaves in one glass of water and
boil for 15 mins.
Add sugar and drink the
tea every 6 hours (Adults)
For children - use 10
water (above 6 years)
-
27
17.JASMINE (JASMINUM SAMBAC)
a)
For REDNESS OF EYES., SORE EYES Place 3-4 flowers in 1/2 glass of
boiling water.
Let it cool till water
becomes light yellowish.
Strain out
the petals and use as eye wash 3 to 4
times daily.
b)
AS LACTIFUGE
(TO STOP MILK SECRET
IONS) - Crush leaves and flowers and
apply to breasts of the mother and
bandage.
c)
FEVERY,
COUGH, STOMACH-ACHE, HEART
BURN DUE TO ULCER - Prepare a decoction
with 8 to 12 flowers (fresh or dried) in
one glass of water.
Divide into parts
and drink 3 times daily.
d)
SKIN ULCERS, WOUNDS, SPRAINS - Apply
crushed leaves or flowers or roots on
affected parts and bandage.
Chemicals - Tannin, glucosides, calcium
exalate, silicon & fats in
flowers,
iron in stem &
roots.
ContainsD. Linaloal
& Benzyl acetate & mericyl
alcohol.
alate, peroxidese, pectic,
substances, alkaloids, styp
tic for wounds.
a)
For ANEMIC PATIENTS, NURSING MOTHERS Leaves and flowers are used as dietary
supplements.
They are good sources of
iron, calcium,
b)
For SORES & SKIN ULCERS - Wash fresh
leaves and stems or bark and crush the
juice out and apply on affected parts.
c)
For PAINFUL AREAS IN RHEUMATISM Roast the seeds of the fruit, powder,
then mix with oil and warm over fire and
apply the mixture on areas.
d)
For GLANDULAR SWELLING - Leaves are
applied as poultice
e)
For HICCOUGHS, ASTHMA, GOUT, LUMBAGO,
RHEUMATISM, enlarged SPLEEN & LIVER Root of tree is made into decoction and
give 2-3 times daily to drink.
f)
Root if chewed and applied to snake
bite area will prevent poison from
spreading.
20.TURMERIC (CURCUMA LONGA) HALDI
18.TAMARINDUS INDICA (TAMARIND)
Chemicals:
Chemicals: Tannin,
pectin,
potasium
bitartrate, citric, acetic,
butyrine, tartaric & exalic
acids.
a)
a)
For CHEST AND ABDOMINAL PAIN, IRRE
GULAR MENSTRUATION - Use dried pieces 6
- 9 small slices, pound and make a
decoctionin 2 glasses of water.
Boil
till it becomes one glass. Divide
into 3 dose and take daily.
b)
For WOUNDS AND SWELLINGS - Pound a
piece and apply on affected area
without rubbing it.
c)
For SPRAINS AND BRUISES - Make
paste and apply on area.
d)
For LIVER AILMENTS AND DISEASE OF
BILLIARY DUCTS - The yellow dye may
stimulate bile contraction of the gall
blader.to increase bile production.
For FEVER & DEARRHEA - Squeeze out
the pulp from ripe fruit and mix with
water.
This juice is given to drink.
Add sugar to taste.
Adults - 1 tablespoon of juice 1 cup of
water 3-4 times daily.
b)
c)
For WOUNDS,
SORES,
BOILS - Make a
decoction of the leaves, fruits and
bark and use for washing the affected
parts.
For COUGH as expectorant - leaves
and stem are useful for making cough
sytup.
19.DRUMSTICK (MORINGA OLEIFERA)
Chemicals:
28
Rubrifacient, mild antisep
tic, carminative.
a
21.GARDENIA JAMINOIDES BLLIS (BUTTER CUP)
Chemicals: Crocetin,
crocin-,
and B-Sitosterol
mannitel
Tannin, sulfar, calcium ex
HEALTH FOR THE MILLIONS
AUGUST 1984
juice from leave in a teaspoon
coconut milk as purgative.
The fruit is the main medicinal part,
appears from September to November.
Its
none leaves and stem can be used.
a) AS ANTI-INFLAMMATORY, ANTI-HEMORRAGE
ANTI-PHRETIC (FLU), JAUNDICE, ANTI
FUNGAL, AND ANTI-BACTERIAL action -
of
d)
For SCABIES - Leaves can be warmed in
coconut oil and applied to areas.
e)
For HEMORRHOIDS - Powdered root,
fruit or seeds, mixed with oil and
applied externally - has an astringent
effect.
Boil one handful of leaves, stem and
one fruit (if any) in 2 glasses of water
till it becomes one glass.
24.(KALANCHOE PINNATA)
- Devide into 3 parts
take 3 times daily.
Adults
Children
Chemicals : Tannin, sulfur, calcium ex
alate, formic acid, peroxiase.
- Decrease the dosage.
Precution - Not good
cases
(CUCURBITA
a) EXTERNAL USE FOR
WOUNDS,
BOILS,
SPRAINS, BURNS, ECXEMA & OTHER SKIN
INFECTIONS - Make a poultice of fresh
leaves and apply.
Amino acid, cucurbitin found
to have anthelminitic acti
vity .
b) DIFFICULTY IN PASSING URINE - Powdered
leaves with small amount of salt is
applied to lower part of abdomen
externally.
22.SQUASH OR YELLOW
MAXIMA DUCH)
Chemicals:
and
for
PUMPKIN
Diabetic
a) For TAPEWORMS specifically - Use 15 to
25 tablespoon (60-100 gms) of fresh
seeds after removing the seed coat.
Crush the seeds and mix with sugar
water or milk. Give on an empty
stomach followed by a purgative after 1
or 2 hours.
For children - Decrease the dosage.
23.BITTER GOURD (MOMORDICA CHARANT1AL)
Chemicals:
Leaves are
antibacterial
(gram positive),
alkaloid
principle, glycasides, cal
cium exalate in leaves &
stem.
Fruit
and
leaves
sources of vit. C; leaves
also contain iron, folic acid
& calcium.
c)
For HEADACHE, FEVER - Apply crushed
leaves on forehead and other parts of
body for fever.
(LEUCAENA
25.
LEUCOCEIHALA)
a) Seeds as Anthelminatic (ROUNDWORMS) for Adults use 20-40 seeds, powereed
and mixed with water 1 cup and sugar to
taste.
Take early in the morning on an
empty stomach.
Children
- decrease the dosage.
Precaution - Avoid over dose,
may
cause diarrhea, falling
of hair.
26.FRANGIPANI )PLUMIERA ACCUMINATA)
Chemicals: Alkaloids, saponins
a) For COUGH, DIARRHEA, DIABETES - extract
of fresh leaves taken 3 times daily.
Adults
- 1 tablespoon x 3 times.
b)
For COLITIS AND BACILLARY DYSENTRY
CHRONIC ULCERS OF STOMACH - Juice from
leaves or small green fruit to be
given.
c)
As
PARASITICIDE
HEALTH FOR THE MILLIONS
-
1
teaspoon
AUGUST 1984
a) SCABIES - One cup of chopped bark is
boiled in one cup of coconut oil and is
applied on affected areas.
b) For ARTHRITIS, RHEUMATISM, ITCHING Mix latex (white sap) and warm in
coconut
oil
and
apply
in areas
affected.
of
29
For ASTHMA - Dried
cigarettes.
c)
leaves
black pepper.
are used is
4.
Precaution -
Do not use
latex on open
wounds or lesions.
Externally for Rheumatism’
pains and sprains.
muscle
Roots crushed in oil can be applied.
(IXORA
27.
COCCINEA)
29.LIQUERICE (JASTIMADH)
Chemicals : Saponin,
tannin,
glucosi
des, Calcium oxalate, sul
fur, peroxidase.
a) DIARRHEA, BRONCHITIS, NAUSEA, HICCO
UGHS, LOSS OF APPETITE, IRREGULAR
MENSTRUATION,
AMENORRHEA,
COUGH Decoction of roots 3 gms. or fresh
flowers 3 gms. and take in divided
doses daily in 1 glass.
b) SORES AND ULCERS - Decoction of leaves
for washing areas.
Purpose:
1.
For vitality, blood purifier, urinary
disorders, gastric ulcers.
2.
Cyronic fever
infections.
3.
Mild purgative, jaundice, skin dis
orders .
CENTELLA
30.
ASTATICA
c)
SPRAINS, ECZEMA,
FURNUCLES - Pound
fresh stem and leaves and apply as
pultice.
Chemicals : Pectin sugers colatile oil,
Vit. B. Calcium Phasforus,
iron and other minerals,
tannins, glycosides.
d)
HYPERTENSION - Flower
used.
Purpose:
decoction
is
1.
Chemicals : Voltile oil - citral and
methyl haptenone terpenes
and dipentene oil-has insectisteicdial properites.
For upper respiratory tract infec
tion diuretic, boil 20-60 grams fresh
plant in 2 glasses of waterand drink 23 times daily.
2.
For external use, use crushed plant
and apply for skin ulcer exzema
brusies.
Uses - Carminative, pain reliever, dia
phoretic .
3.
It is used as a tonic for diarrhea
dysentry.
For dysentry fever and as
anti inflammation.
28.LEMON GRASS (ANDROPOGOD CITRATUS)
Preparation -
1.
31.ANDROGRAPHIS PANICULATA (Chinese
flower)
Fever, cold
Whole
used
plants
leaves
roots
2.
Chemicals:
For Stomach ailments -
Above decoctions mixed with ginger and
used.
3.
For Dysmanorrhea
Above
decoction
is
white
can be
Make decoction using one plant in 2
glasses of water boil for 5-10
minutes. Divided into equal parts and
drink 3-4 times daily.
30
and cough, bronchial
used mixed with
Glycosides and
properties.
antibiotic
Purpose:
For different inflammatory and digestive
system - Form for colds, cough, bronchitis
pneumonitis, dysentry - Boil 3-9 gms. of
dried or fresh plant in one glass of water
and drink 3 times.
Prepared by: Sr. Bernice, SCMM
Maner health Centre
KURJI HOLY FAMILY
HOSPITAL
PATNA
Credit: Bihar Voluntary Health Association.
HEALTH FOR THE MILLIONS
AUGUST 1984
News
Indore-Jamkhed Workshops
evaluation conducted at the end of the first
session.
Two teaching methodologies workshops were
held in Indore and Jamkhed (Maharashtra) to
give Nurse Tutors and Public Health Nurses
particularly those teaching in Female Health
Worker/ANM Schools an opportunity for
Several interesting methodologies were used
to make TA concepts more relevant to nursing
and community health needs.
Dramas, a mini
workshop on preparation of study guides,
animated discussion of group reports on the
dynamics of group functioning, etc were the
mainstay of the workshop at Indore.
a)
reorientation
and
learning
of
new
teaching methods appropriate and relevant to
the needs of Health personnel working in
communities and giving Primary Health Care.
b)
experience in preparing and trying out
participative teaching - learning experience
which they could use in their own schools.
The Voluntary Health Association of India,
Mid India Board of Examiners of Nurses of the
CMAI and the comprehensive Rural Health
Project of Jamkhed collaborated in organi
zing the programme and facilities.
The workshop was divided
sections, as follows -
into
two
major
At Indore, MP
(June 2-9)
Teaching
Psychology to Health Workers including
Transactional
Analysis,
stressing
interpersonal relations in nursing
Planning practical experience in psycho
logy and nursing.
At Jamkhed (Maharashtra) June 11-16 on
appropriate learning experiences in commu
nity health related subjects.
There were 30 participants representing the
state governments and voluntary institutions
from Andhra Pradesh, Assam, West Bengal,
Bihar, Rajasthan, Himachal Pradesh, Haryana,
Uttar Pradesh, Madhya Pradesh, Maharashtra,
Gujarat, Tamil Nadu, Delhi and a nurse
student from Nepal.
At the initial programme in Indore a session
was devoted to drawing up participants
expectations
and
objectives
for
the
workshop.
The learning and
expressed as most
health for the millions
insights gained were
satisfactory from the
AUGUST 1984
Fourteen participants travelled by the night
bus from Indore to participate in the next
session at Jamkhed from June 11 to 16.
The learning experiences at Jamkhed were
unique in so far as the content of the
workshop was equally balanced with theore
tical study applied to field study. Three
villages were visited.
Exercises on communication and creating
attitudes, new ideas in teaching -- adapting
games, drills in using a new book, use of case
studies, task analysis assignments, prepara
tion of a study guide on sociology, self study
in use of "Teaching for Better Learning" by
Abbot were used.
In the evaluation following the Jamkhed
workshop, participants respnded favourably
to the degree of skill they gained in
identifying special needs, learning about
methods
and
techniques
of
follow-up,
application of psychology in evaluation (of
self, of others and teaching programmes);
"Team work and cooperation" were understood
in a new dimension by a week's stay in the
Comprehensive
Rural
Health
Project
at
Jamkhed where one gained new insights every
day in regard to cooperation in members of a
health team and representatives of organiza
tions .
The observation visits to villages gave
learnings about application of psychology
and sociology in teaching students.
These two workshops gave all the participants
a visible inpetus to beome self-confident and
self-reliant.
It
also added
to
their
understanding of the complimentary roles of
health personnel involved in primary health
care.
31
REPORT
Twenty participants from health programmes
and schools attended a week long school
health workshop in Patna organised by the
Bihar Voluntary Health Association.
Dr Mira Shiva and Augustine Veliath from VHAI
served as resource persons. Among the guest
speakers were Ms Anita Paul IAS, Director,
Bihar Rural Women and Children Development
Programme and Dr Subhash Chandra, UNICEF
representative.
On the concluding day participants made group
presentat ions.
Sr Jacinta from Ranchi won the prize for the
‘best session with maximum involvement of
group’ and Ms Indumati Devi from Manor for the
best eduction session and Ms U Jojo from
Patna, best acting.
"AINA Newsletter will be of interest to
anyone who is performing anesthesia duties,
working in intensive care units, or who is an
Administrator who would like to upgrade his
knowledge in anesthesia.
It is suggested
that anyone who would like to take the Nurse
Anesthesia Course would be interested to read
the newsletters for sometime to obtain
information about anesthesia studies, duties
and challenges. Continuing education and
self studies are also a goal of the
newsletter.
AINA Newsletter is issued bi-monthly for
subscription contribution of Rs. 6.00 per
year. Kindly send by Money Order give
complete address including Pin Code No. to:
Mary K. McNabb, BA CRNA
Editor, AINA Newsletter
Bethesda Hospital
Ambur P.O.
North Arcot Dt.
Tamilnadu 635 802."
VHAI Nurse Anesthesia Workshop held at Bethesda Hospital
15th to 25th June
front row L to R : Sr. Abbie George, Sr. Servia, M. Me Rabb, Sr. Celine, Sr. Lillian
back row L to R : Sr. Posenthy, Sr. Lucicanma, Sr. Lucy Matthew, Sr. Alex, Sr. Brigit,
Sr. Karuna, Sr. Raephael
HEALTH FOR THE MILLIONS
AUGUST 1984
RAKKU’S STORY
HEALTH CARE
IN INDIA
STRUCTURES OF ILL-HEALTH
AND THE SOURCE OF CHANGE
§eorye ^osepfi
esrocfiers
SHEILA ZURBRIGG
3\Lariamma
The Historical Background
^Kafatfiil
9
The Traditional Systems, The British Period, The Post
Independence Model, The Search for Alternatives
Health For All
31
Origins of the Idea, The Indian Study Group, The National
Health Policy
The Present Situation
46
Achievements, Failures and Limitations, Mortality Rates,
Disease Patterns, Conditions of Children & Women, Family
Planning, Nutrition & Development, Inadequate & Inequi
table Services
Towards a Proper Analysis
64
What Went Wrong?, Why These Failures?, Health and
Society, Health & Vested Interests, Conclusion
Emerging Trends and Meaningful Experiences
82
Developed Capitalist Countries, Socialist Countries, Serving
the People, Prevention First, Traditional & Western Medi
cine, Community Health Workers, Mass Mobilization &
Organization, Health & Revolution, Conclusion, The State
of Kerala
Possibilities of Relevant Action
105
Community Health Care, Potential and Limitation, Basic
Characteristics, Conscientization, Political Action & Health,
This study takes ill-health out of the medical realm into the arena of
poverty and powerlessness. It analyses that poverty within a social and
political context, not as an immutable or inevitable situation but rather
as the result of specific and historical forces in process in the country. It
argues that the existing socio-economic order which perpetuates
underdevelopment, contains within it an inherent ill-health “logic” as
well. Such a perspective demands a re-assessment of the relevance of
current “primary health care” activities in the country.
The purpose of the book is to shift the attention and efforts of health
workers to the poverty — dependency — ill-health dynamic, and to
suggest how issues of ill-health can be used to strengthen the broader
struggle by the labouring poor for health and social justice.
Available from:
Available from:
Voluntary Health Association
C-14, Community Centre
S. D. A. New Delhi-110016
This book turns the usual approach to health analysis on its head. It
begins by looking at continuing ill-health in India through the life of a
labouring village woman, exploring the forces which keep her from
adequately feeding and caring for her children and herself. It probes
the source of ill-health, not by focusing on missing nutrients, drugs or
skills, but by looking at the way disease and malnutrition are
distributed in society — an approach which necessarily sheds light on
the distribution of food and all resources, and thus also, the
distribution of power. Inequalities within the existing health care
system thus become a window on the structures and forces operating
throughout society.
Pages
Price
143
Rs 4
Voluntary Health Association
of India
C-14, Coraisiualiy Centre
S. D. A. New Delhi-110016
Pages
Price
234
Rs 10
JUST RELEASED
HEALTH ACTION SERIES—DIARRHOEA
A TASTE OF TEARS
1 glass
Compiled by:
(200 c.c.)
water
DR MIRA SHIVA M.D.
ASPI B. MISTRY
Pages 118
Contents
Introduction-A Solution in the Hands of the People
1 pinch
(three fingers)
salt
The Magnitude of the Tragedy
What is Diarrhoea?
The Treatment of Diarrhoea
The Dangers of Anti-Diarrhoeals
Diarrhoea and Malnutrition
Traditional Home Remedies
Programmes in Diarrhoeal Disease Control
Controversies in ORT
Summary of Proceedings —ICORT
VHAI's Role in Diarrhoea Care
Book Review
Diarrhoea and Malnutrition: Interactions, Mechanisms and
Interventions
Further Reading
Appendices
For
copies
write
to
1 Scoop
(fourfingers)
sugar
Voluntary Health Association of India
C-14,
FOR PRIVATE CIRCULATION ONLY
Community
Centre
S. D. A.
New Delhi-110016
Rs. 6
MDUKOQGM®
Vol. X
No. 5-6
A Bimonthly of the Voluntary Health Association of India
OCT-DEC 1984
Editorial
Disputes Free Zones
HEALTH FOR THE MILLIONS
No. 5-6
Vol. X
Oct.-Dec.1984
Voluntary organizations have to recognize
the fact that the majority of workers even in
our charitable hospitals, primarily work for
wages. What the law provides for should be
the minimum we give to our staff. We need not
wait for the law to force us to do our duty.
In this issue
Is the Hospitals Bill a solu
tion
Labour Laws and Voluntary
care Institution
1
Health
3
The Controversial Bill
17
For Your Eyes
18
o
Travellers Notes
News
-
Opportunities
Charity
begins
at
home
and
in
our
institutions. We cannot run a charitable
institution and be unfair to our employees.
Ignorance is not always bliss and certainly
not when it comes to matters pertaining to
law. Hence
this
detailed
attempt
at
understanding "The Hospitals and other
Institutions (Settlement of Disputes) Bill,
1982." The labour laws like all other laws
in a welfare state are intended to provide
relief and protection to the working class.
19
,
20
22
This issue of HFM was put together by
Augustine Veliath (Editor) Aspi B.Mistry
Padam Khanna and cover and illustration.
*
are by Ms. Usha Devrajan.
Owned and published by the Voluntary
Health Association of India, C-14,
Community Centre, Safdarjung Development
Area, New * Delhi-110016, and printed at
J.K. Offset Printers, Jama Masjid,
New Delhi.
However, there are certain points in the
bill, discussed in this issue that will
multiply dispute rather than reduce strife
and conflict. These have been pointed both
by experts like E.H.McGrath and by the
Commission for Justice and Development of the
Catholic
Bishops
Conference of
India.
Catholics, it may be noted, run over 1500
hospitals and dispensaries. These have been
reproduced in this issue that a wider debate
on some of these controversial aspects could
take place.
Managements
have
always
been
powerful
Labour unions are increasingly becoming
powerful. But the worst sufferer in case of
an "industrial" dispute in a hospital, is the
patient. He or she has no lobby, is not
organized. A labour dispute in a hospital
can inconvenience and kill patients - hence
the need to keep all our institutions dispute
free.
WE REQUEST OUR READERS TO RENEW THEIR
SUBSCRIPTION FOR HEALTH FOR THE MILLIONS
WHICH IS DUE NOW.
Fr. E.H. McGrath
Adapted by Darieena David
Is The Hospitals Bill A Solution
Adapted by Ms Darleena David from an,article
by Fr.E.H.McGrath in the Ecconomic Times.
The reasons stated for the introduction of
this bill seem humane and considerate to
hospitals and other similar institu- tions
which must maintain an atomosphere that
’eschews strife and conflicts' and at the
same time protect the workmen in such
institutions by establishing a machinery for.
the resolution of their disputes. In the!
article the author has taken the position
that the weaknesses of the bill far outweigh
glimpses of positive labour relation philo
sophy.
Though highly commendable this bill
rather than reduce strife and conflict will
dramatically multiply dispute and the
machinery proposed by the bill to protect the
dignity and rights of the workmen is inappr
opriate and dysfunctional.
contains
The
bill
provisions:
five
majorc
1.
Provision
unions;
2.
Provision for setting up a grievance
settlement committee;
3.
Provision
council;
4.
Provision for arbitration of griev
ances as well as demands; and
5.
As a counter balance to 4, the pro
hibition of strike (go slow, work to
rule, gherao) and lock-outs.
for
the
recognition
of
beneficial to the workers c) has not less
than 60 percent of the workmen as members; and
d) where the office bearers are workmen
employed in the 'establishment' on similar
establishment,
such
a
union must
be
recognised.
Where more than one trade union exists
recognition must be given to the union which
represents the larger number of workmen.
The disturbing elements are
as
a)
inclusion
bearers
b)
lack of decisivenes on the manner of
ascertaining membership.
of
outsiders
office
The
step
toward
settling
the
union
recognition problem however outside this
positive element there is little else in the
bill that will contribute towards sound
labour-management relations. The bill will
Dramatically increase conflicts
for
a
consultative
The Bill provides that where a union is:
a) registered; b) has as one of its
objectives the carrying on of activities
HEALTH FOR THE MILLIONS
OCT-DEC 1984
and disputes within the organisation
Two institutions provided by the Bill, the
grievance settlement committee and the
consultative committee comprise of equal
members of management and workmen/union
representatives, so there is likely to be
arbitration almost inevitably in the case
of individual disputes (Grievance Settlement
Committee' .
In case of industrial dispute,
(Wage, Leave etc.) the consultative council
may refer the dispute to an arbitrator agreed
upon by both the parties or where there is
failure to agree on such an arbitrator, to a
board of arbitrators, consisting of an
independent person and two other members, one
representing
the
employer,
the
other
1
representing the workmen in such establish-ments.
a)
The lack of conciliatory process will
create a bit.ter win or lose situation.
b) Given the equal membership stiputation for
the committees, there can only be block
and constituency, voting in emctionaly
coloured issues such as terminations and
conditions of employment, leading to
constant litigation and waste of time.
The decision making process will pass to a
third party (the arbitrator or board of
arbitrators) that has little responsibility
for
the
present
and
future
of
the
institution.
Cripple the efficient working
of the organisation by undermining
authority of the chief executive
the
The grievance settlement committee as
well as the consultative council place the
chief executive in a position of inferiority.
Note the provision, (Section 12.. 2)., "The
grievance settlement committee shall after
giving such workman and his employer a
reasonable opportunity of being heard and
after making such an enquiry as it deems fit,
pass such order in respect of such individual
dispute as it deems to be just and appropriate
and such order shall, subject to other
provisions of this section, be final".
What results will be the anomaly ot an
employer being given a hearing by a body
established, by himself and .the erosion of
authority and discipline in such a situation.
Shift from the path of negotiations
to interference and control by opting for
arbitration over collective bargaining.
Third party intervention has increasingly
shown its inadequacy and counterproductive
ness over the last 30 years. Mutual
negotiation, which although never supported
by legislation, has proved to be the only
method which has shown any success.
Prove ineffective and dysfunctional
labour management relations.c Ordinarily,
employees neither want strikes nor can they
afford them, nor can the management in
hospitals and similar institutions. Strikers
do indicate disagreement but often they, clear
the air.
Escalate costs arbitration
unequally distributed between management and
labour.
The costs include the cost of arbitration
proper,
travelling
and
compensatory
allowances, cost of time off involved will be
considerable. Where arbitration has been
resorted to, management has been asked to
bear the lion's share.
(In one state, the
provision is that ninety percent of the costs
to be borne by the management and ten percent
by labour) . Only where costs are equally
shared imaginary, and groundless grievances
filtered out. As it stands, almost every
grievance and demand will go into the
machinery.
VHAI
NEEDS AN
EXECUTIVE
DIRECTOR
The main goals of the Association
are community health for the lowest eco
nomic levels of society, with emphasis
on health education, promotion and main
tenance of health.
Application or information helpful
toward finding a suitable person, will be
appreciated.
There is a staff of thirty
people plus related State level associa
tions.
Write to
The Executive Director
Voluntary Health Association of India
C-14, Community Centre,SDA
New Delhi-110016.
By prohibiting stikes the Bill removes the
most potent guarantee of reasonableness in
2
HEALTH FOR THE MILLIONS
OCT-DEC 1984
Ravi Srinivasan
Labour Laws and Voluntary
Health Care Institution
Labour laws is
the entire body of law that deal with the
employer-employee relationship. It covers
both legislation enacted specially for the
purpose of governing and protecting the
fundamental and legal rights of the employer
and employee, as well as the various
judgements and rulings of the different
courts on these issues, or what is known as
case law.
These laws empower the government to
regulate the employer-employee relation
ship, keeping in mind the welfare of society
as a whole.
In the context of voluntary health care
institutions, the employer is the Registered
Society or Trust, its governing board, or the
administrator, who is entrusted with the
responsibility of running the institution.
The individuals working in the institution
are the employees.
Labour laws governing different aspects
of employer and employee relations have
existed in our country for a long time. In
fact one of the earliest legislations was the
Trade Disputes Act which was enacted in
The judgement of the supreme court
and the applicability of labour laws to
hospitals, has to be seen in the following
background. India is a welfare stat£, where
the dominant role of legislation .is to
provide welfare and relief to the weaker
sections of society. The labour laws too are
intended to provide relief and protection to
the working classes and employed citizens,
who form the majority of the population. Yet
this majority is seen to be in a weaker
position when compared with the management or
the owners of organisation and industry.
To
determine
whether
a
charitable
institution is an industry or note, first one
has to analyse the elements of the charitable
economic enterprise, established and main
tained
for
satisfying
human
wants.
According to the Supreme Court judgement,
charitable institutions fall into three
categories:
a)
those that yield profit, but the profits
are siphoned off for an altruistic purpose.
1929.
These labour laws were enacted mainly for
the industries. Till the recent past very
few of them affected the voluntary health
care institutions.
Labour laws have acquired particular
importance for health care institutions,
after the judgement delivered by Justice
Krishna Iyer, in the case of the BANGALORE
WATER SUPPLY AND SEWAGE BOARD VS A.RAJAPPA,
(reported in A.I.R. 1978, S.C.R.548 - 1978
LAB-I. C. 467. ) With this judgement, hospitals
Mr. Ravi Srinivasan is currently Manager, Man
Power Development Punjab Agro Industries
Corporation Ltd. Chandigarh.
HEALTH FOR THE MILLIONS
were brought within the definition of
"Industry". This means that most of the
labour laws applicable to industries will now
hold true for health care institutions, even
those run by charitable organisations.
OCT-DEC 1984
b)
those that make no profit but hire the
.services of employees as in any other
business, but the goods and services that are
the output, are made available to, at low or
no cost to the indigent poor.
c) those that are oriented on an humane
mission fulfilled by men who work, not
because they are paid wages, but because they
share a passion for the cause and derive job
satisfaction.
According to the supreme court judgement in
B.W.S. & S.B. Vs A Rajappa in 1978, the first
two are industries, but not the third, on the
assumption that both of them involve the
3
.cooperation of employer and workmen and there
is a distinct economic relation between them,
which is included in the definition of
industry: as. defined- in the I.D. Act, 1947.
Thus>, ras per the judgement, charitable
organisation rendering health care services
will be covered by the (I.D.Act) definition
of industry;
The main criterion
is the employer-employee relationship.
It
has also to be kept in mind that labour laws
were primarily framed to safeguard the
interests of the employee and to regulate the
employer-employee
relationship. Thus,
irrespective of whether the profit is used
for altrustic purposes or whether the output
is supplied at lower cost to the needy, these
institutions employ individuals for wages.
The employees are not concerned with the
destination of profit or pricing of services.
They work and receive wages and are normally
treated like any other workers in any other
industry.
The application of income for philan
thropic purpose instead of filling"private
coffers", makes no difference to the employee
or the nature of activities, hence, the first
two categories of charitable institutions
are industries.
In the words of Justice Iyer :
"They (employees in charitable institutions)
contribute labour in exchange of wages. For
them . the charitable minded employer is
exactly like the commercial minded employer.
Both exact hard work, both pay similar
*
wages
: both treat them as human machine cogs
and nothing more. The material difference
between the commercial and the compassionate
employers is not with reference to the
workmen but with the reference to recepient
of goods and services. Charity operates not
vis-a-vis the workmen in which case they will
be paying liberal wages and generous extras
with no prospect of strike". From the point
of view of workmen there is no charity. Thus,
these institutions can be legitimately and
legally described as industry.
The only exemption will be an institution.
*Most of the time, employees in the voluntary
sector receive less wages than their
counterparts >in industrial establishments.
4
founded on charitable purpose, where there is
no economic relation between the head (who is
the employer) and others who "emotively flock
to render services", as described under the
chird category. To determine ' whether a
charitable institution is an industry or not,
one should see the predominant character of
the institution and the nature of the
employer-employee relationship.
Very few wage-earners in a charitable
institution will not make the institution an
industry. Similarly, a minority of nonwage
earning workmen will not mean that the
institution is not an industry.
For instance, consider a charitable hospital
run by religious sisters, where the total
number of workmen is 100 and out pf that 60 are
wage-earners and 40 are religious sisters,
not
working
for
wages. Still
the
institution will come under the definition of
industry because the majority workmen have an
economic relationship with the employer.
The most obvious implication will be that
the government labour office (conciliation
officer) gets the jurisdiction to intervene
in any dispute between the management and
workmen.
The workmen, can invoke
the government machinery to intervene in
their dispute with the employer/management.
Even before this judgement, the workmen
were free to form trade unions (under the
T.U.Act 1926) to agitate collectively for
redressal of their grievances, but the
Government
machineries
for
industrial
relations, eg. labour officer, conciliation
officer, labour court and so on were not
available to them. They could only go to
civil court and the civil court had no power
to order the reinstatement of a terminated
employee.
At the same time, it was realised that, in
their basic or true sense voluntary hospitals
are neither industry nor belong to the world
of trade or commerce. These are noble
institutions, established on the basic
principles of compassion and philanthropy.
There is no element of profit either in the
intent or purport behind their establishment. These institutions are to take care of
sick people, through provision of medical
care, treatment and attendance.
HEALTH FOR THE MILLIONS OCT-DEC
1984
In view of the above, the Ministry of
Labour proposed a bill in 1978. This bill
was called "The Hospitals and Educational
Institutions
(conditions of service of
employees and settlement of employment
dispute), Bill 1978". The main objective of
this bills was "to consolidate and amend the
law relating to the conditions of service of
employees
employed
in
hospitals
and
educational institution with a view to
securing the welfare of such employees, and
for the investigation and settlement of
disputes
between
employees
and
their
employer,
and
for
matters
connected
therewith or incidental there
into’’.*
However this ” bill was not passed by
parliament.
Again in May 1982, the Central Government
proposed two bills in parliament. If these
bills are passed by parliament, then, the
judgement of the Supreme Court in 1978, will
become past history.
The first bill entitled "Industrial
Dispute (Amendment) Bill 1982," sought to
exclude
hospitals
and
certain
other
institutions
from
the
definition
of
industry. The reason being the realisation
that hospitals have special and distinct
characteristics of their own and therefore,
an atomosphere must be maintained in such
institutions that eschews strifes and
conflicts.
The second bill was entitled, "the
hospitals and other institutions (settlement
of disputes) Bill 1982." The purpose of this
was to frame laws to protect the interests of
the workmen and to create a machinery for the
resolution of individual and collective
industrial disputes.
The "Industrial Dispute (Amendment) Bill,
1982" was passed in May 1983, by parliament
and has also received the President' s assent.
It was also published in "The Gazette". But,
it has not come into force since it is
stipulated in the amendment that NOTIFICA
TION CONCERNING DATE OF ENFORCEMENT WOULD BE
ISSUED LATER.
To date the government has not specified the
date of enforcement of this Act. But, the
"The Hospitals and other institutions
(settlement of disputes). Bill '82 is still
pending in parliament (as on 29/5/1984).
♦Preamble of the Bill.
HEALTH FOR .THE MILLIONS
OCT-DEC 1984
However, keeping in mind the eventuality
of this bill being passed and becoming an Act,
one has to be aware of the possible
consequences and implications for voluntary
health care- institutions.
THE HOSPITALS AND OTHER INSTITUTIONS
(Settlement of disputes)Bill, 1982.
Q.
1 Why was this Bill framed ?
In May, 1983, the parliament passed the
Industrial Disputes (Amendment) Act 1982.
Through this bill hospitals, among certain
other institutions, were excluded from the
definition of industry, as in the Industial
Dispute Act, 1947. Simultaneously a need
for legislation to safeguard the interests of
employees and workmen in hospitals was felt.
To fulfil this need, the "Hospital and Other
Institutions (settlement of disputes), Bill
1982" was framed and presented to the
parliament.
Q. 2 What is the purpose of this Bill ?
This bill seeks to provide for the
investigation and settlement of disputes
between workmen employed in hospitals and
certain . other
institutions
and
their
employers, and for any other related matters.
The major purpose of this bill is to fill
the vacuum created by the enactment of I.D.
(Amendment) Act, 1982. It was duly recognised
that workmen employed in hospitals, be it
voluntary or commercial, need protection and
there is need for government machinery for
resolution of individual and collective
disputes in a hospital.
Q. 3 What is a dispute ?
The dictionary meaning of dispute, is to
debate, discuss, oppose, contest and so on.
in this bill 'dispute ' has been broadly taken
as 'difference'. Two types of disputes are
mentioned, they are:
i) Individual dispute: Any dispute or
difference between andy workman and his
employer in respect of
a) Termination of employment of any
workman, whether by way of discharge,
dismissal or retrenchment or otherwise.
b) Suspension of a workman
c) Money due from the employer to
workman, or the amount at which a benefit,
which is capable of being computed in terms of
money, is to be computed.
d) Any matter not referred to in the
above three or in the industrial dispute,
relating to the terms of employment or the
conditions of labour of any workman.
ii) Industrial dispute means any dispute or
difference between any workman and his
employer in respect of:
According to
All remuneration capable of being express- ed
in terms of money, which would, if the terms
of employment, expressed or implied were
fulfilled, be payable to a workman in respect
of his employment or of work done in such
employment- and includes:
i)
Such allowances (including dearness
allowance) as the workman is for the
time being entiled to.
ii)
the value of any house accomodation or
of supply
of
light,water,medical
attendance or other amenity or of any
service or of any concessional supply
of food grains or other articles.
iii)
any travelling concession but does not
include
a) Wages, including the period and mode
of payment.
b) Compensatory and other allowances.
c)
Hours of work and rest intervals
d)
Leave with wage and holidays.
e)
Medical benefits.
f)
Superannuation benefits.
the I-D. Act 1947, "wages" are:
(a) any bonus
(b)
any contribution paid or payable
by the employer to any provision
fund or provident fund for the
benefit of workman under any law
for the time being in force.
(c)
any gratuity payable on the
termination of the service.
Q. 4 Who is a workman, under this Bill ?
Workman means any person (including an
apprentice) employed in any establishment
for hire or reward, whether the terms of
employment be express or implied, and for the
purpose of any proceeding under this
(proposed) Act in relation to any dispute,
includes any such person who had been
dismissed, discharged or retrenched in
connection with or as a consequence of that
dispute, or whose dismissal, discharge or
retrenchment has led to that dispute, but
does not include a person, who is employed
mainly in a managerial or administrative
capacity. It also excludes a person being
employed in a supervisory capacity who draws
wages exceeding Rs.1,600/- per mensem or
exercises, either by the nature of the duties
attached to the office or by reason of the
powers vested in him, functions mainly of a
managerial nature.
Q. 6 Are doctors workmen ?
By the definition of.workman, two absolute
criteria for being defined as a workman are
that the person should not be
Q. 5 What is wages ?
The Bill does not define wages. In this
case, as per section 2(p) of the bill, the
definition of "Wages" in the Industrial
Dispute Act '48 will be applicable.
6
HEALTH FOR THE MILLIONS
OCT-DEC 1984
(i) working in a managerial oi
administrative capacity
(ii) working in a supervisory capacity and
drawing a salary exceeding Rs.1,600/per month.
In the case of doctors, we have to apply the
above two criteria. The doctor's nature of
work, will have to be analysed. Ordinarily
the functions of a doctor are mainly patient
care, which in itself is not a managerial or
administrative or supervisory function.
Thus, if the doctor's role is limited to
patient care then he will be deemed to be a
workman even if he draws a salary of more than
Rs. 1,600/- a month.
The
managerial
or
administrative
or
supervisory element will come in, if the
doctor's work also involves supervising
employees working under him. For instance a
Registrar, directly supervising the work of
Interns is in a supervisory capacity. In case
he draws a salary of more Rs. 1,600/- month, he
will not be a workman.
If the doctor is responsible or incharge of a
department or service or activity and such
responsibility
also includes assigning
duties, granting leave, monitoring perfor
mance of subordinates and so on, then the
doctor will be deemed to be in a managerial or
administrative capacity.
As such medical knowledge is specialized
knowledge requiring a good deal of study and
experience,
in
that
highly
technical
knowledge, thus,if a person is employed as
medical man, he would just be an employee
doing a technical job. Therefore, he would
fall within the definition of workman.
Q. 7 Who is an employer ?
As per the bill "employer" has been defined
only in context of establishments under the
control of State or Central government and
local authorities.
In cases of govt.
establishments the "employer" will be
authorities prescribed by the government or
in case no authority has been prescribed, the
head of the department.
In case of local authority, the chief
executive officer of that authority will be
the employer.
The
"employer"
in
HEALTH FOR THE MILLIONS
context
of
voluntary
OCT-DEC 1984
organisations has not been defined in the
bill. However, according to the general legal
principles tne "employer" of a voluntary
organisation would be the members of the
governing board or the standing committee of
the governing board and the chief executive
officer of the institution.
in
a
typical
voluntary
health
care
institution generally the Medical Super
intendent or the Administrator and the
members of the governing board of the
registered society or trust may be called the
employer.
Q. 8 Are Voluntary hospitals included ?
under the term "hospital" as defined in the
Bill?
The Bill's definition of "hospital" includes
a nursing home, a dispensary or other
insitiution for the treatment or for
reception and treatment of persons requiring
medical attention or rehabilitation.
All the activities mentioned above are
carried on in a voluntary and charitable
hospital. Thus, voluntary hospitals may be
included in the definition of hospitals..
HOWEVER, SECTION 28 OF THE BILL EXEMPTS
HOSPITALS
OWNED OR MANAGED BY ANY
ORGANISATION WHOLLY OR MAINLY ENGAGED IN
ANY CHARITABLE; SOCIAL OR PHILANTHROPIC
SERVICE, FROM THE PROVISIONS OF THIS
PROPOSED ACT.
The bill does not specify the criteria for an
institution to be termed as a charitable,
social or philanthropic institution.
However, going by the Supreme Court judgement
in the Bangalore Water Supply and Sewage
Board Vs. Rajappa and other (A.I.R. 1978,
S.C.R. 548), the following criteria may be
taken as the test for an institution to be
truly charitable, social or philanthropic
and exempted from the coverage of this Bill.
The institution is founded for a charitable
purpose and there is no economic relationship
between the employer and majority of the
employees. That is the workmen (substantial
number of them are not working.
Q.9 WHAT ARE THE MAJOR PROVISIONS
of the proposed act?
The main provisions are:
7
i) Constitution of a Grievance Settle
ment Committee, which will be the
employer's responsibility.
ii)
Constititution
Council.
iii)
Constitution of a Local Consultative
Council.
Q. 11 What is a consultative council ?
iv)
For arbitration of disputes not
resolved by the Grievance Settlement
Committee or the Local Consultative
Council or Consultative Council.
This committee is for resolving industrial
disputes, in institutions covered by the
proposed act. every employer has to establish
a Consultative Council, within six months of
coming into force of this Bill.
v)
Recognition of trade unions of workmen.
vi)
Procedure of settlement of disputes
through the above machineries.
vii)
Prohibition of strikes and lockouts,
etc
of
a
Consultative
Q. 10 What is a Grievance Settlement
Committee ?
This committee is to be set up for resolving.
individual disputes in institutions. This
committee has to be established by an
employer within a period of six months from
the day this Bill comes into force.
This committee shall consist of a membership
of a minimum'of four and a maximum of eight,
representing both employer and the workmen.
Out of the total members at least half should
be the workmen's representatives. That is, in
case there are eight members in this
committee,
at
least
four
should
be
representing the workmen. They may be more
than four. The employer's representatives
are nominated by the employer and the
workmen's representatives are elected by the
8
workmen. The method of election may be
prescribed by the recognised Trade Union or
in its absence by the workmen. One of the
employer's representatives in this committee
will be nominated by the employer as
chairman.
This council shall consist of a minimum six
and maximum twelve members, representing
employer and workmen. The number of workmen's
representatives will be equal to the number
of employer's representatives. The emp
loyer's representatives will be nominated by
the employer and workmen's representatives
will be elected by the workmen ..The method of
election will be prescribed by the recognised
Trade Union or in its absence by the.workmen.
Employer
shall
nominate
one
of
the
representatives as chairman of the council.
Q.12 What is the difference between
Grievance Settlement Committee
Consultative council?
the
and
The Grievance Settlement Committee is for
resolving individual disputes.
The
Consultative
Council
or
Local
Consultative Council is for the settlement
of industrial disputes.
Q. 13 a What is a Local Consultative Council ?
In case a person (or a legal body)
is the
IdFAtTH FOR THE MILLIONS OCT-DEC
1984
employer in relation to two or more
establishments, wherein activities of the
same nature are carried on, he has to
establish a Local Consultative Council for
each of the institution. Where two or more of
such Local Consultative Cozsiittees exist,
(in relation to the same employer) , they have
to establish a Consultative Council.
These are like branches or units of the
Consultative Council.
Q.14 What are the terms of office of members
of the Grievance Settlement Committee,
Consultative
Council
and
Lodal
Consultative Council?
Subject to the rules prescribed by the
government alongwith the enactment of this
bill, the term of membership in the above
bodie, will not be less than two years or more
than five years.
Q. 15 What are the other provisions ?
This council will have a minimum of four and
maximum
eight
members,
with
equal
representation from employer and workmen.
The mode of nomination or election of
representative
is
same
as
for
the
Consultative Council_
Q. 13 b Which is the higher body ?
Local Consultative Council or the
Consultative Council.
The workmen's
representative, who are
members of the above bodies, shall be paid by
employers, in relation to any function
discharged by them as member, such as
travelling and compensatory allowance, as
may be prescribed.
Q. 16 What are Trade Unions ?
• 0
Total organisation
with
The Trade Union Act 1926 defines a trade union
as meaning any combination whether temporary
or permanent, formed primarily for the
purpose of regulating the relations between
workmen and employers or between workmen and
workmen, or between employers and employers
or for imposing restrictive conditions on the
conduct of any trade or business, and
includes any federation of two or more trade
unions.
Local Consultative
Council
Q. 17 Which Trade Unions are eligible for
. recognition ?
In case of only
one institution
CONSULTATIVE
COUNCIL.
(ii)
related to these bodies?
Consultative Council
Local
Consultative
Council
According to the Trade Union Act 1926, a Trade
Union will be eligible for recognition with
respect to an establishment, if:
Local Consultative Council
In case of more than one institution
under the organisation, each institution has
one Local Consultative Council. Apart from
this on top of these local Consultative
Council,
the
Organisation
has
one
Consultative Council.
a) It is registered under the Trade Union
Act 1926.
b)
It has as one of its objects the
carrying on of activities for the
benefit of workmen employed in such
establishment.
c)
It has a membership of atleast 30% of
the total workmen in that establish
ment .
d)
Each of its office bearers is a workman
in the establishment or any other
establishment in which this Act is
applicable.
Consultative Council
Institution
I
Institution
*
II
Institution
III
Local Consultative
Council I
Local Consul
tative
Council II
Local Con
sultative
Council III’
HEALTH FOR THE MILLIONS
OCT-DEC 1984
Q. 18 In case more than one Trade Union exists
in
the
establishment,
which
are
eligible for recognition, which Trade
Union will be recognised?
The employer shall recognise the trade union:
i)
Which represents the larger number of
workmen,
ii)
If they represent equal number of
workmen, then recognise both of them.
Q. 19 How long will such recognition be in force ?
The recognition will be atleast for a period
of two years.
Q. 20 Is the Grievance Settlement Committee
the first step in resolving individual
disputes?
No. The employer has to frame regulations and
procedure for settlement of individual
disputes. The workman has to go through the
procedure, before he applies to the Grievance
Settlement Committee.
At the time of
enactment, the appropriate government may
give a model regulation and procedure, to be
adapted by the employer.
at
first goes
through
the
established by the employer.
If the dispute is not settled then he may
apply to the Grievance Settlement Committee.
The Committee after giving sufficient
opportunities to the employer arid workmen, to
be heard and after making enquiries, uassos
such order (in respect of the dispute} a~ it
deems just and appropriate. This order shall
be passed within two months of the date frer
the date of such application., race by the
workman.
If the Grievance Committee fails to pass ar.
order with in two months of application or it
the workman is aggrieved even after the
committee’s
order,
then
the
worsran
(aggrieved) may refer the dispute for
arbitration, to an arbitrator, agreed to by
both parties to the dispute.
—
— - - -
a. In case of an individual dispute
what are the steps that the workman
follows?
H3KAMA
Requires
1.
Pathologist
2.
Pha rmac i s t (B.Phar>.\
3.
Pharmacist (with diploma'
4.
Lab Technician
Contact:
Q. 21
--------- - --------------------
NAZARETH HOSPITAL
The Administrator,
Nazareth Hospi t a1,
Mokam-a P.O.
Patna Pist.
Pin Code
302.
In case of an individual dispute, the workman
HEALTH FOR THE NlUiess
10
OCT-EEC 19S4
Q.21)
b.
Flow chart for settlement of individual dispute.
Individual Dispute
Machinery set up by employer,
according to the "model" regulation for
setting up such machinery, made by
appropriate government.
Dispute
Q. 22 Whet is arbitration
This term has its origin in ’Arbiter', which
means to judge or to umpire. The term
arbitration refers to the process through
which the dispute is referred to a neutral
person(s), acceptable to both the parties.
This person(s), called the Arbitrator (or
Board of Arbitrators), makes the decision
regarding the dispute. When an individual
dispute
is not
resolved
through
the
Grievance Settlement Committee then the
parties to the dispute can refer the dispute
to an Arbitrator. The appropriate Government
shall maintain a roster of arbitrators from
wnicn the parties to an individual dispute
(and also industrial dispute) may choose an
arbitrator. The parties to the dispute are
however free to refer the dispute to a
mutually agreed upon arbitrator, whose name
may not be included in the roster of
arbitrators.
HEALTH FOR THE MILLIONS
OCT-DEC 1984
Dispute not settled
Q.23) What happens, if the parties to the
dispute
Fail to agree on the
arbitrator ?
In -such
case,
the
appropriate
government will constititute a Board
of Arbitrators, and refer the dispute
to this board.
Q. 24 What about their decision making power ?
The award (decision or judgement) of
the arbitrator or Board of Arbitrators
will be final. That is the decision
made by them will be binding on both the
parties.
Q. 25 a What is the process for settlement of
industrial disputes
If any Local Consultative Council has
11
oeen established for any branch/unit
or office of any establishment, then
the industrial dispute is referred to
this council by the workmen, any
recognised Trade Union or employer,
for settlement of dispute.
Q.25
b)
In the
case of non-existence
of
In
the case
— or failure
any local
Consultative
Council
of the Local Consultative Council, then
the dispute is referred to the Consulta
tive Council for settlement.
Flowchart for settlement of industrial dispute-
Industrial Dispute
Local Consultative Council
Dispute settled
Dispute not settled or if the
Local Consultative Council is
not required
Consultative Council
Dispute
not settled
Arbitrator or
Board of Arbitrators
Award is Binding on
both the parties
Q. 26 What happens in these Councils ?
When
any
industrial
dispute
is
referred to the Council, it shall make
all efforts to promote a fair and
amicable settlement of such dispute.
When a settlement is arrived at between
the parties, it shall be recorded in
the form of a memorandum and signed by
the parties to the dispute or their
authoriesed representative and the
members of the Council. The settlement
of industrial disputes by the Local
Consultative Council and Consultative
Council or the Award given, shall be
binding on the parties to the dispute
12 •
and on all wortaaen in the establishment
from the date when the dispute was
referred to the local Consultative
Council or the Consultative Council.
(Also on persons who will subsequently
become employees -)
Q. 27 What happens if.
the Consultative
Council fails to settle the dispute?
If the council fails to settle the
dispute within three months from the
date on which the reference is made,
then it has to refer the dispute for
arbitration, to an arbitrator mutually
HEALTH FOR
MILLIONS
OCT-DEC 1984
agreed upon by the parties to the
dispute.
Q-28) What happens, if the parties do not
agree upon an arbitrator?
In this case the Council shall refer
the dispute to a Board of Arbitrators
constituted
by
the
appropriate
Government.
Q. 29 What will be the constitution of the Board ot
Arbitrators?
There will be a minimum of three
members of this board. Out of this:
i)
ii)
iii)
One will be an independent person
who will be the chairman of this
board.
One representative
ployer .
of
the
em
One representative of the workmen.
Apart from this the Board may appoint
one or sore person, having special
knowledge
of
the
matter
under
consideration as Assessor(s). Their
role will be to advise the Board in the
proceeding before it.
Q. 30 What about the decisions of the Board ?
Normally,
the
decision
will
be
unanimous- In
case
of
divided
opinion, the decision of the majority
will be deemed to be’the arbitration
award. This award will be final and
binding on the parties to the dispute.
Q. 31 What are toe powers of the Arbitrator
or
Board of Arbitrators?
They shall have the same powers as the
civil court, with respect to the
following matters:
a)
Summoning
and
enforcing
attendance of any person
examining him on oath.
the
and
d)
Such other matters as may pre
scribed.
Q. 32 What are the various terms
used to ref er
to the decisions of the Grievance
Settlement
Committee,
Local
or
Consultative Council and Arbitrator or
Board of Arbitrators?
The Grievance Committee passes orders.
Consultative
Council
or
Local
Consultative Council settles disputes
(i.e. settlement of industrial
disputes) and Arbitrators or Board of
Arbitrator give Awards.
Q. 33 When do these Orders or Settlements or
Awards, come into effect?
They come into operation on and from
the dates as may be specified in the
order, settlement or award. In case
no such date is mentioned, then they
come into operation from the date when
such an order, settlement or award was
given.
Every Award of the Arbitrator or Board
of Arbitrators shall become enforce
able on expiry of thirty days from the
date of pronouncement.
The only exception to this will be when
the appropriate government is a party
to the dispute and is of opinion that
the award may affect the national
economy or social justice adversely.
In
this
case
it
may
through
notification in the official Gazettee,
declare that the award will not be
enforced on the expiry of thirty dates
from the date of pronouncement of 'the
award. In this case, the appropriate
Government should make an order,
rejecting or modifying such award,
within 90 days of pronouncement of the
award. The same has to be presented to
the
state
legislature
or
the
parliament.
Q. 34 What about Strikes and Lockouts ?
b)
Compelling
the production of
documents and material objects.
The proposed Act prohibits workmen
from going on strike or indulge in
anyother form of cessation of work or
retardation of work.
c)
Issuing
commissions
for
the
examination of witnesses, and
It also prohibits the employer from
Locking-out.
HEALTH FOR THF MILLIONS
OCT-DEC 1984
13
Q. 35 What are me penalty clauses.?
regarding non-compliance of the pro
visions of this Act by the Employer?
If the employer -
i)
Does not establish a Grievance
Settlement Committee or a Consul
tative Council or Local Consult
ative Council,
ii)
Fails to pay the travelling and
compensatory allowance payable to
Q. 37 What about the organisation
already
having Joint-Consultative machinery
for settlement of disputes consisting
of representatives of workmen and
employer?
If such machinery exists and the
appropriate government is satisfied
that such machinery i ~ functioning
effectively and is beneficial to
workmen, then through notification the
government may exempt that organisa
tion from some or all of/the provisions
of this Act.
After the enactment of this Bill, the
Government shall make rules, which
will clarify the following aspects of
the proposed Act.
the workmen's representative, who
are members of the Grievance
Settlement
Committee
or
the
Councils,
iii)
Refuses to comply with the orders or
the settlements or awards, which
have became final,
iv)
Locks out any or all of his workmen,
v)
Fails to make provision, for
establishing procedure for settle
ment of individual dispute, even
before it is referred to the
Grievance Settlement Committee,
then he is liable for punishment
with imprisonment upto six months
and/or with a fine upto five
thousand rupees.
i)
The authority which is the employer in
connection with an establishment under
the control of Central or State
government.
ii)
The manner of choosing the members who
are workmen’s representative) of the
Grievance
Settlement
Committee,
Consultative
Council
and
Local
Consultative Council.
iii)
The procedure
Council.
iv)
The terms of office of members of the
Grievance Settlement Committee and the
Councils.
v)
Travelling and other compensatory
allowances payable to members of the
Grievance Settlement Committee and the
Council, (being workmen's represen
tative)
in
connection with any
functions discharged by }them as
members.
vi)
Manner
for
verification,
recognising a Trade Union.
vii)
To specify the time period
14
viii)
be
followed
by
for
a)
for referring a dispute to
Consultative Council or Arbitra
tor or Board of Arbitrators.
b)
other matters
Q. 36 What about the workmen ?
If a workman goes on strike or indulges
in any other form of cessation of work
or retardation of work, he shall be
punishable with imprisonment upto six
months and/or a fine of- Rs.5,000/-.
to
Compensation or remuneration payable
to an Arbitrator or Assesor or member
HEALTH FOR THE MILLIONS
OCT-DEC 1984
Of a Board of Arbitrators.
Some of tile Limitations
Act, from the
organisations:
view
Khadi Industry is elected as workmen's
representative in a hospital. And he will
be totally unfamiliar with the situation
in the hospital.
of the proposed
point of voluntary
a) The limitation of the proposed Act has not
been specified. That is even a small
hospital with 5 & 6 workmen may come under
the purview of this Act. Even in the
Industrial
Disputes
Act
1947,
only
establishments employing more than 20
persons are covered under the Act.
e)
The proposed Act does not provide for
derecognition of a Trade Union, in case
their representation becomes less than
30% of the workforce in the establishment
or if they indulge in unfair practices.
These are only some of the possible loopholes
in the proposed Act.
b)
The
suggested
constitution of the
Grievance Settlement Committee, with
equal representation from employer and
workmen may result? in a stalemate. ThxS
proposed Act does not specify the process
to be followed in case of such a tie up.
It is possible that this bill may not be
passed by parliament and may not become
applicable to hospitals. It is also true that
the Supreme Court judgement of 1978,
including hospitals under the definition of
'industry', does not hold any longer.
c)
The provisions regarding election of
workmen's representatives may lead to an
unjust situation. Because, the proposed
Act provides for electon of workmen
through the recognised Trade Union (if it
exists). Under this proposed Act, a Trade
union may be recognised even if it
represents 30% of the total employees in
the establishment, rest of the 70% may go
unrepresented-
Then the question may be, what is
importance of all this information.
d)
Section 8(2) of the proposed Act, creates a
situation, where a non-employee in an
establishment may be chosen as workmen's
representative.
As this Act applies to varied institutions
like Hospitals, Educational Institu
tions, Khadi Industry, etc. (by section
8 (2) ) it may happen that a workman in a
HEALTH FOR THE HILL I (MS
OCT-DEC 1984
the
The
idea
is to understand that our
organisations are no longer thought of as
charitable and given blanket exemption from
all legislation. Very rigid criteria may be
used to assess whether an organisation is
charitable or not- Even if they are deemed to
be charitable, then also they may not get
blanket exemption rrom labour legislations,
which are framed to safeguard the interests
of the workmen.
The Supreme Court judgement of 1978 and the
"Hospital and other institutions (Settlement
of Disputes) Bill '78 and '82, reflect the
present trends and thoughts about conditions
of workmen in charitable or other hospitals.
15
This makes it necessary for the voluntary
hospital to come out of the dark ages of the
Master and Servant relationship in their
organisations. The old practice of hire and
fire will have to be forgotten. Voluntary
organisations have to recognise the fact that
majority of workmen, even in charitable
hospitals, work for wages primarily. In fact
their wages are not sufficient for them to be
charitable and take less wages or to give hard
work in what may be adverse working
conditions.
Voluntary hospitals have to think of ways and
means to ensure that just and appropriate
terms and conditions of employment are
provided to their workforce. Voluntary
organisations
should
not
wait
for
legislation to be enacted to safeguard the
interests of their workmen. At the same time
they should be aware of the new laws, which
may came into force and become applicable to
them.
The laws which already exist or may become
applicable to voluntary hospitals are:
Central Acts:
i) The Contract Labour (Regulation and
Abolition) Act 1970.
ii)
The Employment Exchange (Compulsory
Notification of vacancies) Act 1959.
iii)
Employee’s Provident Fund Act, 1952.
iv) Payment of Gratuity Act.
v) Payment of Wages Act 1936.
vi)
Wages act 1948.
vii) Ttade Union Act 1926
16
* HEALTH FOR THE MILLIONS
OCT-DEC 1984
A CBC1 Report
The Controversial Bill
"Hospitals and other Institutions” (Settle
ment of Disputes) Bill, 1982.
3. ArbiLidlion
In arbitration there
is little scope for conciliation. Besides
the decision voice being that of an outsider,
this would create bitterness and suspicion
among the parties.
The Commission for Justice, Development
and Peace of the Catholic Bishops’ Conference
of India, having studied the above Bill
through its Section for Labour and at a
National Consultation of delegates composed
of administration and staff of hospitals,
educational
institutions and production
centres, and experts in legal and management
matters, at New Delhi on 5th and 6th August
1982, came out with the following report:
Further arbitration as the machinery
for settlement of disputes may only increase
the proclivity for raising disputes and thus
defeat the very purpose of the Bill and even
render it counter productive.
Provision for arbitration will rule out
collective bargaining, which is a denial of
the right of workers.
While appreciating the concern of the
and
other
for
hospitals,
government
institutions to create and maintain an
strikes
and
----- ----which
eschews
atmosphere
lockouts and at the same time to protect the
rights of the employees in these institutions
for justice and fair treatment, we wish to
express our apprehension regarding certain
aspects of the Bill which would have grave
consequences on employer-employee relation
ship and harmony in the very institutions:
4. Financial Implications
The un
equal distribution of cost of settlement of
disputes between the employer and the
employees, will be an inducement to workmen
to raise issues continuously, with crippling
effects in industrial relations.
Hence the Bill in the present form would
be counter productive and would need
substantial revision.
In the light of the above, we specially
appreciate the provisions in the Bill for
alternative machineries for settlement of
grievances (article no. 24) .
In this context
we wish to propose the following structures
which are found successful in promoting
healthy atmosphere in several institutins,
hospitals and educational institutions,
preventing conflicts and resolving disputes:
1. Trade Unions
It is welcome that the
Bill enjoins on the management to recognise.
representative organisations of workmen.
However the Bill does not spell out the
exclusion of outsiders as office bearers, nor
the manner of ascertaining membership of
Unions: both of these are essential to make
the provisions of the Bill effective in
eschewing strifes in these institutions.
2.
Grievance Settlement Committee
There is a serious
fear that the machinery proposed under the
Bill (Grievance Settlement Committee and
Consultative Council) with equal represen
tation of management and employees, would
constantly create situations of inconclu
siveness, instead of conciliation, thereby
perpetuating
strifes
and
dissentions,
destroying the homely atmosphere of the
CONSULTATIVE COUNCIL:
&
A. Administration Council
in order to
ensure
adequate
participation
of
all
sections of people involved in the running of
the
institution,
there
shall
be
a
participative administration council, with
adequate representation of all sections of
the institution.
B. Staff Council
There shall be a
staff
council
in
each
institution,
representing various functionaries, which
institution.
HEALTH FOR THE MILLIONS
OCT-DEC 1984
17
shall
meet frequently
to advise
functioning of the institution.
the
C. Conciliation Committee
There
shall be. a Conciliation Committee to resolve
grievances of the members of the institution.
This committee shall be composed of persons
generally acceptable to the various groups
and capable of representing all the interests
ihvolved, and chosen by the participative
administration-/council.
D. Inter-Institutional Panel
where
several institutions are run by the same
agency,
there
shall
be
an
interinstitutional panel of reconciliation in
order to resolve differences that might
remain unsettled at the institutional level.
(CBCI
COMMISSION
FOR
JUSTICE,DEVELOPMENT
&
PEACE)
********
News Report
For Your Eyes
The extent of financial aid to voluntary
organisations to set up eye banks should be
quantified
so
that
non-Governmental
Organisations and voluntary bodies could
come forward in this area.
Inaugurating a
meeting of the Medical Officers Incharge of
Mobile Ophthalmic Units here recently,
Kum.Kumud Joshi, Deputy Minister for Health
and Family Welfare said that these eye banks
would support Ophthalmic Surgical Centres in
hospitals and Mobile Units which provide
surgical and medical eye care in the rural
areas.
Stressing
the
need
to
involve
voluntary
organisations
and
private
practitioners in the National Programme for
the Control of Blindness, the Minister said
that of the total nine million blind in the
country, as many as fifty five per cent were
due to cataract alone, which is curable
through surgery. The traditional eye camps
had, so far concentrated on this aspect
alone. But, if the other preventable causes
of blindness, such as eye infections,
malnutrition and eye injuries which took a
heavy toll could be prevented through
education and timely relief, blindness
especially in the younger age-groups could be
avoided. The Ministry had,
therefore,
proposed one mobile unit with two eye
surgeons and supporting staff for each
district during the Vllth Plan period.
There are at present 80 mobile units each
covering five districts.
Calling for a concerted drive to prevent
quacks from operating specially in the rural
areas, Kum. Joshi said that this could only be
done if eye care facilities are provided in
the remotest parts of the country.
Emphasising the role of Mobile Units, in
this regard, the Minister said, "The onus of
demonstrating model ’Eye Camp' on scientific
lines, with an integrated approach of
rendering preventive, promotive, curative
and rehabilitative services at the door
steps of the people, lies with your units."
She asked the doctors to give weightage to
post-operative eye care after the camps were
over.
Referring
to
the
epidemiological
picture with regard to blindness, Kum. Joshi
said that present data was based on Indian
Councial of Medical Research studies carried
out as early as 1972-7 3. She suggested that
specific epidemiological surveys in the area
covered by each Mobile Unit should be taken
up. This would be possible only if the
doctors camped in the field during the entire
period of the eye camps.
18
HEALTH FOR THE MILLIONS
OCT-DEC 1984
M Zaman
TRAVELLERS MOTES
— Some More Questions
The monsoon may have come to an end, but does
that mean travelling is made any easier? Not
in my experience!
For the last two weeks I have been subjected
to a variety of travelling experiences,
accompanied
by a
fractured
left
toe.
Crammed into a car with miles, and miles of
tortuous road ahead; sitting patiently in
overcrowded, slow puffing train with no
regard for the perfunctory time table,
walking painfully to meet a non-existant jeep
in a remote village area. Although it has
been a little tiring it certainly makes me
happy when I recall of meeting wonderful
people like you all!
The
initial
visit was
to the member
institutions of the South Bihar region.
Fortunately in this tour I was accompanied by
our President Dr.Silas Singh, Mrs.Singh and
her sister, and Mr.J.M. Singh the Executive
Secretary of UP VHA.
In Koderma we visited Holy Family Hospital,
Sr.Francis greeted us very cheerfully and
showed us the Hospital.
I was quite happy to
see that their pharmacy supply was free from
these drugs which are supposed to be banned.
We reached St .Columba ' s Hospital, Hazaribagh
towards the evening, where we spent our
night.
Dr.(Ms)
Pushpa
Das
(Medical
Superintendent) and Mr.P.K.Mandal (Business
Manager) both were very kind enough to
provide us all the facilities to spend the
night.
We discussed with Dr.Das about active
participation
in
BVHA
activities. She
assured us of her full cooperation m BVHA.
I had
On 11th morning we started for Ranchi.
Rural
an
appointment
with
the
Bihar
Development Centre, Ranchi to enlighten
Workers on Community Based
their Health 1—- —
Health Programme.
It was a good opportunity
HEALTH FOR THE MILLIONS
OCT-DEC 1984
for BVHA to
Programme.
integrate
with
Government
During the day we visited St. Barnabas
Hospital, Ranchi and Seventh Day Adventists
Hospital, Ranchi.
In both hospitals we had a short meeting with
the Medical Superintendents. Dr.Pandit,
Medical
Superintendent
of
SDA,
was
acquainted with BVHA and its activities as he
was not aware of it. Since there is a vacancy
on the Governing Board, our President has
offered Dr.Pandit to be the coopted member of
Governing Board of BVHA. He promised us that
he will consider the offer. Towards the
evening we started for Mandar Holy Family
Hospital. Sisters at Mandar gave us a warm
welcome. We discussed with Sr.Lucy and
other sisters about ways and means to
strengthen BVHA.
On 12th we visited St.Ursula Hospital,
Lohardaga and Nav Jivan Hospital, Satbarwa.
At both of these places we were assured of
their support in the activities of BVHA.
I also visited Fatehpur. There I met Mr-Nand
Lal, a school teacher who is very much
interested in health education. He is ready
to carry out the suggestions to start school
health activities.
The visit was arranged by Ms. Giuseppina, a
British Volunteer from Action Health 2000,
Cambridge, as an attempt to form links with
people
who
are
interested
in
health
activities
and
working
in
relative
isolation.
Grave flood situation in North Bihar
Darbhanga, Saharsa and Madhubani have been
the districts worst hit by floods.
On 18th of September Fr. Abraham Odalany and
Sr.Basil came to us asking for help as the
19
situation was beyond control. I accompanied
them to the residence of Shri Lahtan
Chowdhary, Revenue Minister-who sought help
from Voluntary Institutions to provide
medical facilities to the flood victims.
Government was ready to give us medicines and
conveyance to reach there. We discussed
with Sr. Ann D' Souza of Kurji Holy Family
Hospital, Patna, who agreed to send her
staff, Ms. Ursula Jojo, Ms. Ursula Soreng,
Messers C.George and Puna Paswan. They left
for Saharsa on Sept. 19th. They were there
tor ten days providing medical relief to the
flood victims.
Madhipura Christian Hospital had also sent a
medical team to Saharsa for the relief
operation for a week inspite of shortage of
manpower in their hospital. They are again
planning to send their team for medical
relief there.
If possible, others may also send some of
their
medical/para
medical
staff
to
St.Antony's Dispensary, Jaraila, Saharsa.
NEWS
VHAI
Grieves
Congratulates
Seema Rani, Information Service
,
*
VHAI and
wishes her and Ashwani Munjal happy married
life.
MP VHA
The MP VHA office has been moved across the
street into the Christian Hospital Compound.
It is situated just above Dr.Daniel's
residence.
the passing away of Dr.Helen Gideon MBBS„
MPH, Senior Community Health Consultant with
VHAI till 1977 and a close associate
afterwards, in her residence at Simla on
September 12, 1984.
Welcomes
back Fr.James S.Tong as its new Executive
Director. He says it will be a short temporary
reign.
Bids farewell
to Mr. Averthanus D'Souza who resigned as the
Executive Director on September 30, 1984 to
Mr.Ravi Kumar Srinivasan who has taken over
as Manager, (Man Power Development) with
Punjab
Agro
Industries
Corporation,
Chandigarh and to Ms Ponnamma George who has
joined the Centre for Development of
Instructional Technology
(CENDIT),
New
Delhi.
20
MP VHA has announced a two-week workshop on
Community Health in Sagar, primarily for
people from Sagar, Raisen and Guma districts.
There may be place for 5 or 6 from outside this
area. Dates set are: November 12 to 23.
BVHA
A School Health Workshop was held from
August 6 to August 12, 1984. It
was
conducted by Dr. Mira Shiva and Mr.Augustine
Veliath. The Workshop was attended by 21
participants
which
included
4
school
teachers. A11 the Participants were very
enthusiastic and were interested in starting
LsX r
heaith
e
in
their
UNICEpU p511,5' Df’
Subash Chander from
described "th ** alS° shared his ideas and
care of ch 'aCtlvities °f UNICEF in the
number
dren and woman. He distributed a
education
aseful and relevant health
education materials tn
Miss Amita Paul (IAS)
n- partlclPants■
Development Project B^r T?
participants u
'
h r' enlightened the
development
*
Vflrious Scf“ and
development programmes of the Government.
HEALTH for
the MILLIONS
OCT-DEC 1984
PRESS INFORMATION BUREAU
GOVERNMENT OF INDIA
SMALL POX ERADICATION BRINGS DOWN
INCIDENCE OF BLINDNESS
INCREASE IN CATARACT OPERATIONS
New Delhi: August 26, 1984
Bhadra 3, 1906
An Indian Council of Medical Research
collaborat ive study has indicated that there
are about nine million blind and 45 million
visually handicapped people in India.
As
per ICMR surveys the main causes of blindness
in India are:
Cataract-55 per cent;
Trachoma and associated infections -.20 per
cent;
Small Pox - .03 percent;
Malnutrition - 0.02 per cent;
' Injuries - 1.20 per cent;
Glaucoma-0.50 per cent and other causes - 18
per cent.
The launching of a National Programme
for Trachoma Control has brought 400 million
people in 3530 blocks of 293 districts under
treatment- About 5 per cent of the.blindness
is estimated to have been reduced in the
population covered due to elimination of
blinding complications of Trachoma.
The other factors mainly responsible
for the success of the blindness control
programme is the Vitamin ’A’ Prophylaxis ana
Nutrition Supplement Programme. Over two
lakh
I.U.
of
Vitamin
’A’
are
being
administered twice a year orally to children
below 6 years through a vast network of M.C.H.
services.
The Applied Nutrition Programme
and
the
Integrated
Child
Development
Programme have also contributed towards
also con---improvement of the nutritional
--itional status of
children.
As the Programme for the Control of
blindness has been included in the 20 Point
Programme, Government is proposing a five
fold increase in the Vllth Plan allocation
for this Programme over the provision of
Rs.5,6 crores made for this Programme for the
Vlth Plan period.
The targets set under this Programme
include developing a potential to train 1200
eye
specialists,
318
specialists
in
community eye care and 2000 para-medical
personnel every year by the year 2000 A.D.
Once this target is achieved, there will be
one eye specialist for every 50,000 people,
one bed reserved for Opthalmic surgery and
treatment for every 15000 - 20000 population
and a potential to perform 25 lakh cataract
operations yearly.
At present 10 lakh cataract operations
can be performed per year as against five lakh
operations in 1980. Eye care facilities are
available at 660 Primary Health Centres.
360 District Hospitals have specialist
services and -there are 80 Mobile Eye Units
each covering an average of five districts.
Cataract, the main cause of blindness
accounting for 55 per cent of the total
incidence is curable by surgery. Concerted
efforts are, therefore, directed to perform
as many cataract operations as possible, both
through Government and voluntary agencies.
10.45
lakh
cataract
operations
were
performed during 1983-84 as against 8.5 lakh
in 1982-83.
The ultimate goal of the National
Blindness Control Progran
me
*
as defined in the
National Health Policy is to achieve
reduction in the incidence of blindness from
1.4 per cent in 1975 to 0.3 per cent by 2000
AD.
Dr. Ruth Harnar is now a nurse
1 consultant with the Christian Medical
Commission in Geneva. She will be there
for the next two years. She can be
contacted at:
Office: Christian Medical Commission
World Council of Churches
150, Route de Ferney
1211 GENEVA, 20
Switzerland
Phone:(022) 916111
Home:
Chemin Francois Lehman,8
CH-1218, Grand Saconnex
Geneva, Switzerland
Phone:(022) 982980
21
HEALTH FOR
the MILLIONS
OCT-DEC 1984
ii)
Obstetric
&
Gynaecology
M.D./M.S./M-R-C-O-G-
iii)
Pathology-M.D. with experience in
Histopathology-
opportunities
ST. *
S
STEPHEN
HOSPITAL, DELHI-54
REQUIRES
iv)
Ophthalmology-M.S.-experience in
eye surgery.
1.
Head of the Department
i)
Medicine/Cardiology
D.M./M.R.C.P.
ii)
Obstetric
&
GynaecologyM.D./M.S./M.R.C.O.G.
-
Salary : in the grade of Rs.1100-501500EB-60-1800EB-100- 2000
plus
allowances (total emoluments in the
range of Rs.3,000/— to Rs.4,300/per month).
M.D./-
4.
Experience: 15 years after post
graduation
in a large reputed
hospital including 5 years as Head of
the
Department
with
teaching,
research, and administrative expe
rience and leadership qualities.
Age:
Prospects to become Nursing Superinten
dent in a year or two.
Below 50 years.
Salary: At the appropriate stage in the
scale of Rs.2000-100-3000
with
allowances (total emoluments in the
range of Rs.4,000/- to Rs.6,000/per month).
Salary Scale
:
Rs.590-30-680EB-40800EB-50-900 plus allowances (total
emoluments
in
the
range
of
Rs . 1,400/- to Rs. 1,900/- per month) .
52.
Senior Specialist
Minimum 10 years experience after post
graduation with above qualities.
i)
Medicine/Cardiology - M.D./D.M.
/M.R.C.P.
ii)
Obstetric
&
GynaecologyM.D./M.S./M.R.C.O.G.
iii)
iv)
Deputy Nursing Super intendent
M.Sc. or B.Sc. , in Nursing.
Preferably
post basic. Minimum 5 years experience
in Nursing Administration, of which 2
years in the senior cadre of a fairly
large general hospital (300-500 beds.)
Pathology - M.D. with experience
in Histopathology.
Ophthalmology - M.S. - proficient
in eye surgery.
Pharmacist
B.Pharm. Minimum 2 years
experience in a reputed hospitalSalary Scale: Rs.425-15-560EB-20-640
plus allowances (total emoluments in
the range of Rs.1,100/- to Rs.1,500/per month).
6.
Laboratory Technicians
with 2 years experience in a reputed
hospsital.
i) Biochemistry Diploma after B.Sc.
ii) Microbiology Diploma after B.Sc.
Salary : in the grade of
Rs.1500-60-1800 EB-100-2000EB-1002500
plus
allowances
(total
emoluments
in
the
range
of
Rs . 3,500/- to Rs. 5,000/- per month) .
Medical Laboratory Technician
from^recognised hospital.
Salary Scale:
Rs.330
560
plus
allowances and the total emoluments
will be about Rs.1,000/-per month
starting.
Specialist
OTHER BENEFITS:
iii)
3.
5
3years experience after post
graduation in a medical college or in a
fairly large hospital.
i)
22
Medicine/Cardiology
D.M./M.R.C.P.
-
M.D./-
Provident Fund, Medical Assistance,
L.T.C. and Family accomodation in
the campus.
^pply to the Medical Superinten
dent, St.Stephen's Hospital, Tis Hazari
Delhi-HC 054 within 30 days.
HEALTH FOR THE MILLIONS
OCT-DEC 1984
WOMAN VILLAGE WORKER (Hindi)
Rs.12.50
Pages 88
A compact, easy to read adaptation of the "Woman Village
Worker" is now available in Hindi.
In 15 chapters this small books deals with
team worker extension education
methods and techniques of persuasion
people who influence village decision making
simple organization of village development
village youth leaders
health
agriculture
how to start a programme and be accepted
how to evaluate your own programme
This booklet looks to the future especially into
women's emancipation
women’s role in development
This Hindi edition is aimed at the lower level of village level
workers. This is especially useful for those who are organising
Mahila Mandals, youth club s, income generating programmes for
women.
The original English edition was born out of a workshop led by
Dr. Ensminger in which many well known workers in social
organization attended.
Limited copies are available from VHAI.
write to:
For copies please
Voluntary Health Associa tion of India,
C-14, Community Centre,
Safdarjung Development Area,
New Delhi-110 016.
JUST RELEASED
BOOKS ON
SMOKELESS CHULHA
2.
HOW TO MAKE AND USE THE NADA CHULHA
A Construction Manual
For
Mistris
About
How to build the Chulha step by
step
How to use and maintain
How to deal with common problems
Developed out of a pilot training progra
mme for dissemination of improved Nada
Chulha.
The Nada Chulha, smokeless and fuel
efficient, is designed to make a substan
tial impact on the quality of women's
lives and ensure better health and child
care.
Simple text. Profusely Illustrated
Price Rs. 10.00.
3.
USERS INFORMATION SHEET
Users
For
About
How to use and maintain the
Chulha
Size 20" x 30"
12-16 illustrations
We have published a revised and improved
version of the following materials, deve
loped and tested at our training sessions,
Price Rs. 1.50.
1.
NADA CHULHA - a Handbook
Trainers/Coordinators/
Supervisors
For
About
How the improved Chulha affects
woman's lives.
The scientific principles on
which the Chulha works
How to build the Chulha to suit
varying needs
How to solve common problems
faced by users.
Simple Text. Profusely Illustrated.
Price Rs. 15.00
for private circulation only
4.
PROMOTIONAL POSTER
For
General Public
About
Main benefits of chulha
Size 18"x22"
Rs.1.00
For copies write to :
Voluntary Health Association nf t
C-14, Community Centre, S.D A f Indla
New Delhi-lio 016.
Position: 124 (19 views)