Health for the Millions, Vol. 11, No. 2 - 5, April - Oct. 1985
Item
- Title
- Health for the Millions, Vol. 11, No. 2 - 5, April - Oct. 1985
- extracted text
-
HEALTH FOR THE MILLIONS
SELECTIONS
OF THE
YEAR
bto"
IN INDIA
AiCH
-
p°oaj
ge Joseph
l Desrochers
\nma Kaiathil
CONTENTS
EDITORIAL
Selection of the year presents ten I
excerpts from a number of health!
publications received by VHAI.
Nol
VHAI publication has been included!
in these selections.
We begin with an article that mea-1
sures the condition of India's poor,
explaining
in
detail
the
Physical
Quality of Life Index (PQLI).
Editorial
Beyond Social'
\
Band aids
The second article "Beyond Social
Band-Aids"
reviews
the
personal
and collective involvement in social
action.
Specific
health
action
is
seen as one of many issues around
which the poor can organise and|
act.
" Questions
Healthy
Questions "
analyses
systematically
the
potentials and limitations of using
health
issues to conscientise and
organise the people and
its ap
proach
requirements
from
health
professionals.
"Village
Organisation"
focuses
on
possibilities
and
alternatives.
"Teaching Family
and Friends
in
Your Community" charts the basics
of
rural
and community
oriented
education.
What
happens
when
people evaluate a project?
The case
study from " When People Evaluate "
is self explanatory.
What
do
Government
policies
achieve? We have all been watching
the progress of the daring Bangla
desh Drug Policy.
The achieve
ments of the policy have been re
corded by "WAR on Want" a British
based Agency.
Meanwhile in India,
the National Health Policy has been
announced.
What does it intend to
achieve?
Excerpts from the policy
provide us
with glimpses of the
dreams that may come true.
Teaching Family £
Friends in Your
Community.
15
II
Community
Organisation
Ultimately
it
still
depends
on
you and me to correct the great
strains in our society. Where do we
start? John Platt has the answer in
'Start Here' and that
is
it
start
here----------Selections of the year
action note .
26
28
Miles To Go
Achievements
To Date
20
ends on this
When People Evaluate
32
When
you
. come
across
an
interesting
article on
health
do
alert us so that we can include it in
the selections of the yeai---------next
year.
In The News
was
Start Here
- -------- .
compiled
Khanna.
Produced by design.ed
and
edited by
Augustine
with the assistance
v\’r
- ••
0 %
$an93
\t^a
\ b\ocV-
COUNTING
THE HUNGRY
In the various attempts to mea
sure development and/or
welfare,
well over a hundred indicators have
been used.
Excluding those that
are solely measures of political or
economic development leaves a small
number.
Of these, only three —
infant mortality, life, expectancy (at
age one) and basic literacy — are
the
component
indicators
of
the
Physical Quality of Life Index.
(1)
None of the three measures
assumes any
particular pattern
of development or
depends in
any way on the particular organiza
tion of the economy.
A system can
be non-market, non-urban, non-in
dustrial; it can be a centrally plan
ned economy or a market economy.
The indicators are still relevant.
(2)
The three indicators are prob
ably
as
unethnocentric
as
it
is
possible
to
get
in
an
imperfect
world. The infant mortality measure
assumes that,
generally speaking,
people everywhere prefer that new
born children
not die.
The life
expectancy
measure
assumes
that
people prefer to live longer rather
than shorter lives.
Some suggest
that longer life expectancy may be
accompanied by more illness. This
is probably not the case. But even
if it were true, it
would probably
not
diminish
the general
human
preference to live rather than die.
Some societies have
not histori
cally set much store by literacy.
Others have been biased against
universal
literacy,
the ability
to
read and write being the monopoly
of privileged groups. This is a bias
that appears to be dwindling rapid
ly
for males, but there are still
many societies where the opposition
to female literacy
is still fairly
strong.
Nevertheless,
literacy
is
now an objective to which every
national society has committed itself
in principle. If
it is not really a
universally accepted value, it comes
close.
It is possible to argue that none
of these indicators reflects values
that are truly universal. It is clear
that where choices
must be made,
some societies favour the survival
of males over females. It is also
true that literacy may not be an
absolute good but can serve as a
subtle Instrument that enables the
powerful to dominate the lower or
ders with a minimum of physical
coercion. One can push such co
nundrums to the point of total rela
tivism where no international
(or
even
interpersonal)
comparison
is
possible. This is not the place to
examine this subtle issue. In prac
tice, comparisons are made and the
three indicators — literacy, infant
mortality
and
life
expectancy
raise fewer problems of international
and intercultural comparison
than
others.
(3)
Each of the three indicators
measures results.
This is clear for
infant mortality and life expectancy.
In the case of literacy, it can also
be seen as an input.
There is
particular justification to treating it
as a result where the object is to
measure benefits going
to the
very poorest groups. To the extent
that social participation and control
over
one’s
environment
represent
desirable goods in themselves, the
spread of basic literacy can be seen
as a measure of expanded power
and improved status
which is pro
bably desired by increasing num
bers of poor people. In the words
of a Delhi construction worker: "At
least now we can read measurements
when we are working and when a
letter comes from home we don’t
have to wait till the babuji agrees
to read
it to us." (The Statesman,
New Delhi, August 8, 1979, p.3)
(4)
Each of the measures is fairly
sensitive
to
distribution
effects.
While the three indicators do not in
themselves explicitly
identify how
the benefits they reflect are distri
buted among social groups at any
moment,
an improvement in these
indicators means that the proportion
of the people sharing the benefits
almost certainly has risen. This is
quite obvious with infant mortality
and
literacy.
Individuals
cannot
accumulate
what
is
measured
by
either of these indicators. Each is
an "either-or" measure. An infant
eitner lives or dies; a person either
does or does
not meet the
basic
Measuring
The
Condition
of
India's
Poor
The
Physical
Quality
of
Life
Index
is
written
by
Morris
David
the originator
of
Morris
Ph D,
the
Physical
Quality
of
Life
Index.
He
is
a
Professor at
Brown
Uni ersity,U .S .A. ,and
Ms.Michelle
B. McAlpin,
Ph D,
is
Associate
Professor
of
Economics.
It
is
published
by
Promillla
8
Co.,
"Sonali",
C-127,
Sarvodaya
Enclave,
NewDelhi-110017.
MORRIS DAVID
MORRIS MICHELLE
B.Mc ALPIN
literacy test.
An improvement
in
either of the indicators means that
the benefit
that indicator reflects
has become more widespread and
thus the distribution more equal.
Life expectancy is a different
kind of indicator. It is the estimat
ed average number of years a per
son of a given age -- age one in
this case — can be expected to
live, using the current schedule of
age-specific mortality.
(The PQLI
uses life expectancy at age one in
order to avoid double counting the
infant mortality rate) . Social equali
ty does not mean that everyone has
the same life span; rather, every
one
has
equal
life chances
and
there are no socio-economic differ
ences
in the proportion of people
who die at each age.
The major mortality declines in
the last two centuries have come
mainly via declines in the impact of
diseases
like
cholera,
malaria,
plague,
typhus,
and
small-pox.
The techniques that produced these
results appear not to have been
very income elastic within societies.
They
either
have
been
almost
equally accessible to rich and poor
(smallpox vaccination) or depended
on social efforts — providing clean
water or eliminating malaria-carr ying mosquitoes from
which it
was
hard to exclude the poor.
(5)
The three indicators are fairly
simple to construct and understand.
Moreover, the indicators are based
on information that all governments
must gather if they even pretend to
apply any self-conscious economic
or social policy whatsoever. Gather
ing these data therefore does not
impose novel or extraordinary bur
dens on poor countries. The over
riding problem is that poor coun
tries do not have facilities to collect
any data very well, but it is no
more difficult — in fact, probably
easier - - to collect infant mortality,
life expectancy
and literacy data
than, for example, data on many of
the components from which GNP is
constructed.
The
fact
that
GNP
data seem to be available in greater
profusion and with higher levels of
apparent precision is not proof that
they are easier to come by; during
the past quarter century there has
been
a
formidable
international
effort to collect them. This effort
has been complemented by a sus
tained search for agreement on con
ventions by which inferior data are
to be used. A similar effort to get
mortality, life expectancy and liter
acy data should produce results at
least as satisfactory.
(6)
The individual indicators lend
themselves to international compari
son. Infant mortality and life ex
pectancy involve technical defini
tions of life and death that can be
applied to all humans without re
gard to culture. Literacy is diffe
rent
in that it reflects personal
control over an individual skill in a
particular country. However, basic
literacy
standards
established by
individual countries
in cooperation
with UNESCO produce ratios that
are
comparable
among
countries.
For this as with the order indica
tors, the most important feature is
that the definitions within countries
remain constant over time.
In
GNP
calculations,
various
goods and services can be combined
via a common element, market price.
The three indicators used in the
PQLI — life expectancy at age one,
infant mortality and literacy — have
no common numeraire that values
them all.
Instead, a simple index
ing system is used.
For each indi
cator, the performance of individual
countries is placed on a scale of 0
to 100, where 0 represents an ab
solutely
defined
"worst"
perfor
mance and 100 represents an abso
lutely defined "best" performance.
Once performance for each indicator
is scaled to this common measure, a
composite index
is calculated by
av.eraging
the
three
indicators,
giving equal
weight
to each
of
them. The resulting Physical Quali
ty of Life Index thus also is scaled
0 to 100.
The index is able to show change
in performance over time—not only
change between past and present
but also change that will occur in
the future.
It is constructed to
allow for improvement even by those
countries
with
the
best
current
performance without going beyond
100 and to show some deterioration
even by poor performers without
using negative numbers.
But this
is primarily a matter of conve
nience.
While
a
few
countries
have data that go back a very long
time,
comparative data on world
wide scale only
became available
after World War II and the limits for
each indicator are based on that
experience.
If future work sug
gests
that
the
limits
should be
adjusted, recomputation is simple.
The PQLI is pinned to absolute
standards at top and bottom.
This
implies that over time countries can
normally be expected to close the
gap between their current levels of
performance (in either the PQLI or
the individual components) and the
explicitly defined and fixed upper
2
limit.
This is different from per
capita GNP which can show the gap
between countries to be increasing
over time whether or not absolute
progress is being made.
For exam
ple,
more attention certainly has
been
paid
to the
fact that the
"income gap" between developed and
less developed countries is increas
ing than to the fact that real per
capita incomes in virtually all deve
loping countries rose between 1950
and 1975.
(Morawetz,
1977, Table
A-1).
Creating the 0-100 scale for basic
literacy, of course, poses no prob
lem.
Using the proportion of the
population 15 years and older who
are literate, the index is identical
with the percent literate.
Infant
mortality, being expressed as the
number of infant deaths per thou
sand live births, could lend itself
to a similar solution.
The worst
conceivable situation (=0) would be
one in which every child died with
in the first year; the best (= 100)
would be one in which no child died
during that period.
However, rates
of 500
deaths per thousand are
very rare and even rates of 250
occur only among relatively small
groups in the total population of
any country.
Gabon’s infant mor
tality rate of 229 per thousand live
births is the worst recorded by the
United
Nations
for
any
country
since 1950.
The next worse rates
are all below 210.
At the upper
end, the best performance has been
8 per thousand.
In order to avoid
clustering
all
countries
into
the
upper .one quarter of the 0-100
scale, 229 deaths per thousand is
set as 0 and 7 per thousand (the
best
national
achievement
to
be
expected by the year 2000) is set
as 100.
If a country were engulfed
by a great social catastrophe that
raised infant mortality above 229,
the index would show the result as
a negative number.
Because each
indicator is equally weighted, only
a disastrous infant mortality ex
perience could produce a negative
PQLI.
The advantage of a scale
that fairly effectively spreads infant
mortality across the 0-100 range is
worth
the outside chance of an
occasional negative number.
The lowest reported life expect
ancy at age one for the entire
post-World War II period is 38 years
for Vietnam in 1950.
This is used
as the low end (= 0) of the life
expectancy index.
The upper limit
was set at 77 years for men and
women
combined
(= 100)
on the
basis of various expert judgements
of what could be expected for the
year 2000.
Thus the range for each index
was based on the examination of
historical
experience,
modified
where appropriate by expectations
of possible change.
The literacy
index ranges from 0 literacy to 100
per cent literacy^. £he, infant mortal
ity index ranges from 229 to 7 per
thousand births; the life expectancy
at age one index ranges from 38 to
77 years.
Table 1 shows for Nig
eria, India and United States how
the indicators were changed to in
dex
numbers and
then
averaged
(equally
weighed) to generate the
PQLI.
The PQLI is designed primarily to
measure
the
performance of the
world's poor countries in meeting
the most basic needs of people.
(That the PQLI can highlight inter
esting and important facts
about
other countries is purely serendipi
tous.)
The PQLI is not concerned
with the methods by which results
are achieved.
In fact, it is deli
berately
designed
not
to
give
weight to inputs, to effort or to
good intentions.
By focusing on
results,
the
index
can
identify
countries that have used simple,
inexpensive means of obtaining wel
fare gains.
This may encourage
those who think about development
to think more radically about alter
native strategies.
What
does the PQLI
measure?
Life expectancy at age one and
infant mortality appear to be very
good indicators of the results of the
total social process, summing the
combined efforts of social relations,
nutritional
status,
public
health,
and family environment.
To the
extent that changes in income and
calorie intake do result in changes
in life and death patterns, they are
exhibited in infant mortality and life
expectancy rates.
Although infant mortality rates
and
life
expectancies
appear
to
measure the same thing--"health"-they actually reflect quite different
aspects of social performance.
This
is suggested by the tact that the
historical behaviour of the two indi
cators has been (and remains) quite
different.
Mortality rates of people
over age one declined significantly
in many western countries during
the second half of the 19th century
remained
while
infant
mortality
improvestubbornly
resistant
to
The decline
ment.
------------ of
- infant mortal
ity was a separate and later pro
cess.
This different behaviour also
characterizes our own time.
Infant
mortality tends to be due to parti
cular
conditions
and diseases
to
which the adult population is both
•
•
vulnerable.
less exposed and less
family practices
as
Maternal
and
well as the .role
— and position
... of
women within the family are decisive
during infancy.
After infancy
it
is the much broader and al -embra
cing environmental impac
a
efines the level of life and death
chances.
Measuring the condition of India’s Poor
Table 1.
The literacy indicator provides
information about the potential for
development
and
the
extent
to
which poor groups can share the
possibilities and advantages of dev
elopment
activity.
While
literacy
typically is defined as the capacity
to read and write,
the potential
power of the poor initially rests on
the
ability
to read.
Writing
is
obviously
important,
but
profes
sional scribes can always be hired.
The skill of a scribe does
not
establish a monopoly over compre
hension and thus over opportunity.
But whatever definition is used,
literacy is a more useful measure
than
enrollment
or
numbers
of
classrooms or teachers.
These lat
ter often
either do not provide
information about results or simply
reflect the benefits (secondary or
higher education)
that are going
primarily to elite groups.
In con-
Life Expectancy at Age One, Infant Mortality, and Literacy,
Actual Data and Index Numbers, Early 1970s
L ife expectancy
at age one
Years
I nfant mortal ity Literacy
1 ndex
number
Per
1 ndex
Per 1000
Index
live births number cent number
N iger ia
49
28
180
22
25
25
25
1 ndia
56
46
122
48
34
34
43
U.S
72
88
16
96
99
99
94
Birth to six months
most babies protected
by breast feeding.But
overworked and under
nourished mothers
mean babies at risk.
One baby in six is born
underweight and is
vulnerable to disease
Six months to two
years poverty and
lack of parental
education can mean
inadequate solid
foods and unhygienic
environment, death
rate rises to 30 or 40
times as high as in rich
countries.
Inadequate diet and
heavy workload for
pregnant mothers.
CYCLE
Age three possibility
of mental stunting
because of malnutrition
or because listless
child does not demand
the stimulation needed
for mental development.
Lack of energy
and poor
performance
at school.
In the Sixth Plan (1980-85) a
daily intake of 2,400 calories per
capita in rural areas and 2, 100 in
urban areas,
corresponding to a
consumption expenditure of Rs. 65
per capita per month in rural areas
and Rs. 75 per capita per month in
urban areas, has been adopted to
define the poverty line.
The per
capita consumption expenditure is
based on 1977-78 prices.
On this
basis,
51 per cent of the rural
people, 38 per cent of the urban
people and 48
per cent of
the
people in the country, as a whole,
are living below the poverty line.
3
bating
to
an
economic
and
so
cio-political
interpretation
of
illhealth;
that is,
to analyse and
explain the societal roots of the
health
problems being confronted
within one's daily work.
For exam
ple, instead of lamenting the "igno
rance" of a dying village woman
brought to a clinic for a difficult
childbirth,
the health worker can
point out the barrier of poverty
which
prevents
her
family
from
bringing her to medical care soon
er, and at the same time expose
how the organization of the health
services can create further bar
riers.
Likewise, there is a need
for factual recognition of the limited
role of medical techniques in impro
ving
health
in
society.
Coming
from
health
professionals,
such
analysis can contribute to weaken
ing
the
medical-model
ideology
which
continues
to dominate and
thus legitimize the status quo. In
deed, there is continuous need to
expose and challenge the ideological
content of positions taken by the
medical establishment or contained
in official health policies.
So neg
lected is this whole area that it will
be
useful
here
to consider one
recent example in detail.
Interpretation of physical or so
cial reality can be shaped by ideo
logy.
Such an ideological influence
can clearly be seen in the current
debate over the definition of the
"poverty line" — a debate which
contains profound health and politi
cal
implications.
The
debate
has
involved criticism by P.V. Sukhatme
of the extent of
undernutrition he
feels
is
implied by the poverty
estimates given by Dandekar and
Rath's 1971 report. Poverty in In
dia. Sukhatme accepts that a signi
ficant proportion of the population
is
smaller in size (body weight)
than
properly
nourished
people
should
on
average
be.
But
he
argues that many of the poor have
successfully adapted to lower food
intakes
and
are
not
necessarily
unhealthy.
("The
body
build of
children living on intakes smaller
than
the
average
was
certainly
small, but the inference that they
were
either
undernourished
or
anaemic or otherwise not
healthy
was
found to be unwarranted on
biochemical
examination
of
their
blood.")
He
therefore
concludes
that the official minimum food re
quirement, as a measure of pover
ty, should be lower
than for indi
viduals
with normal
(ie. optimal)
weight. ("It is necessary to adjust
intake data for body weight before
comparing it with the expected dis
tribution of requirement.") In other
words, because of this "adjustment"
capacity of the poor, it would be
misleading to apply the
minimum
nutrition standard for wellnourished
Indians to the population as a whole
when seeking to "define" poverty.
6
Dandekar replies that Sukhatme's
statistical
methods and analysis are
faulty,
and that the experimental
data on
intra-individual variation
upon which he bases his argument
are inadequate and inappropriate.
Dandekar also points out the dan
gers of "vested interest in a pseu
doscientific proposition".
For as
sessment of these two positions the
reader is encouraged to refer to the
original papers.
I agree with Dandekar's position.
More importantly, what is revealed
in
Sukhatme's
argument
is
more
than fuzzy statistical thinking. One
is also compelled to ask what the
consequences
are
of
Sukhatme's
theory. Several critics have warned
that Sukhatme's argument can lead
to a "politically-expedient" re-defi
nition of poverty: lowering the re
quired food intake allows those in
power to minimize the "problem" of
poverty, or even re-define it out of
existence. But this debate is also
important in the way it reveals the
role of ideology in shaping the way
people perceive social issues. And
it is because health standards are
being
used as a vehicle for promo
ting particular ideological positions
that the health worker's role in this
debate is so important.
What is
meant by "ideological
position"? Ideology refers to a sys
tem of socio-political beliefs which
is
not scientific,
but rather,
is
comprised of opinions and values
which are derived from the social
position
of
the
people
originally
expressing them. It is crucial then
to find out whose "opinions and
values" are represented. The state
ment that lower (than optimal) body
weight for one section of the popu
lation is not a problem, that it is
acceptable,
is
not
scientifically
based. (In fact, the correlation of
increasing
disease
and mortality
rates in
adults and children with
decreasing income and food expen
diture suggests precisely the oppo
site.) It is thus an ideological posi
tion, as Sukhatme interestingly ad
mits: "What constitutes the expected
level of physical activity and body
weight depends on culture, ideology
and other factors."
The
point
is
that
Sukhatme's
conclusions are a prescription not
for himself, but for others — for
the
labouring poor.
His position
contains two elements. First, a ra
tionalization of two different stan
dards of physical life. And second,
an
implicit
justification
of
the
powerlessness of those in the lower
nutritional standard to choose for
themselves which standard they will
belong
to,
or
to
challenge
the
double
standard
itself.
Thus
Sukhatme's argument is ideology of
and for the ruling class.
This is even more clearly revealed
in Sukhatme's interpretation of why
the issue of hunger is important.
He explains: "A hungry man is a
social liability. He cannot work...
he will retard economic and social
development".
Now
Sukhatme's
meaning of "hunger", it appears, is
not the ordinary meaning. There is
no doubt that
landless and subsis
tence-farming families suffer acute
hunger for
varying parts of even
an average year, as Banerji's recent
studies document, and as is imme
diately evident
in
most villages.
Obviously,
this is not the hunger
which Sukhatme has in mind. What
kind of hunger then is he concern
ed
about?...
Hunger
which
re
bounds upon society; hunger which
is,
in his own words,
a "social
liability". In other
words, hunger
which interferes with the work out
put of
the poor, and thus
is a
liability
to
those
who
presently
benefit from that
labour. Hunger
therefore
upsets
and
threat
ens the socio-political status quo.
Highlighting the
ideological con
tent of Sukhatme's argument raises
the
more important question as to
the source and support for such
thinking
within
the
social
order
generally. In other words, it is not
surprising
that
one
individual
should hold such beliefs. But the
fact that such a position has re
ceived much attention and sympathy
within a significant portion of the
scientific
community
and
ruling
class as well makes critical res
ponse necessary.
What
distinguishes
Sukhatme's
position
is
the
rationalization
of
differing standards for physical life
and
inherently,
for
physical
well-being and survival.
Such an
ideological position is an
implicit
declaration of "class war". Yet at
the
same
time,
so
forthright
a
statement is hardly surprising. For
it can be expected that as the
contradictions in the social order
deepen
and
thus
exacerbate
the
economic and political crisis in the
country,
the
"democratic"
and
"socialist path" rhetoric will increa
singly
be
discarded
—
slogans
which in the past have served "as
useful frills or covers for the reali
ty of strengthening of the various
vested interests in the Indian poli
tical economy".
What enables Sukhatme to bypass
this crucial ideological issue — in a
sense, to remove it from debate —
is his sudden emphasis on the tech
nological needs of the poor (such as
water
and
environmental
hygiene
and sanitation). In this way atten
tion is taken away from the central
issue,
namely the distribution of
economic
power
and,
therefore,
food. Instead,
he shifts the dis
cussion to a technical focus which
is "safe'1 — safe, because the rul
ing class maintains control as "dis
tributors" of
such benefits. The
heat is off, so to speak, and the
poor become once more the passive
recipients of handouts from those in
power. Furthermore, in case anyone
is still left with questions, access
to
this
imminently
social-political
debate is denied them by submer
sion of the argument within un
necessarily abstruse statistical lan
guage.
Admittedly,
the
scope for
social
health analysis within existing me
dical
institutions
may
be
rather
limited.
Predictably, such efforts
will
be
discomforting
and
even
threatening for many official and
voluntary health institutions.
Thus
the implications for job security are
not
insignificant!
However,
the
exact scope for such analysis which
may be possible within established
institutions remains to be fully ex
plored.
Three basic issues are revealed
by Sukhatme"s position in the pov
erty line debate. The first is the
degree to which ideology shapes the
interpretation of social reality — in
this case,
the very definition of
health.
The
second
shows
how
powerfully ideology can appropriate
scientific tools to serve the inter
ests of a particular group in socie
ty. And the third raises the ques
tion of where the health profession
stands
in this debate. Curiously
enough, it
has been an economist,
rather than a nutritionist or health
worker, who has most clearly chal
lenged Sukhatme's argument. Yet it
is
health workers who are
most
immediately
confronted
with
the
human consequences of undernutri
tion and ill-health... The potential
role of health workers in challeng
ing health injustice and the ideolo
gical beliefs which rationalize
such
injustice is undeniable -- and, one
might add, yet unrealized.
As useful and needed as such
social health research may be, how
ever, is it realistic to expect that
even such efforts could bring about
any substantial change within the
activists are
considered in an at
tempt to define what role there may
be
for
health
action
within
the
broader struggle for social trans
formation .
2.
Social Action:
Collective Involvement
From the example of Kerala it
becomes clear that action for health
change must include collective ac
tion to create pressure from below
for
the
re-distribution of health
resources and skills and accounta
bility
for
those
services.
Only
such
an
organized
response can
hope to challenge the forces and
interests which maintain the system
Social Health Research
In addition to exposing ideological
positions relating to health care and
ill-health, basic research into the
relationship
between
poverty
and
disease must be carried out.
One
example would be collecting data on
TB deaths by socio-economic class,
urban and rural.
For the rural TB
data, this would particularly involve
deaths of villagers who never reach
TB
clinics
to
be
registered
as
cases.
Another
example:
simple
documentation of what the labouring
poor manage to eat over the course
of a year, and what such a diet
implies for health; or careful analy
sis of the costs to the poor in
seeking health care,
in terms of
lost
wages,
travel,
interest
on
loans, medicines, as well as fees
charged by the voluntary health
institutions.
At
the same time,
this basic
research must be offered back to
the people whose lives it describes,
rather than being lost to them in
inaccessible
medical
journals
and
documents.
Social health analysis
thus represents an invaluable op
portunity for raising basic ques
tions among the poor, establishing a
beginning analysis of their collec
tive predicament and re-enforcing
the validity of such questioning.
profession and health services as a
whole?
Placed within a market eco
nomy frame work, the practice of
medicine acquires an internal dyna
mic which resists appeals to social
relevance.
What
action,
then,
might have broader significance for
social change?
Indeed, can working
at the "source" of ill-health be done
within the realm of health activities
at all?
This is of course the key
question for the individual health
worker interested in social change.
It is always easier to identify a
problem than to know how to take
part in solving it!
In the following
pages the experiences and thoughts
of a number of health workers and
as
it
is.
Advocacy
for
this
struggle is a central task of the
health worker.
Her presence in a
community with a visible commitment
to the labouring families can be a
significant source of strength.
But
in what way can the health worker
best fill the role of advocate?
In
the last few years various perspec
tives have emerged.
Health as an “Entry Point"
As we have seen in earlier chap
ters,
the
influence
of
isolated
health
projects
on
the
national
problem
of
ill-health
is
limited.
Recently, however, health care act
7
ivities have been presented as use
ful points for involving communities
in organizing themselves politically.
Since issues of ill-health are less
intimidating
(than,
for
example,
land reform)
they may serve to
begin a process of collective ques
tioning and organizing.
It is ar
gued that such efforts can lead to
greater consciousness and create a
base of solidarity
for the poor to
confront
the
more difficult,
and
admittedly
more
important,
social
issues.
But using health activities as an
“entry point" for the mobilization
and organization of the poor creates
is real, it may to a certain extent
counterbalance
the additional
de
pendency created by the substitute
health activities.
Theoretically at least, it has been
suggested
that
the health
entry
point can lead the labouring families
to organize themselves to pressure
for changes in other areas, such as
minimum wages, land reforms, ade
quate day care/creches for young
children, and so on.
But the tran
sition from health entry point to
broader socio-economic issues is not
easy.
The
political
demands
of
such broader action make it likely
that the health workers and some
Several rural health projects have
recently begun to discuss the diffi
culties involved in trying to move
beyond
health-related
activities.
Their experiences call in question
the validity of the “entry point"
concept.
In actual practice, there
are few comprehensive rural health
projects which have moved signifi
cantly beyond their original health
focus.
In part the reluctance to
involve themselves in broader eco
nomic and political issues may stem
from
the socialization
process of
health
workers,
a process
which
may have made them especially un
willing to participate in an egalita
rian relationship with the oppress
ed.
As well,
it may reflect the
constraints imposed by health care
work itself.
The costly nature of
many health care activities — rela
tive,
that
is,
to the disposable
income of many village families —
makes
some
degree
of
external
funding
unavoidable,
a
situation
which creates inherent limits and
controls to the activities.
This is
so whether
the external
funding
source is a development agency per
se, or income from fees selectively
charged for curative services.
On
the other hand, the tensions arising
from broader political action inevit
ably jeopardize continuation of such
funding.
This creates an anguish
ing dilemma for villagers receiving
life-saving care — for example, TB
treatment.
For
to support such
action might very well risk conti
nuation of their treatment.
At the
same time, project health workers
themselves may be reluctant to risk
the security of their own jobs and
income.
It therefore becomes im
portant to recognize these difficul
ties.
Indeed, some health workers
would even consider them an abso
lute barrier.
The Health Worker as Activist
special problems. First, providing
even an initial health service of
itself creates an additional depen
dency
within
the
community
to
maintain that “crutch" or substitute
service.
This is understandable,
considering the immediacy of health
needs
which
are often
life-death
issues.
But because dependency is
precisely the condition which deter
mines their Ill-health in the first
place, it is essential that the rural
poor collectively control the activi
ties of the health programme and
the
participation
of
the
health
workers themselves.
If this control
individual villagers will draw back,
fearful
for
the
survival
of
the
health project itself.
But clearly,
to draw back at this stage deprives
the health activities of any societal
meaning and reduces the effort to
that of providing health care to one
or a few of the six or seven lakh
villages
in
the
country.
Such
limited action neither touches the
basic cause of ill-health in that
community, nor does it contribute
to societal change.
The problems encountered in this
essential “transition" are common.
Perhaps
in
response
to these
difficulties
a growing
number of
health workers in the country are
choosing to work within a broader
social action framework — a frame
work in which the main objective is
the political organizing of the rural
poor.
Within such work, specific
health action is simply seen as one
of many issues around which the
poor can organize and act.
In choosing to work at this level
the health worker commits himself to
work with the labouring people in
order to bring about fundamental
change in the social order.
In this
way, the health worker accepts the
role of an "activist".
The decision
to work within a broader political
process,
also
means choosing
to
work simply as one member Of a
team
consisting of villagers
and
other
activists
from
beyond
the
community.
GEORGE JOSEPH
JOHN DESROCHERS
MARIANNA KALATHIL
QUESTIONS
HEALTHY QUESTIONS
Community health care demands
much from health professionals: "A
lot of pain and frustration accompa
nies
our
de-schooling
and
re
schooling
process.
We
have
to
undo practically everything that we
have learned, and face the lament
able fact that we are totally unpre
pared to answer the health needs of
our people.
We have to review and
study more on tuberculosis, schis
tosomiasis, malaria and other com
municable diseases.
Our work has
to emphasize health education, sani
tation and hygiene, maternal and
child health care, use of medicinal
plants,
and
traditional
massage.
And we have to do research and
documentation
on
our
indigenous
forms of medicine.
To make our
communication and training methods
more effective,
we must translate
scientific medical jargon into a lan
guage more understandable to the
people.
We have to learn from the
people, especially from the tradi
tional
healers."
One should add:
"We
must
be
involved in broad
socio-economic and political issues".
Conscientisation,
and Health
Political
Action
There is the possibility and even
necessity of using health issues -along with other issues — to con
science and organise the people.
Let
us now analyse,
in a more
explicit and systematic manner, the
potentials
and
limitations of
this
approach.
The basic problem can
be described as follows: "Health for
and by the people cannot become a
reality fully except in a society that
is
’healthy' in its structures and
its institutions.
The question then
is: how can community health work
contribute to the transformation of
the whole society?"
Or, in other
words:
"What
health
action
has
meaning
and
relevance
in
the
broader national struggle for health
and social justice"?
What health
action attacks the root causes of
tion and community health can play
a vital role in increasing people's
consciousness not only about their
health needs but also about the
evils in society which are the main
causes
of
their
sickness
and
ill-health." "Even illiterate, trained
health workers are quite capable of
reaching a critical understanding of
the functioning of society." "Com
munity health should also be a way
to motivate and mobilise the people
to resist the domination of the tra
ditionally powerful."
In Werner's experience, "health
activities become an important tool
raising .awareness and organising
the people."
And there are already
ill-health?
Many writers have lately empha
sised that health work should in
clude conscientisation and organisa
tion, and at least sometimes lead to
direct political action.
Approaches
5, 6 and 7 of Table 16 represent
various possibilities, and degrees of
involvement, in this field.
Accoi ding to Kaithathara, "health educa
Health Care in I ndia is jointly
authored by George Joseph, John
Desrochers and Mariamma Kalathil
and
is
published by Centre for
Social Action, Bangalore. This book
is available from Voluntary Health
Association of India for Rs. M/-.
programmes where the CHWs' chief
role is to assist in the humanisation
or conscientisation of their people.
Abhay Bang asserts that Community
Health Care projects "can be media
for conscientisation of medicos and
of the masses," and Anant Phadke
that
"conscientisation
about
the
medical system is as important as
other
aspects
of medical
work."
For Andrew Clerk, the underlying
purpose of medical work is to assist
in the removal of poverty.
And
"poverty is not the lack of medical
services as such, but the absence
of power flowing through the veins
of the poor."
Broadly speaking,
"poverty is powerlessness" and "the
usual
basis
of
power
for
poor
people is organisation."
"Medicine
is a small, but important, sub-sys
tem" and it "may be a practising
ground for newly organised people
to try... (various) social actions".
F. Muller and D. Werner therefore
conclude
that
Community
Health
Care projects should be judged by
their "political effectiveness," that
is, their contribution to the redis
tribution of wealth and power in
favour of the poor and oppressed.
9
In this context. Community Health
Care is often presented as an entry
point
for
initial contacts,
human
development,
leadership
training,
conscientisation
and
organisation,
and even sometimes, direct political
action.
The groups represented at
the
"International
Convention
on
People's
Participation
in
Develop
ment" in the fields of non-formal
education,social housing. Community
Health Care and women's develop
ment,
for example, "viewed these
inputs only as tools for the educa
tion and organisation of the op
pressed
groups
who alone could
become agents of change in their
society"; they wanted to go beyond
their respective entry point.
In
the words of A. Madiath, "we con
stantly used our involvement thro
ugh 'health' to build up awareness
in the community on other aspects
of their lives," "We succeeded with
the entry point because it was (1)
broad-based and brought us into
close contact with all sections of the
village community; (2) met immedi
ate needs of people;
(3)
it was
slow,
steady,
non-aggressive and
kept pace with the people's accept
ance of us as strangers."
It grad
ually
worked
towards
"a
wider
awareness building process" and led
to the tackling of important socio-economic and political issues.
At
that stage, the work spread rapid
ly.
Each entry
point
"has
the
capacity to create a new atmosphere
within a depressed community and
to
awaken
new
aspirations
of
self-realisation
in
an
oppressed
people.
A base is laid which makes
'development from below' possible,
enabling the people to get organis
ed, to gain bargaining power and
gradually transform their numerical
strength into political power."
In
more
theoretical
writings,
Banerji sees the struggles for Com
munity Health Care and health jus
tice as a lever for broad socio-eco
nomic and political changes.
"While
it is now being gradually realised
that
it
is
unrealistic
to
expect
improvement in the health status of
the population of a country without
appropriate political, economic and
social action, it is often overlooked
that efforts to alleviate the suffer
ing
caused
by
health
problems,
can, in its turn, contribute to the
initiation of such action."
This is
particularly
true
for
Community
Health Care.
"In the first place,
the very alleviation of suffering has
political
significance
because,
at
least in this field, it narrows the
gap between the ruling classes and
the masses.
Because of this the
masses
are
in
a somewhat
more
advantageous position to wrest their
rights
from
the
ruling
classes.
Secondly, the health services also
provide an entry point to change
agents who would make use of this
opportunity to work with the people
10
to
initiate changes
in the other
social and economic fields. Promo
tion of alternative health care sys
tem may prove to the people that
they can create better conditions
for solving their health problems.
By generating such social awareness
health work may turn out to be a
lever for promoting similar develop
ments in other social and economic
fields, such as: education, employ
ment,
land
reforms,
cooperative
movement,
legal
protection
and
social justice. In short, it has the
potential of initiating a chain reac
tion which will lead to a rapidly
increasing
democratisation
of the
masses. A campaign for active pro
motion of a people oriented altei—
native health care system thus in
fact
becomes
a
potent
tool
for
pressing for change in the political
system." Political parties and com
munity organisations should there
fore utilise the present concessions
of the Government to pressurize for
more radical changes in health care
and society.
Local conscientising and organis
ing
efforts progressively provide
the poor with "some free space in
society
where
they
can
breathe
more freely and begin to stretch
themselves". They "create a base
for joint action which is relatively
free from the control of the locally
powerful".
Such
efforts
should
however
give
rise
to
a
broad
people's movement.
The "Interna
tional Convention on People's Parti
cipation in Development" therefore
states:
"The
educational
process
that begins with these aspects of
human reality must finally culminate
in a nation-wide people's movement
with a threefold aim. The first is
their acquiring power to wrest for
themselves their basic human rights
and their rightful place in society.
The second goal of the movement
will be to put an end to the control
by the few over housing, health,
education and other human needs.
Finally,
the movement will create
new values in order to influence
changes
in
a culture to ensure
greater respect of persons.
Ultimately, trade unions and poli
tical
parties
should
shake
their
lethargy and take up such grass
roots demands.
In this way,
the
people's struggles for their health
and other — needs
will be
grounded in a massbased political
movement
and
linked
with
the
struggle
for
a
socialist
society.
Qadeer and
Zurbrigg go further
and emphasise the necessity and
priority of well-organised political
struggles. Qadeer criticizes Banerji
for his utopianism, which mistakes
spontaneous mass action for planned
political struggles, and points out
that "a secondary lever for political
change,
that is, health services,
must not overshadow the primary
lever which is the struggle of the
people for control over resources
and
their
distribution."
"Health
programmes have only a supportive
role in the political actions of the
working people." While recognising
the
usefulness
of
"reforms
that
bring
about
some
relief
to
the
people...
even
within
the
con
straints of the existing system",
those who want to change today's
society should therefore adopt, as
primary concern, the strengthening
of the working class movement and
situate their health efforts in this
framework.
In practice,
the work of con
scientisation and organisation has to
be carried out at several levels.
Villageor
neighbourhood-level
awareness enables people to con-
front local issues and oppressors.
Besides
being
involved
in
non
health questions,
larger organisa
tions can demand "the proper im
plementation of those government
services,
including
public
health
and drinking water, to which they
are entitled", and fight corruption
and inefficiency among public ser
vants. They can pressurize for ac
countability. Rather than establish
ing
substitute
services
—
over
which continuation the people have
usually no firm control--,
health
professionals should directly parti
cipate in such agitations , protests.
They
should
also
support
these
struggles by informing the people
about Government programmes and
the results of social health research
"necessary
evidence
when
it
appears as medical symptoms, of the
systematic deprivation, exploitation
and harassment from which the poor
suffer'. These issue-oriented strug
gles do not aim at transforming the
health system, but at implementing
the already recognised rights.
At a broader level, systematic
efforts should be made to conscientise the various health professionals
-- through societal health analysis
and concrete experiences in Commu
nity Health Care products — and
the general public. So much can,
and
should,
indeed
be done
to
expose the injustice of the present
health system and its ideology, and
to contribute to a social and politi
cal interpretation of ill-health. While
focusing
on
non-health
targets,
political parties, trade unions and
other
mass-based
movements
can
and
should
struggle
for
better
health policies and even an alterna
tive
health
care
system.
Health
professionals should involve them
selves in such people's movements
and help them to identify, formulate
and
adopt
the relevant
demands
that will really benefit the poor and
oppressed. This will be their pro
fessional
contribution
to
people's
movements and struggles.
We may end this section with two
convincing calls for a broad in
volvement. Galvez-Tan writes: "We
did not realize that working among
the people would demand new roles
for us. We were trained in medical
practice,
but the situation called
rather for someone in the role of a
change agent with special skills in
health care. To be a change agent,
we have to be a community organi
zer,
catalyst,
teacher,
learner,
researcher, conscientiser, coordina
tor, supervisor and health worker,
all at the same time. We learn how
to arouse and organize the people,
systematizing
their
experiences,
feelings, skills and action as well as
their dreams so that they can mobi
lize themselves to move out of their
dehumanized conditions." "My work
with the peasants" has awakened me
Participation
as a way
to control people
to the deep need of fundamental
structural
changes.
"How
will
a
Filipino doctor answer this chal
lenge? I am a Filipino doctor. What
can I do to change this situation? I
would like to think of myself first
as a Filipino and only secondly as a
doctor, and this means going be
yond medicine and health .. . Doc
tors who consider themselves Filipi
nos first and doctors second cannot
remain
apolitical —
we must be
aware of what is happening around
us and try to be of greater service
to the people. This means uniting
with ...
(other groups) in their
struggle for nationalism and demo
cracy. Our expertise in health must
be devoted to that wider struggle."
Werner
is
no
less
eloquent.
Speaking
of
his experience with
Mexican
villagers,
he
concludes:
"The cruel and unnecessary hard
ships these people suffered were
not simply because they were poor,
but because they were on the bot
tom, because they were stepped on,
belittled,
cheated,
and
exploited
time and time again. Such is the lot
of most of mankind. To separate
such
needless
suffering
and
its
human causes from what we call
"basic health needs" is to separate
our minds — indeed, our hearts —
from our bodies. It is to add our
seal of silent approval to the abuses
of man by man.
If such talk is
political, let it be so. I will stick
up for the interests of man. The
poor first. But ultimately for the
interests of all mankind, rich and
poor. For unless man learns soon to
overcome his greed, his greed will
soon overcome him. We must learn
to be kind. We must learn to let
others have an equal share and an
Participation
as a way for
people to gain control
equal chance. We must learn to be
more truly and wholly human. This
is what health-- and healthy politics
-- is all about... Clearly, alterna
tives are needed; alternatives that
restore dignity, responsibility, and
power to the people on the bottom;
alternatives that allow and encour
age the poor to analyse the whole
physical, social and political reality
of their situation and to organise so
that they gain, through their own
actions, greater control over their
health and their lives." We must
therefore
work
with
courage
to
make these alternatives a reality.
Many things have become clear:
for
example,
the magnitude
and
urgency of the problems; the in
efficiency and injustice of the pre
sent system; the impact of various
socio-economic and political factors
on health (food, water, sanitation,
housing, and consequently employ
ment,
wages,
land
distribution,
representation
and
participation,
etc.); the need for a radical re
orientation of priorities, budgets,
and training of all health profes
sionals and workers. In this light,
it is undeniable that a major and
immediate shift should be made in
favour of the poor and especially
towards rural areas and backward
and vulnerable groups. And that
significant improvements in health
conditions and in society as a whole
will only take place when the people
come forward and assume responsi
bility for their own development and
health.
The people must express
their needs and priorities at ail
levels. Health for and by the people
is absolutely essential. The Commu
nity
Health
Care
approach
has
therefore to spread everywhere and
11
the people have to become conscientised about health and other issues
so as to take charge of their lives
and build various types of organi
sations to work for justice in every
field of life.
Our
nation
is
undergoing
an
overall crisis of confidence. In this
context,
most health professionals
pursue their ordinary activities in
the present system, but without a
sense of deep achievement and a
conviction of contributing much to
the building of a better nation. And
the more socially enlightened among
them risk to become paralysed by
the immensity of the problems and
their
uncertainty
about
relevant
action. It is however our contention
that the possibilities of meaningful
involvement are clear enough for all
to come out of their indifference,
lethargy and discouragement and to
rediscover a new sense of direction
and purpose. To remain passive and
silent makes us partly responsible
for the continuation of the evils
that exist in the health field and in
the society at large. Not to oppose
the system means to support it, at
least in practice. Time has come for
each individual, group and institu
tion to confront
the basic issues
and to make the required decisions.
The insights contained in the book
have indeed very concrete implica
tions and challenges for all of us.
These challenges first of all con
cern us as individuals — whether
one is a doctor, nurse, development
worker, social activist or an ordi
nary citizen. Here are some of the
questions one must personally ans
wer :
‘How can I concretely make an
option for the poor and put my
capacities and skills at their ser
vice?
*How can I promote Community
Health Care in my sphere of work?
‘How can
I
spread a proper
understanding
of
health
issues,
conscientise others around me, and
take part
in
political
action
for
better and more just health ser
vices?
‘How to change my own ideas,
values and attitudes towards health
and health care and free myself
from my class biases?
‘How can I
develop a proper
vision and perspective?
Besides such questions that may
already
bring
some
significant
changes in our present work and
life, there are still more challenging
ones:
^What should indeed be my prior
ities and focus of action? In other
words,
what
should be my own
approach? Taking into account not
only my personal background, ex
periences, and skills, but also the
people's needs,
and the objective
hierarchy of relevance spoken of in
12
this book, where should I work —
in what area and with what target
groups? — and with what institu
tions or groups? And how can I
efficiently
collaborate
with
those
who follow complementary approach
es?
How can I
remain concerned
with broader issues, while making
my specific contribution?
Here are some of the questions
for various institutions — such as
hospitals,
dispensaries,
research
and training centres:
‘How can they contribute to the
reorientation of the health system
towards the poorest sections of In
dian society, and to the spreading
of Community Health Care and of
conscientisation/political action with
regard to health? In particular, how
can existing dispensaries and clinics
promote
Community
Health
Care,
work
in
collaboration
with other
individuals and groups and help to
conscientise
and
organise
the
people?
‘How can hospitals learn to see
beyond the immediate wants of their
patients,
become
involved
in
people's
problems,
and encourage
community participation in hospital
decisions?
‘How can they contribute to the
establishment of outreach centres
where basic services are provided?
‘How can their personnel and
facilities truly serve the poorest
section, at least much more than
now?
‘How can hospitals promote health
education?
‘How can they transform them
selves
into
referral
centres
and
become models for the future?
‘And how can the various train
ing institutions for doctors, nurses.
CHW’s,
etc.,
really expose their
trainees to the health needs of our
country, give them a genuine ex
perience of Community Health Care
and provide them with a proper
societal health analysis?
‘What training programmes will
conscientise the future health pro
fessionals and workers about larger
issues and prepare them to become
community animators and organizers
and to work as a team with the
people and other development work
ers and social activists?
‘And how can our research pro
grammes be truly focused on India's
health needs and the integration of
modern and traditional medicine?
All
the institutions that sincerely
want to serve the people's needs
must , devote enough time to reflect
on these issues and decide their
future course of action.
In some
cases,
they
must
even
question
whether they should not close down
and become involved in more rele
vant approaches.
Voluntary organisations,
action
groups,
religious
congregations,
and even broader organisations face
such important challenges. Efficient
hospital and curative services, as
well as specialist care will always be
needed. What is wrong is not that
such services exist, but that they
are unequally distributed, and that
more basic needs are not met and
more essential services are not pro
vided.
In consequence, what should be
the main approach or focus of ac
tion of your group/organisation or
religious congregation?
How to turn yourself towards the
most needy?
What does today's emphasis on
Community
Health Care and conscientisation/political action concret
ely mean for you?
What target groups and areas
should you mainly serve?
In what institutions or projects
should you be involved?
What % of your members should be
in each of these? Should some mem
bers of your group/ organisation or
religious
congregation
work
in
Government institutions — as for
example hospitals and PHCs — and
try to transform them?
If there are greater needs than
those you presently meet, and bet
ter services than those you pro
vide, how to reorient your work?
Do you possess the courage to
close down or hand over less im
portant services and institutions to
begin more relevant ones?
And how to ensure that all your
members have a proper understand
ing of today's issues and are pro
perly conscientised, motivated and
involved?
Broader organisations like trade
unions and political parties have
moreover to discover how they can
reflect and support people's aspira
tions for better health and better
lives,
and integrate people's de
mands in their movements.
The socio-economic, political and
ideological structures of our coun
try impose limitations in our work.
This is true for both Community
Health Care and conscientisation/political action.
But how can this situation be
changed? By starting where we are
and
using
every
possibility
for
transforming action! The only means
available
are
Community
Health
Care, conscientisation, and various
people's
movements and organisa
tions, and we must learn how to
use and develop them. Vested in
terests and reactionary/conservative
forces will undoubtedly oppose ra
dical changes in health and other
fields.
But,
once again,
how to
change this situation? The only way
is to counteract these forces by
uniting the people in their action.
This book has presented and as
sessed various possibilities of rel
evant action. It is now our respon
sibility to take a stand, choose our
approach and make our contribu
tion .
TEACHING GUIDE OF TRAINERS OF
VILLAGE HEALTH WORKERS.
Dr. PATRICIA F WAKEHAM.
THE FEEDING
AND CARE
OF INFANTS AND
YOUNG CHILDREN
This teaching guide is a series of
lesson plans which give basic facts
about a wide range of health topics
with some suggestions as to how
these facts can be taught often to
illiterate village women.lt has been
written
primarily
with
non professional village health workers
in mind
(eg.Nurse aids,
drivers
etc) it
may
give
fresh
ideas
to
professional
health
workers
too.
These lesson plans are available in
a detachable file. Pages
260, Rs
60/Please write to VHAI.
ADVERTISEMENT
REVISED,
ENLARGED,
BROUGHT
UP TO DATE !
Now in its 5th Edition
Rs.18/- , Pages 182.
FOR COPIES please write to
The Publication Officer
Voluntary Health Association of
India
C-14,
Community
Centre
Safdarjung
Dev. Area
New
Delhi-110016.
We are looking for a Hindi-speak
ing doctor to help
run a small
rural
health
project
in
Santhal
Parganas, Bihar. Salary negotiable.
Applicants please write giving de
tails of qualifications and experience
to
M. Ganguli,
P.O. Jagdishpur,
Via - Madhupur,
Deoghar Dist.,
Bihar - 315 353.
13
MAHARAJA
SAID IT
Statement by the Maharaja
of Travancore at the
opening ceremony of
the Trivandrum Civil
Hospital in 1865:
"I take this opportunity earnestly
to impress this fact on the minds of
all my native subjects and to urge
them to seek for themselves, for
their children,
for their friends,
and for their servants, the great
protection of vaccination.
"They will see the strength of my
conviction in the fact that there is
no member of my own family that
has not had this protection con
ferred at an early age."
ASSIGNMENT CHILDREN
1U
COMMUNITY
ORGANISATION
Subject:
Community Organisation
Goal:
Organising
the Powerless
Power.
(iii)
for
What is Community Organisation:
(a) Definitions:
Community organisation is the
alignment of groups/or groups of
people living in the same socio
economic and socio - cultural milieu
with identical or similar interests.
(b) Examples:
Negative
Village Panchayat is not a com
munity organisation because people
with
opposing
interests
are
grouped together.
Alternative
"Village Sangham" is a community
organisation, because,
(i)
It unitedly protects the
members
from
their
oppres
sive structures.
Now Existing Forms
There are different community
ganisations existing based on.
or
(ii)
It is a democratic organisa
tion respecting the decisions of its
members.
(iii)
It provides scope and forum
for all its members
(iv) It provides opportunities
for
discussion
and
sharing
in joint action.
(i)
Positive
Trade
union
is
a
community
organisation because members have
similar
interests
such
as
higher
wages, better facilities and better
social status.
(ii)
Still, trade union cannot be a
full-fledged community organisation
because,
it concentrates more on
economic
demands
and
ignores
socio-cultural
dimensions
of
the
group.
(v) It
settles
the
internal
disputes
between
the
members among themselves without outside intervention.
(vi) It believes in equality,
human
rights
and
dignity,
mutual friendship and solidarity.
(vii) It
participates
in
the
socio - cultural
life
of
all
its members, such as the marriages
and
death
ceremonies,
sickness,
festivals,
entertainments,
cultural
activities, etc.
(viii)
It has identical political or
class perspective.
Sikh
Religion: (Christian
Muslim, communities).
H indu.
On caste and ethnic basis;
such as Brahman, Vysya,
Reddi,
Sila, Mala, Madiga, Banjara, Akali,
Nirankari etc.
sucn as pan
Rayalseema,
(iii)
On Geo-political
chayat,
Telengana,
etc.
(iv) On linguistic such as Telugu,
Malayalee, Hindi, etc.
Union of Members
Alternative
Members whose product
labour is exploited.
from
their
How continued:
Alternative
(i)
By meeting together regular
ly-
(ii) By articulating and sharing
their problem/s.
(iii) By identifying
the problem/ s.
the cause of
(iv)
By identifying achievable
solutions
to
solve
the
pro
blem/s .
15
(v) By assessing their strength
to achieve.
(vi) By identifying
sympathisers.
allies
and
Tamil
against
Telugu,
Akali
against Nirankari, small and mar
ginal farmers against landless la
bourers .
Positive:
(vii) By arriving at a common
decision
on
the
joint
ap
proach and identifying leadership.
(viii)
By analysing and
responsibilities and tasks.
assigning
Alternatives:
Industrial labour against indus
trialists,
Right wing against left
wing parties, peace
group against
gists against pollution and deforest
ation, Fishermen communities again
st
mechanised fishing industrial
ists, Small scale and cottage indus
try workers against
large indus
tries and multi-nationals. Sustenan
ce
and
biofarming
against
agro
business.
HOW
As Practised
(i)
By taking an area or harmo
nious village approach.
(ii) By meeting influential cate
gories in
the
village (elite)
e.g.
Sarpanch, Karman, village officer,
landlords and selecting
target
groups
as
beneficiaries
that
are
suggested by the elite.
(iii) By paternalistic actions (dis —
tribution
of
wheat,
milk
powder
etc.)
(iv)
By making tall promises.
Alternatives
(i) By observations and structur
al analysis (to categorise the deci
sions of people on economic, politi
cal, socio-cultural factors).
(ix) By
rehearsing
demands,
preparing slogans, posters, hand
bills etc.
(x) By setting
negotiation
and
or withdrawal.
strategies for
compromise
(xi)
By reflecting on the out
come both positive as well as nega
tive
and
analysing
the
cau
ses.
Specific Activities:
Selection of target group:
Definition
Target group consists of' those
who
have
individual
or
group
grievances against any other indivi
dual or other group of individuals
because of socio-economic, political,
and
cultural clash of interests.
(iii) By conducting street-corner
meetings to
discuss some is
sue common to many in that street.
(iv) By conducting joint meetings
with selected topics emerging out of
street - corner
meetings
for
final selection of target groups.
(v) By reducing to writing of
resolutions,
minutes,
etc. and of
the group decision on the composi
tion of the members of the group.
(vi) By enrolling members and
collecting membership fees, etc.
(vii) By selecting the ad hoc exe
cutive workers or electing executive
body, etc.
Examples:
WHY NOT
Negative:
A major reason of underdevelopment
is inequality, exploitation and op
pression practised by the elite in
the area. By a total area develop
ment approach inequality and eco
nomic gaps will widen resolution in
Reddies
against
Chowdaries,
DMK against ADMK, Hindus against
Muslims,
Maias
against
Madigas,
A.I.T.U.C.
against
C.I.T.U.C.,
16
arms
race
groups,
Agricultural
labour against landlords.
Tenants
against
absentee landlords, Harijans against upper
castes. Ecolo
(ii) By family visit to verify and
confirm
or
alter
the
findings
on categorisation and for exchang
ing views and to build up rapport
and
credibility.
ween the action groups and target
groups and rejection of the former
by the target groups.
WHY
The alternative approach
on the following rationale.
is
based
(i)
Survey, observation,
etc.,
make the selection "need-based".
(ii) Meetings will make the ap
proach participative, democratic and
collective and will lead to identifica
tion of
interests
common
to the
majority. Such majority members will
fix and determine procedures.
9
Procedures help disciplined union of
the target group (majority) who will
be probably capable of responsible
action in future.
increase of not only economic
but
also
political,
socio-cultural
oppressive and exploitative power of
the elite.
Paternalism
increases
dependency
and will reduce self-reliance of the
target groups.
Tall promises will create illusion and
will raise hopes and aspirations and
finally lead to credibility gaps bet
This
article
is
taken
from
"Dialogue", an occasional publication
of
Dialogue
group,
61,
Dr Radha
Krishan
Road
Madras-600 004.
OATELSNE OEM
SPIRIT OF PARTNERSHIP
Over 40 Non-Governmental organ
isations from
all
over
India es
pecially those
involved in health
and development programmes parti
cipated in Health Ministry's meeting
with
NGOs.
Mrs.
Sarla
Grewal,
Secretary to the Health Ministry, in
her introductory words expressed
the need to involve
the non-health
sector in the national health activi
ties. She stressed the need for a
consultative body to look into the
problems of NGOs.
"We are partakers in the health
work.
We
should
work
hand
in
hand. We shall together think, dis
cuss, plan and evolve a new way of
working," she told the NGOs.
Dr. Mutalik, WHO, Geneva, stated
that governments have come to a
conclusion all over the world that
the helping hand of the NGOs is
not
merely
a
necessity
but
an
indispensable one. Many of the par
ticipants
shared
their
views,
problems,
needs and suggestions.
Some of them are given below :-
1)
Involving NGO's in areas of a)
health
education
Monitoring
and
evaluation of health activities c)
Research and Pilot studies d) Self
help promotion.
2)
Setting
up
of NGO
Federation.
3) Making vaccines
available
free
of charge to the
Indian Medical
Association
branches
and
minimal
service charges be allowed.
4) Coordination
labour
and
ministries.
between
social
5) Setting
to NGO's.
loans
up of
and
health,
welfare
grants
6) Production of essential
drugs
and making them easily available all
over the country.
7) Changing the drug departments
from
the
Chemicals
and
Fertilizers Ministry to the Health
Ministry.
8)
Constructive dissent.
9)
Exclusion
of
hospitals
Industrial dispute act.
from
10) Subsidy in
road,
water
electricity taxes for NGO's.
and
11) Introducing
scheme.
12) Integrating
with
agriculture
education.
health
insurance
health education
and
adult
13) Updating
the
family
with health information.
folders
14) Selection
of community health
workers in consultation with
local
NGO'S.
This meeting paved the
way for
mutual
support
and
cooperation
between the government and the
non-governmental
organisations.
Voluntary agencies will not be the
last
resort
but
the
first to be
consulted. A special chapter on the
voluntary
agencies
is
being
included in the
seventh five year
plan. In conclusion, the spirit of
partnership was reaffirmed.
17
MURRAY
TEACHING
DICKSON
FAMILY AND FRIENDS IN YOUR
COMMUNITY
Do not attack a belief because it is
traditional.
Many
traditions
are
more healthy than "modern" things.
Often, instead of telling people that
their belief is wrong, you can re
mind them of a different tradition
that is healthy.
lot of added sugar which quickly
makes children's teeth rotten.
Also, do not
milk or tea.
sweeten
your
child’s
When she is young she can learn to
enjoy drinks that are not sweet.
BE A GOOD EXAMPLE
Other people like to watch what you
do before they try something dif
ferent. First show members of your
family and then they will be an
example to others in your communi
ty. For example:
1. Instead of buying all your foods
from the store, buy fresh fruits
and vegetables from the market. It
is even better to grow food in your
own garden.
Learn to use several different kinds
of food in each meal. Mixing foods
is a healthy idea. Invite friends to
share your meals and see the num
ber of different foods you have at
each meal.
Clean, cool water,
tea with little
sugar, milk, or water from a young
coconut are best to drink. Fresh
fruits are delicious when you are
thirsty.
Most important: do not give your
especially
child a feeding bottle,
one with a sweet drink inside.
3. Keep your children's teeth clean.
Your friends will notice clean teeth
or teeth that are dirty or have
cavities. Remember, clean teeth are
healthy teeth.
An older child can clean his
teeth if you show him how.
A younger child cannot. He needs
help.
Each
day
someone
older
should clean his teeth for him.
own
2. Do not buy fizzy drinks like
Coca-Cola or Fanta. They have a
When you teach, remember that as
others learn, they too become tea
chers. Each person can teach an
other.
Encourage
people
to
pass
along
what you have taught. Mothers can
teach family and friends. Students
can talk at home with brothers,
sisters, and older family members.
If all learners become teachers, a
simple message can begin in the
health clinic or school and reach
many more people at home.
FINDING THE BEST WAY
TO TEACH
Deciding what to teach is important,
but just as important is how to
teach.
Learning cannot take place when
you use words that people do not
understand. They will learn some
thing only when they see how it is
"Where There Is No Dentist" is
written by Murray Dickson with an
introduction
by
David
Werner,
author of "Where There Is No Doc
tor" and is published by The Hes
perian Foundation.
This book will
soon be available in India through
Voluntary
Health
Association
of
India.
related to their lives.
Remember
this
when
you
teach
about eating good food and keeping
teeth clean. Design your own health
messages, but be ready to change
them if people are not understand
ing or accepting what you say.
Here
are
five
teaching well.
suggost’onS
1. Learn First From
the People
member to emphasize eating good
food
and
keeping
teeth
clean.
Repetition helps people
remember.
Get involved in your community's
activities.
Learn
about
people's
problems, and then offer to help
solve them. People will listen to you
when
they
know
that
you
care
about them and want to help.
Sit and talk
with people.
Learn
about their customs, traditions and
beliefs. Respect them.
*Let people see what you mean.
Use pictures,
puppets, and plays.
4. Teach Wherever People
Get Together
An even better way for a mother to
learn is to let her clean her child's
teeth while you watch. A person
discovers
something
for
herself
when she does it herself.
Pick out a child and clean his teeth
yourself. Let his mother watch.
Use a soft brush (or for a baby, a
clean cloth).
Gently but quickly
brush or wipe his teeth. Do the
best you can even if he cries.
Learn also about tooth decay and
gum diseases in your community.
Knowing where to teach is some
times
as
important
as
how
you
teach. Instead of asking people to
come to a class you have organized,
go to them. Look for ways to fit
into their way of living. You both
will gain from the experience. They
will ask more questions, and you
will learn how to work with people
to solve problems.
Make people smile —
their mouths.
5. Teach Something People
Can Do Right Away
Now let each mother clean her own
child's teeth. Teach her to clean on
top and on both sides of every
tooth.
It is good to tell a mother to keep
her child's teeth clean, but it is
better to show her how to do it.
She will remember how if she ac
tually watches you clean her child's
teeth.
Ask her to do the same at home
each day. At the next clinic, look
at the children's teeth and see how
well the mothers are doing. Give
further help when needed. Always
praise and encourage those who are
doing well.
Learn
about
their
health habits.
Improving
health
may
require
changing some habits and strength
ening others.
then
look
into
Find out how many children and
adults
are having
problems
with
their teeth and gums. Do a survey.
2. Build New Ideas
Onto Old Ones
People find their own ways to stay
healthy. Many traditions are good,
helpful,
and worth keeping.
But
some are not.
When you teach,
start with what
people already understand and are
doing themselves.
Then add new
ideas.
This method of teaching is called
"association
of
ideas".
It
helps
people
to
understand
new
ideas
because they can compare them with
what they already are doing.
In this way people can more easily
accept, remember, and do what you
suggest.
3. Keep Your Messages
Short and Simple
Instead of partially
teaching
too
many things, it is better to discuss
a few things well. After learning
what health problems the people feel
are greatest, decide what informa
tion
will
help
them
solve
these
problems.
Then think of how to
share the information. Try to:
* Use simple words. If you must
use a big word,
take the time to
explain it.
* Teach people when they are ready
to learn. A
sick person, for ex
ample, usually wants to
know how
to prevent his sickness from re
turning. He will remember what you
tell him.
* Repeat the most important mes
sage many times.
Whenever you
teach about staying healthy,
re
If mothers make this into a habit,
the child will expect to have his
teeth cleaned and will soon cooper—
ate — just the way he does to have
lice removed from his hair.
ASHOK DAYAL CHAND
M IBRAHIM SONI
WHEN
PEOPLE EVALUATE
communicable
diseases
were
prevalence health problems.
high
Objectives
A CASE STUDY FROM INDIA
Evaluation, if
its
main purpose is
to
help
a programme achieve its
objectives, cannot be simply an iso
lated, terminal
event. It must be
part of a continuous process of
two-way
communication
between
health workers and the community,
and be based on the routine moni
toring of key indicators of person
nel
performance
and
programme
effectiveness.
'Participatory evaluation' can be
defined
as
a
process
of
self
realization in which an organization,
working
with
the
community,
studies the strengths and weaknes
ses of its
programme through the
participation of the community and
all levels of health workers. The
Ashish Cram Rachna Trust based at
Pachod, in Maharashtra State, has
followed
this
approach
since
the
start of the Comprehensive Health
and Development
Project
in
July
1977.
In the following article we
shall present the results of our
experiences
during the first three
years of the project, from July 1977
until June 1980.
BACKGROUND
The setting
The area originally assigned to the
project by the government covered
72 villages and hamlets (reduced tc
50 in 1980) in the southern part of
20
Paithan development block, Auran
gabad district, Maharashtra State.
In
1977
the population numbered
about
67,000
people
living
in
12,500 households. The area of 575
km
has low rainfall and only limit
ed irrigation facilities. One in three
households
is
landless,
and
half
own less than four hectares. The
main crop is jowar, a type of millet.
Only one in five villages is serviced
by buses;
the remainder — far
from the main
roads
— can be
approached omy by bullock cart or
on foot and are virtually inaccess
ible during the monsoon.
The majority (70 per cent) of the
population is Hindu, but there are
sizeable Muslim and Buddhist minor
ities. Marathas comprise the domi
nant caste. Female literacy levels
are low: only 16 per cent of women
can read and write, compared with
45 per
cent of males. In 1979 two
out of every three households had
an average monthly income of less
than 200 rupees.
Health problems
The most prevalent health problems
in 1977 included chronic malnutri
tion,
xerophthalmia
(night
blind
ness), diarrhoea, and tuberculosis.
Infant and maternal mortality rates
were
high, and only a small minor
ity of mothers and children were
immunized.
Owing to the lack of
safe drinking water and adequate
sanitation,
intestinal parasites and
In 1975, when the project was
being planned, the following objec
tives were set for the first four
years•
1.
Reduction in the crude birth
rate 36 to 25 per 1000 population.
2. 50 per
cent reduction in the
infant mortality rate of 128 per 1000.
live births.
3. 50 per
cent reduction in the
child
mortality rate of 48 per 1000
children under five.
4. 50 per cent reduction in malnu
trition of under-fives.
5. Treatment of 80 per cent of
existing blindness among patients
with
curable eye diseases, and 80
per cent control of xerophthalmia.
6. Effective
ante-,
intra-,
and
post-natal
care
and
immunization
against tetanus to 80 per cent of
pregnant women.
7. Bringing under control 80 per
cent of tuberculosis cases (15 per
1000 population).
8. Bringing under treatment 80 per
cent of leprosy cases.
9. Training of traditional midwives
(dais) in all project villages
and
training of Multi-purpose Workers
(MPWs) for all the sub-centres.
10. Dissemination of health educa
tion through regular mass health
education programmes
in
all vil
lages .
As a result of rigorous self-eva
luation from an early stage, how
ever, some of these objectives were
modified during the course of the
first three years of the project.
Personnel
Project staff at the base hospital
(20 beds) in Pachod consisted of
two national doctors,
one public
health nurse, one nutritionist, one
demographer,
six
auxiliary nurse
midwives (ANMs), and various ser
vice
personnel. Workers at 'grass
roots' level comprised
eight male
MPWs, 20 women Community Health
Workers (CHWs), and 37 dais — all
recruited from within the project
area and trained by the project
staff.
COMMUNITY
PARTICIPATION
IN EVALUATION
A process of two-way commumca
meagre
living
as
an
agricultural
labourer.
This was
far short of
their
expectations.
The
project
staff
therefore
explained
the
impracticality of the people's hopes:
the cost factor alone
ruled out
constructing a clinic and placing a
nurse in every village. Gradually,
though at first reluctantly, these
explanations were accepted.
Three years after the start of the
project,
the dais had established
themselves as key health workers in
the community. Around 70 per cent
of mothers were receiving ante-natal
care from the dais; they conducted
56 per cent of deliveries and were
rendering post-natal and neo-natal
care to 77 per cent of mothers and
children in the project area.
tion with the community was initiat
ed in 1976, before the implementa
tion of any project activities had
started.
This
process
continued
throughout
the
project,
enabling
the community to participate in eva
luating the following aspects of the
programme.
* Setting priorities
* Training traditional birth at
tendants
* Implementation of activities
* Health
and
nutrition
education
* Direction and emphasis of the
programme.
Setting priorities
In 1976 a 10 per cent systematic
sample survey was conducted in 22
villages with a population of 20,000
to
identify
the priorities of the
community. Health
was ranked only
eleventh,
well
behind
priorities
such as food and employment. The
interviewers then tried to establish
the community’s highest priority in
the field of health. In 21 out of the
22 villages the response was mater
nal care,
because childbirth was
usually the only time when imme
diate medical
help was felt necess
ary especially in villages situated
some distance from the hospital.
The project proposal therefore
was
redesigned
to
give
highest
priority — at least during the first
four years — to maternal care and
midwifery
services.
The
revised
plan
involved the
training of a
woman from within each village as a
community
health
worker
(CHW),
with particular emphasis on mid
wifery.
But as the project staff
studied the role of the dais within
the community,
the revised plan
also was called
into doubt. Tradi
tional birth attendants (dais) as
sisted at 6 per cent of all deliver
ies, with 8 per cent assisted by
trained medical personnel and the
remainder by mothers or mothers-in-law. Usually the dai was called
only after serious complications had
set in, by which time it was too
late for her to take any useful
action. To justify her involvement,
however, she
made some ineffec
tive (and sometimes dangerous) ef
forts,
such
as
massaging
and
stretching
the
woman's
vagina.
This
resulted
in
further loss of
time. When, in desperation, the dai
referred the woman to a
health
centre or hospital, it was usually
too late to save
both mother and
child. Yet despite the dai's lack of
midwifery training, knowledge,
and
skills, people in the community still
sought her help during emergen
cies.
The
project
staff
realized
that this pattern of dependence on
the dai would continue with many
people even
if the
village CHW
was given specialized training in
midwifery.
This example illustrates how com
munity
involvement
in
the
early
stages of planning a PHC project
can
make
the project's
priorities
more relevant
to the community's
felt
needs. At the same time, how
ever,
it
shows
how,
through
a
process of two-way communication,
the project can help the community
to a better informed understanding
to how their health needs can be
met.
The village dai today is a
community-supported health institu
tion -- not dependent on the pro
ject for her survival — providing
an effective and widely appreciated
maternal
and
midwifery
service
helping to lower rates of maternal
and infant mortality.
Training dais
The project was therefore revised
a second time. The new starting
point would be the training of vil
lage dais in maternal care and mid
wifery,
with CHWs and MPWs to
come
later.
But
people's
initial
reactions to this plan were luke
warm. They had envisaged a sort of
mini-hospital with a resident nurse
in every village. What they were
being offered . instead was simply
their own village dai — an illiterate
woman of low caste who earned a
This was essentially a process of
retraining,
since
most
dais
had
been assisting deliveries by tradi
tional means for 25 to 30 years. It
involved
changing
a
deeply
en
trenched set of
values,
beliefs,
and
practices. Simply telling the
dais outright that their practices
were harmful
would have created
serious psychological barriers and
resistance to the acceptance of new
knowledge and practices. We there
fore adopted a problem-solving ap
proach to the training process.
Each dai firstly was interviewed,
using a 160-item questionnaire. We
thus formed a detailed inventory of
their
attitudes,
knowledge,
and
practices.
We
then
designed
a
training programme aimed at chang
ing harmful practices, encouraging
beneficial traditional customs,
re
shaping attitudes and values, and
adding
new
knowledge.
Changing
harmful practices required a very
sensitive approach. We designed the
training course so that participants
were exposed to problems and ha
zards in midwifery and suggested
solutions. One harmful practice, for
example, was giving newborn babies
two spoonfulls of
castor oil in the
belief
that a catharsis was necess
ary to remove the fluids of the
womb ingested by the newborn dur
ing birth. This often caused severe
diarrhoea
leading
to
dehydration
and death. But instead of simply
rejecting the
harmful practice, we
tried to modify it and render it
harmless. Granted, we said, a baby
needs a laxative,
but castor oil
is
much too strong. Are there any
alternatives sufficiently mild for a
newborn baby? The dais suggested
various traditional herbal laxatives.
One suggested
honey, which was
readily
available
in
all
villages.
Through concensus it was decided
to recommend a spoon of honey as a
laxative for the newborn, a practice
now
widespread
in
the
project
area.
We
know,
of
course,
that
newborn babies need neither honey
(though it does no harm) nor a
laxative. But by helping the dais to
modify
their
traditional
practices
rather than flatly rejecting them,
we
successfully
discouraged
a
harmful health practice while avoid
ing the creation of psychological
barriers to change.
Implementation of
activities
In each village a health commit
tee consisting of one person from
each caste
or each lane has been
formed. Most committees are maledominated,
despite all the dais and
CHWs being women, and 80 per cent
of
the
project's
services
being
directed
to women and children.
Nevertheless, the committees have
generally played a
useful role by
giving official backing to the health
project
and
overcoming
logistical
problems by providing a building,
lighting, and other facilities for the
mass immunization of children. The
main point of delivery of health
services,
however,
is
the ante
natal clinic,
held twice a month
and organized mainly by the local
dai and CHW in each village. This
22
is also the forum in which women's
attitudes,
beliefs,
and
health
practices are formed. Problems are
aired and solutions proposed and
discussed. One of the major prob
lems with which the
project grap
pled unsuccessfully for two years
was accurate
identification of the
last
menstrual
period
of
new
ante-natal women. Since most women
are illiterate, they were occasionally
15 days to one month
wide of
the
mark
in their estimates.
This in
turn made it
impossible for the dai
accurately to calculate the expected
date of the woman's confinement.
Finally
the dais
and the village
women developed their own solution:
by comparing the
data of each
woman's menstrual period with the
dai's every month, a very reliable
estimate
was obtained.
While the
project's
professionally
trained
health workers had failed to solve
this problem, a group of illiterate
village women devised their own,
disarmingly simple solution.
your blood pressure
normal?
Health and nutrition
education
the first four years of the project
our
village-based
CHWs
used
to
keep and maintain all the under-five
children's
growth
charts.
Every
month they would weigh the child
ren and explain the findings to the
parents: the child's weight, degree
of undernourishment and what is
needed to be done for
the child to
gain
weight.
If
the
child
was
severely malnourished the workers
would give
more intensive nutri
tional and health education.
Rather than using a series of
formal lessons, health and nutrition
education take place in the informal
atmosphere of the ante-natal clinics.
For
example,
while
examining
a
pregnant mother the dai asks ques
tions such as:
'Why am I examining your eyes?
'What
is the cause of your anaemia,
and how can it be overcome?
'Why am I examining your abdomen?
What do I find
out? How can that
help you?'
Aft^r the dai completes her exami
nation the pregnant woman moves
on to the nurse for examination and
vaccination. The nurse asks:
'Why are you having this injection?
'How many more must you have?
'Why
am
I
taking
your
blood
pressure?
What
can
happen
if
is much above
If the newcomer cannot answer a
question, women coming to the cli
nic for
their second or third preg
nancy take great delight in chipp
ing in with the answers. This has
become a kind of game played every
second week at the clinic, and has
established
ante-natal
care
as
a
routine activity within the communi
ty. The same method of informal
health education is also used for
other components of the programme.
In this way the
mothers become
involved in an active learning pro
cess directly related to the factors
influencing their own health
and
that of their children.
In nutrition education the people's
questions and proposals have help
ed to eliminate weaknesses in the
programme of which the staff had
been unaware. For example, during
During
this
whole
four-year
period we explained undernutrition
in terms of first, second, and third
degree malnutrition. Then a chance
episode made us
realize that the
message was not being understood
by the people.
In one village a
grandmother who was always very
particular
about
having
her
grandchild
weighed
commented
to
the
CHW:
'What
is
this
first,
second, and third degree you keep
telling me about? Tell me about the
health of my grandchild in annas
of a rupee.’ The old Indian rupee
had 16 annas and to this day a
traditional form of expressing per
centages in villages is:
100 per cent - 16 annas in a rupee
75 per cent - 12 annas in a rupee
50 per cent - 8 annas in a rupee
25 per cent - 4 annas in a rupee
When we heard about this, we
selected a random sample in all our
villages
to
find
out
whether
'degree of malnutrition' had been
understood by the majority of the
parents or not. We discovered that,
although the parents recollected the
actual weight of their child, they
could
not
recall
the degree of
malnutrition.
This
indicated
that
they did not understand the mean
ing of the word 'degree' in the
vernacular.
We then instructed all our work
ers to tell the parents the actual
weight of the child and to interpret
nutritional status as follows:
- 1 6 annas
in a rupee
first degree
-12 annas
malnutrition
in a rupee
second degree
- 8
annas
malnutrition
in a rupee
third degree
- 4 annas
ma Inu t r i t i on
in a rupee
Today every parent throughout
the project area can express the
nutritional status of their under-five children in terms of so many
annas in a rupee. Once we had
established that parents could do
this, we started giving them a copy
of their children's growth charts to
keep and maintain. The families of
most villages in the project area
now keep growth charts
in
this
way.
norma I
Direction
and
programme
emphasis
of
The CHWs and dais have made a
number of suggestions, based on
practical experience, leading to sig
nificant changes
in the direction or
emphasis of certain aspects of the
programme.
In
the field of nutrition,
for
example, the emphasis has shifted
from treating malnutrition to pre
venting
it. From the
start, the
project
has emphasized nutritional
surveillance of
under-fives
and
nutrition
education
for
mothers.
Good use has been made of locally
available foods, rather
than provi
ding supplementary
feeding
with
food brought
into the region. The
CHWs
and
MPWs
used
to
visit
severely malnourished children
in
their homes twice a month to moni
tor the
children's growth and give
nutritional
demonstration
to
the
parents.
After
three
years
the
proportion of severely malnourish
ed children was cut
to one-quarter
of its former level. But the CHWs
also noticed that
many children in
the 'mild to moderate' category of
malnourishment
were failing to gain
weight and some were even falling
back
into
severe malnourishment.
They therefore
suggested that, in
order
to
prevent
malnutrition
before
it
even started, the pro
gramme should give
greater em
phasis to educating the parents of
children under the
age of four
months. This would better prepare
them to
feed their children ade
quately during the critical weaning
period. The programme now incor
porates this emphasis, though con
tinuing the routine nutritional sur
veillance of all under-fives.
Changes have also occurred in
the technology used to assist deli
veries. Initially
we
provided the
dais with
blades, string, gauze,
cottonwool,
and iodine,
all auto
claved (steam-sterilized) and sealed
in polythene bags. Being autoclav
ed, the blades and string required
no boiling before use. We instructed
the dais, however, to teach families
the
importance
of
boiling
these
items before use if they conducted
deliveries without the dais' assis
tance. We discovered in a survey
that only one in five families was
sterilizing their blades and string
in this way. We reproached the dais
for failing to
educate village fami
lies about the need for sterilization,
but the dais provided us with a
more convincing explanation. Village
women,
they said,
only saw
the
dais break the seal of the polythene
bag,
remove the blade
and
use
it. 'They never see us boiling it.'
They suggested that the project,
instead of giving them autoclaved
equipment in sealed polythene bags,
should simply provide unsterilized
materials similar
to those used by
village
women.
They
then
would
boil them in people's homes, ex
plaining the importance of doing so
to the family. Several dais
now
work
in
this
way,
and
we are
evaluating
the
experiment
before
recommending its wider application.
EVALUATION
AS
INUOUS PROCESS
A
CONT
Evaluation takes place concurren
tly
with other routine programme
activities.
The project staff meet
the dais, CHWs, and MPWs every
week
to assess and discuss one
another's performances, based
on
data collected by a detailed
health
information
system.
Much
effort
has
gone into designing this sys
tem,
which
is
convenient
for
health workers to maintain and for
supervisors
to follow up. All levels
of health workers
keep records on
a
daily,
weekly,
monthly,
halfyearly,
and
annual
basis.
The
basic sources of
information are as
follows:
*Household
records maintained by
multi-purpose workers.
‘Ante- and post-natal records main
tained by auxiliary nurse-midwives.
‘Village files maintained by project
supervisors.
‘Records of vital events maintained
by CHWs and MPWs.
‘Growth
charts
for
under-five
children,
kept by families.
This
health
information system
enables the systematic
evaluation
of changes brought
about by the
health
programme
in
three
main
areas:
* The knowledge, attitudes,
and
practices of health workers.
‘ Health awareness and
practices
in the community.
* Certain key health indicators.
Measuring change
After the programme had been run
ning for three years
an evaluation
of the 22 villages covered showed
significant
changes
in
maternal
health care (see Table 6.1).
These results indicate a marked
improvement in the health awareness
and practices of people — especial
ly
mothers -- in villages covered
by the project. The sharp decline
in the maternal mortality rate is
particularly striking.
The same evaluation also found a
33 per cent
drop in
the infant
mortality
rate
(IMR)
(see
Table
6.2).
During the same period the IMR
among children born to women in
villages in the project area where
maternal care services had not yet
started fell only slightly, from 128
to 120. This marked difference sug
gests that the
programme had a
significant
influence
in
lowering
the IMR in the villages which it
covered.
Another significant indicator of the
well-being of infants and children is
the nutritional
status of under-fives. The evaluation found a 75
per cent drop in the number of
children suffering from third degree
malnutrition (see Fig. 6.4).
One cause of concern, however,
was the continued inferior status of
girls compared with boys
23
Table
6.1.
Changes
in maternal
1 t em
1977
(Before
Proj ect)
1980
(Three
years
imp 1 emen t a t i on)
1 .
Pregnant women cov
ered by ante-natal
serv i ces
On 1y in rare,
complicated cases
70%
of
women
2.
Detection of pregnan
cy by t r a i ned da i
Nil (no trained dais
ava i 1ab1e)
5th mon th
period
3 .
Pregnant women vacc
inated with two doses
of tetanus toxoid
1.5%
55%
4 .
Pregnant women rece
iving iron tablets
for at least one month
Not known (but proba
bly negligible)
55%
5 .
Pregnant women at
tending ante-natal
clinic at least
tw i ce
Nil (no ante-natal
clinic available in
v i 1 1 age)
7 6%
6.
Recently delivered
women receiving
post-natal services
Neg 1 i g i b 1 e
67
7.
Women attended by dai
dur i ng del i ve ry
6.0%
5 6%
8 .
Women referred to
hospital (Ante and post-natal cases)
1.5%
8%
9.
Ma t ernaI
12 per 1000
1 i ve-b i r t hs
Table
6.2.
dea ths
Infant mortality
Popu1 a t i on
Year
1977/78
1978/79
1979/80
15
?S
30
145
015
230
Although the nutritional status of
girls did improve during the three
years, their position is clearly still
inferior to
that of boys: twice as
many girls were severely malnou
rished and considerably fewer were
in the normal range. These findings
ha^/e
important social implications.
Immunization coverage was low
before the programme started. Our
baseline data survey showed that
in 1978 only 8 per cent of children
in the project area had received
three doses of DPT and only 17 per
cent had
received any vaccinations
at all.
The evaluation showed a
great increase in coverage achieved
by our
mobile vaccination team,
which began giving DPT and BCG
vaccinations in 22 villages only nine
months before the evaluation
in
June 1980 (see Table 6.3.)
24
care among mothers
health
rate
Project
total
pr egnan t
of
ges t a t ion
4.5 per 1000
1 i ve-b i r t hs
in project
area
No.of
vi1lages
Li ve births
registered
1n f an t
deaths
Infant mo r t a 1 i t y
rate per 1000
1 i veb i r t hs
12
19
22
203
508
589
23
53
48
123.2
104.3
8 1.5
Table 6.3.
Immunization status of children, June 1980
Under-fives
Under-fives
3
doses
of DPT
No.of
No. of
V illages Underfives
22
Table
2639
6.4.
BGG
Number
%
vacci
vacci
nated
nated
1729
N umber
%
vacci- • vacci
nated nated
65.5
1755
28.3
Family planning acceptors
Method
Year
Tubectomy
Vasectomy
1976
1977
1978
1979
1980
387
187
149
244
395
7i
12 1
0
13
25
Family planning, which can con
tribute to improving the health of
mothers and children through spac
ing births at
wider intervals, has
not yet been actively promoted by
the project. (Even the words 'family
planning'
still
stir
up
negative
associations for many people.) But a
modest number of men and women
came voluntarily to
the base hos
pital for vasectomies or tubal liga
tions
in
1979,
and the numbers
increased in 1980 (see Table 6.4.)
Most
of
the men
and
women
coming to the hospital for steriliza
tions were
referred by CHWs and
dais,
although
they
received no
encouragement
from
the
project
staff to promote family planning.
CONCLUSION
Participatory evaluation has help
ed us match our programme's prior
ities
with the people's felt needs
and
to
design
training
methods
suitable for local
cultural condi
tions. It has guided us in imple
menting activities appropriate to the
special needs of women in rural
Indian
society,
and
in
fostering
health education for women. It has
also enabled us to review the know
ledge, attitudes, and practices
of
our
health
workers,
to
assess
health
awareness
and
practices
within the community, and to mea
sure the effectiveness of the pro
gramme using a set of key indica
tors.
It is important to use the
method as a routine
part of the
programme rather than simply as a
special, isolated activity at the end
of a certain period. We have found
participatory evaluation
to be an
invaluable tool for correcting the
methods, emphasis, and direction of
our health programme.
Postscript,
October 1982
Since the
evaluation in 1980 we
have been reconsidering some of the
concepts
underlying
our
health
programme. We feel
that terms like
'community participation' and 'parti
cipatory evaluation' too often mean
in practice that the community par
ticipates
in
activities designed for
it by outsiders. Despite our efforts
to involve
the
people in deci
sion-making,
implementation,
and
evaluation of the programme, they
still did
not feel sufficiently res
ponsible for
implementing activities
independently in their villages. We
wondered whether 'health
by the
people' could be made a reality
in
a
Third
World
country,
where
health has low priority.
We
therefore decided to start
work in 12
villages not previously
covered, but
without making any
prior
assumptions about the form
or
structure of any future pro
gramme. The people elected repre
sentatives
from
each
caste
and
section
of
the villages,
and
we
helped them organize a survey to
identify
their
most
urgently
felt
needs.
The
representatives
then
took part in processing the infor
mation collected, and held meetings
with
sections of their communities
to discuss the results and propose
ways of overcoming the problems.
We believe this approach is helping
us avoid
the
need for large cor
rections and modifications to the
programme. It is an
improvement
CHAI AND VHAI JOINTLY ANNOUNCE 4
WEEKS COURSE ON COMMUNITY HEALTH
MANAGEMENT
For Whom
Middle level workers
decision making power such as
Programme co-ordinators
Programme Planners
Supervisors
T rainers
on our
approach in 1977, when we
had sociologists and medical stu
dents from Aurangabad carry
out
the initial village survey.
with
: To equip personnel with
Purpose
and
skills
for
innovating
concepts
Health
and
Development
Community
Programmes
Training grass-root level leaders
Medium of the training : English
Venue
: Catholic Ashram, Binjhia
Mandla P.O., Jabalpur, M.P. 481 661.
Date
November,
:
1985.
Each village also selects a tradi
tional birth attendant and a commu
nity development worker for train
ing by our staff. After training,
these village level workers initiate
and
guide
the
development
of
health-related activities within their
own communities, to whom they are
accountable.
This
has
created
a
situation in which the community ,
once mobilized into
action, imple
ments its own programme with tech
nical advice and training from our
staff.
This more
sensitive approach to
community
participation
resulted
from careful evaluation of the first
three years of our programme. We
are confident that lasting improve
ments
in
health
status
can
be
achieved through the community not
only
demanding
health
services,
but providing some of these ser
vices
itself and carrying out in
tensive
self-education. ‘Health by
the people' need not be a Utopian
dream.
Practising Health For All by David
Morley, Jon Rohde and Glen Williams
provides case studies of political
commitment,
peoples
participation
and
programme
development
with
examples
from
all
over
the
world.
This
Oxford University
publication is available from VHAI.
15th
October
For details,
prospectus
forms contact :
and
to
10th
application
The Programme Director
Community Health Deptt.
CHAI, CBCI Centre
Goldakhana P.O.,
New Delhi - 1 10 001.
The Co-ordinator
Community Health Education, Training and
Personnel Development,
VHAI, C-14, Community Centre, S.D.A.
New Delhi - 110 016.
Completed
application
addressed to CHAI to
August, 1985
forms
should be
reach before 20th
25
MILES TO GO
Presently, despite the constraint of
resources, there is disproportionate
emphasis on the establishment of
curative
centres
—
dispensaries,
hospitals, institutions for specialist
treatment — the large majority of
which
are
located
in
the
urban
areas of the country.
The vast majority of those seeking
medical relief have to travel long
distances to the nearest curative
centre, seeking relief for ailments
which could have been readily and
effectively handled at the community
level.
Also
for
want
of a
well
established referral system,
those
seeking curative care have the ten
dency
to
visit
various
specialist
centres, thus further contributing
to congestions,
duplication of ef
forts
and consequential
waste of
resources. To put an end to the
existing
all-round
unsatisfactory
situation, it is urgently necessary
to restructure the health services
within the following broad appro
ach:
(1) To provide within a phased,
time-bound
programme a well dis
persed
network
of
comprehensive
primary health care services, inte
grally linked with the extension and
health
education approach which
takes into account
the fact that a
large majority of health
functions
can
be
effectively
handled
and
resolved by the people themselves,
with
the
organised
support of
volunteers,
auxiliaries,
para-medi
cals and adequately trained multi
purpose workers of various grades
of skill
and competence, of both
sexes. 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 uti
lised and intermeshed with
the
governmental efforts, in an integra
ted
manner.
(2) To be effective,
the esta
blishment of the
primary health
care approach would involve large-scale transfer of knowledge, simple
skills
and
technologies
to health
volunteers,
selected by the com
munities and enjoying
their confi
dence.
The
functioning
of
the
front line of workers, selected by
the community would require to be
related to definitive action plans for
the
translation
of
medical
and
health
knowledge
into
practical
action, involving the use of simple
26
NATQONAL HEALTH POLICY
UNTEGUMTHOW
Net work of services
Health education
Volunteer support.
and inexpensive intervention which
can be
readily
implemented by
persons
who
have
undergone
short
periods
of
training.
The
quality of
training of these health
guides/workers would
be of cru
cial importance to the success of
this approach.
(3) The success of the decentral
ised primary
health care system
would depend vitally on
the or
ganised building up of individual
self-reliance and effective communi
ty participation; on the provision of
organised,
back-up
support
of
the secondary and tertiary levels
of the health care services, provi
ding adequate logistical and techni
cal assistance.
(4) The decentralisation of servi
ces would
require the establish
ment of a well worked out referral
system to provide adequate expert
ise at the various levels to the
organisational set-up nearest to the
community,
depending
upon
the
actual needs and
problems of the
area, and thus ensure against
the
continuation of the existing rush
towards
the curative centres in
the urban areas.
The
effective
establishment of the referral sys
tem would also ensure the optimal
utilisation of expertise at the higher
levels of
the hierarchical struc
ture.
This approach
would not
only lead to the progressive im
provement of comprehensive health
care
services at the primary level
but also
provide for timely atten
tion being available
to those in
need
of
urgent
specialist
care,
whether they live in the rural or
the urban
areas.
(5) To ensure that the approach
to health
care does not merely
constitute a collection
of disparate
health interventions but
consists
of an integrated package of services
seeking to tackle the entire range
of poor
health conditions, on a
broad front, it is
necessary to
establish
a
nation-wide
chain
of
sanitary-cum-epidemiological stations.
The
location and functioning
of
these stations may be between the
primary and secondary
levels of
the hierarchical structure, depend
ing upon the local situation and
other relevant considerations. Each
such
station
would
require
to
have suitable trained staff equipped
to identify, plan and provide pre
ventive,
promotive
and
mental
health care services. It
would be
beneficial, depending upon the local
situations,
to establish such sta
tions at the Primary Health Cen
tres. The district health organisa
tion should have, as an integral
part
of its set-up, a well organi
sed epidemiological unit to coordinate
and superintend the
functioning
of the field stations. These sta
tions would participate in the inte
grated
action plans to eradicate
and control diseases, besides tack
ling specific local
environmental
health problems. In the urban ag
glomerations,
the
municipal
and
local
authorities should be equip
ped to perform
similar functions,
being
supported
with
adequate
resources and expertise, to effec
tively deal with the local prevent
able public
health problems. The
aforesaid approach should be imple
mented and extended through com
munity participation and contribu
tions, in
whatever form possible,
to
achieve
meaningful
results
within a time-bound programme.
(6) The location of curative cen
tres
should
be
related
to the
populations they serve
keeping in
view the densities of population,
distances, topography and transport
connections.
These centres should
function within the
recommended
referral system, the gamut of the
general specialities required to deal
with
the local disease patterns
being provided as
near to the
community
as
possible,
of
the
secondary level of the hierarchical
organisation. The concept of domi
ciliary level and
the field-camps
approach should be utilised
to the
fullest extent, to reduce the pres
sures on these centres, specially in
efforts
relating to the control and
eradication of
Blindness, Tuber
culosis, Leprosy, etc. To maximise
the utilisation of available resour
ces,
new and additional
curative
centres
should be established only
in exceptional
cases,
the basic
attempt being towards the upgradation of existing facilities, at select
ed locations, the guiding principle
being to
provide specialist ser
vices as near to the
beneficiaries
as may be possible, within a wellplanned
network.
Expenditure
should be
reduced through the
fullest possible use of
cheap lo
cally
available building materials,
resort to appropriate architectural
designs
and engineering concepts
and by economical
investment in
the purchase of machineries and
equipments, ensuring against avoid
able duplication of such acquisi
tions,
it
is
also
necessary
to
devise
effective
mechanisms
for
the repair, maintenance and proper
upkeep of
all bio-medical equip
ments
to secure their
maximum
utilisation.
(7)
With a
view
to
reducing
governmental
expenditure
and
fully
utilising
untapped
resourc
es,
planned
programmes
may be
devised,
related to the local requirements and potentials, to en
courage the establishment of prac
tice by private medical professional,
increased investment by non- gove rnmental
agencies establishing cur
ative
centres
and
by
offering
organised logistical,
financial
and
technical
support
to
voluntary
agencies
active in health field.
(8) While
the major
focus of
attention in
restructuring the ex
isting governmental
health organi
sations would relate to establishing
comprehensive primary health care
and
public health services, within
an
integrated
referral
system,
planned attention would also re
quire to be devoted to the esta
blishment of
centres equipped to
provide speciality and super-spe
ciality
service,
through
a
well
dispersed network of centres,
to
ensure that
the present and fu
ture
requirements
of
specialist
treatment and adequately available
within the country. To reduce gov
ernmental
expenditure involved in
the establishment of
such centres,
planned efforts should be made
to
encourage
private
investments
in
such
fields so that the majority of
such centres,
within the govern
mental
set-up,
can provide ade
quate care and treatment to those
entitled
to free care, the affluent
sectors
being
looked
after
by
paying clinics. Care would
also
require to be taken to ensure the
appropriate dispersal of such cen
tres, to remove
the existing re
gional
imbalances and to provide
services within the reach of all,
whether rural or the urban areas.
(9)
Special, well-coordinated pro
grammes
should be launched to
provide mental health
care as well
as medical care and the physical
and social rehabilitation of those
who are
mentally retarded, deaf,
dumb,
blind,
physically disabled,
infirm and the aged. Also, suit
ably organised programmes would
require
to be launched to ensure
against the prevention of various
disabilities.
(10) In the establishment of the
re-organised
services,
the first
priority should be accorded to pro
vide services to those residing in
the tribal, hill and backward areas
as
well
as
to endemic disease
affected populations
and the vul
nerable sections of the society.
(11) In the re-organised health
services
scheme,
efforts should
be made to ensure
adequate mobi
lity of personnel at all levels
of
functioning.
(12) In the various approaches,
set out
in
(1)
to
(11)
above
organised efforts would
require to
be made to fully utilise 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,
specially
those
which seek
to serve the need of
the rural areas and the
urban
slums.
Reorientation of the
existing health personnel
A dynamic process of change and
innovation
is
required
to
be
brought in the entire approach to
health manpower development, en
suring the emergence of fully in
tegrated bands of workers function
ing within the "Health Team" ap
proach.
The Parliament adopted the National
Health
Policy
during
the
winter
session.
Paragraphs
8
8
9
are
reproduced here.
27
FRANCIS ROLT
ACHIEVEMENTS
TO DATE
Ultimately Bangladesh's Drug Policy
must be judged on its achievements;
has the Policy improved the drug
situation in the country and is it a
real step towards Health for All by
the Year 2000? The Drug Policy is
based on the premise that if com
panies are forced to compete with
each
other
to produce a limited
number of drugs,
prices should come down,
total production of essential drugs
should increase, and
transfer pricing should be less of a
problem as local companies take a
bigger share of the market.
Increase in competition
Before the Policy multinational com
panies tried not to compete with
each other. They tended to special
ise in types of drugs and tried to
build up a monopoly in that market.
An article in the newspaper Holiday
reported that "Hoechst has a virtual
monopoly in analgesics and tonics,
Pfizer in tetracycline. Organon in
hormonal
preparations,
Squibb in
vitamins, etc." Bangladeshis argue
that local companies had the capa
city to produce between three and
five times the annual production of
all the multinationals put together.
They argued that "the local com
panies could not manufacture up to
this figure because they had to face
a monopoly in the market created
by the multinationals. They were
quite unable to break this monopo
ly. Their machineries remained idle
and unused." This 'monopoly cartel1
system was destroyed by the Poli
cy. As many of the multinationals'
most profitable items were banned
they had to start poaching each
other's territory to maintain profit
levels. More companies making the
same
drugs
should
mean
lower
prices.
The same Holiday article
stated that "before the Policy came
into effect only four companies, two
local and two multinational,
pro
duced the essential drug ampicillin.
Now thirty-five do so, including all
but one of the multinationals."
Lower prices
In 1980/81 the prices of ampicillin
sold to the Government's Central
Medical Stores (which supplies all
government
health
centres
and
hospitals) was Tk. 995 (30 pounds)
per
1000
capsules.
Four
years
later,
because
of
increased
competition and control of the price
of raw materials, it was Tk. 850 (26
Pounds)
per
1000 capsules. Most
drugs
bought
by
the
Central
28
Medical
Stores
showed
tendencies, see Table 2.
under
another
company's
brand
name and transferring even more
profit than usual out of the country
by arguing that they have to pay a
licence fee for the
name. Drugs
produced under
this arrangement
similar
Market prices of some drugs also
fell — largely because the Ordi
nance declared that "No drug shall
Table 2. Tende r prices paid by the Government
(Taka per 1000 tablets/capsules)
for
different
drugs
1980/81
8 1/82
82/83
83/84
Amp i c i I 1 i n
995
440
Tet racyc1 i ne
140
Pa race t amo1
Ferrous
fumerat e withi
39.45
folic acid
170
An t ac i d
1040
Frusem i de
800
380
107.5
845
375
120
850
390
135
3 1.45
110
510
29.88
150
400
40
170
300
Drugs
Source:
Central Medical Stores, Ministry of Health
after six months from the date of
commencement of this Ordinance be
manufactured in Bangladesh under
licence granted by a foreign com
pany having no manufacturing plant
in Bangladesh if such drug or its
substitute is produced in Bangla
desh.
"The regulation prevents a
company from manufacturing a drug
are
usually
famous brand names
with an established market. Since
doctors, drug sellers and the public
are often ignorant of the generic
names of drugs, a brand name can
build
up
a
remarkable following
even if it is much more expensive
than equivalents on
the market.
Valium is the obvious example of a
branded
product
which
is
much
more expensive and more popular
than any of its competitors.
Table 3.
Price
(Taka per tablet/capsule)
of different
drugs
originally made under licence before and after the Drug (Centre
)
*
Ordinance
Fisons (Bangladesh) used to make
ampicillin under a licence agreement
with Beechams (UK), and sold it as
Penbritin.
The Ordinance forbade
such
arrangements
and
Penbritin
was replaced by Fisons' own brand
name — Ficillin.
The two drugs
were produced in the same factory
by the same workers with the same
raw materials, but because Ficillin
(dry syrup) was not made under
licence it cost Tk. 23 (0.70 Pounds)
as opposed to Tk. 28 for Penbritin
dry syrup. Other drugs previously
produced under licence also went
down in price (see Table 3).
Generic and
brand name
Company
Official
Before
Price
After
Actual
market price
Before After
AMP 1 ClLLIN
Penbritin
(F i c i 1 1 in)
F i sons
1 .69
1 . 64
2 .25
1 .40-70
CO-TRIMOXAZOLE
Sept r i n
(Avo1o t r i n)
ICI
2 . 30
1 . 30
3.50
1 .00-25
MEBENDAZOLE
Ve rmox
(E rmox)
Square
2.10
1 . 20
2.50
1 .00-20
More essential drugs
The main reason for the fall in
drug prices is increased competition
between the 9 multinationals and 25
medium-sized
local
companies.
To
get
a share of
the
market
the
companies have to compete on the
basis of price. Pfizer, for example,
started making Penicillin -- which it
does no where else in Asia — and so
began to tread on Fisons' toes. May
and Baker which previously had the
metronidazole market to itself now
has to face competition from all the
multinationals. As Table 4 shows,
production of essential drugs in
creased dramatically between
1981
and 1983.
Many other drugs are now sold well
below the maximum retail price fixed
by the government; before the Poli
cy this was rare. Even so, prices
generally have not come down as
much as they should have. A mem
ber of the Expert Committee ex
plains
that
"Instead
of
slashing
market
prices
the
companies are
giving 30-35° discounts to the tra
ders who profit, while the people
suffer. If the law was strictly en
forced
the price of most
drugs
would
come down by 20-50°?,
in
some cases 200-500%."
Source: "In whose interest is the national drug policy?"
by Dr. Z. Chowdhury. Bichitra, July 1984.
Table 4. Production
(value
by
thousand
takas)
of
first
essential drugs before and after the Drug (Control) Ordinance
After (Jan-Oct
Value
%
Before
Value
(1981)
%
Total produc t i on
(all d rugs )
1734,003
100
1883,075
100
First 1 2
e s s en t i a 1
drugs
344,435
20
48 1,790
26
Second 33
es sent i a 1
drugs
180,235
10
57 1 , 373
30
524,670
30
1 05 3, 163
56
Sha r e o f first 45
e s s en t i a 1 drugs
Source:
Figures supplied by the
Minister
press conference, 28.12.83.
of
Health
45
1983)
at
a
Fewer wasteful imports
While production was up, imports in
1983 were down by Tk. 24 million
(730,000 Pounds) over the previous
year. They are expected to have
dropped by even more during 1984
as the Ordinance forbade the import
of 531 Schedule III items from Dec
ember 1983 and their sale from June
1984. The imported value of these
items alone amounted to over Tk.
100 million
(3 million Pounds) in
1983. Professor N. Islam suggests
that the policy "will provide a sav
ing of approximately Tk. 800 mil
lion."
Drug policy no<
a total failure w
Transfer pricing under control
It
is
difficult to obtain overall fig29
ures for how much foreign exchange
has been saved by stricter controls
on transfer pricing. However some
figures for individual companies and
drugs are available. It is clear from
these that the Drug Administration
has
tried
to control
the
prices
which companies pay for their raw
materials. For ampicillin raw mater
ial Fisons used to pay Beechams
Ik.
2400
(73 Pounds)
per
kilo.
Since the Ordinance came into effect
it has come down to Tk. 1700 (51
Pounds).
The companies
used to
pay
between
67
Pounds
and
75
Pounds for tetracycline raw mater
ial, now they pay 33 Pounds.
The promotion of the national drug
industry was an important part of
the Drug Policy. Of the 166 licens
ed
pharmaceutical
manufacturers,
the eight multinationals controlled
75% of the market in 1981, 15% was
held by the 25 medium-sized local
companies and 10% by the remaining
133. The Policy, by restricting the
manufacture to local companies of
simple but profitable non-lifesaving
essential drugs like vitamins (apart
from injections) and antacid, boost
ed the national industry.
and consequent upon its impact, the
Company
has
lost
58%
of
its
business...
In
re-organising
the
whole set up of the Company your
services have become redundant."
Workers challenge this figure and
argue that it includes two drugs
(Baralgin and Novalgin) which ac
counted for 18% of total sales and
were
banned
before
the
Policy.
They also say that 11 new drugs
have been approved by the Drug
Administration and suggest that a
17% drop in sales is more likely.
staff were surplus to the company's
needs, as a result of the Policy,
and although Fisons retrenched 22
of
its
staff.
Glaxo's Director of
Production and Sales said that there
was "no question of retrenchment of
any staff or labour because our
business is still expanding not col
lapsing," and, "Factory extension is
a
continuous
process....
as
we
have a programme of product ex
pansion the factory will automatical
ly extend."
Few other companies sacked workers
even though Dr Arnold, then Di
rector of the Association of British
Pharmaceutical
Industries,
warned
Bangladesh that the policy would be
"exceedingly pricey" in terms of the
"cost in local jobs." On the contra
ry,
local factories have expanded
and taken on more workers because
of
the
Policy.
Although
Pfizer's
managing director, in an interview
in late 1982, said that 40% of the
Companies are extremely wary of
giving out production or sales fig
ures. Even annual reports are hard
to come by; but Table 5 shows that
the companies did not suffer major
set-backs.
Table
"Medicare Laboratories Ltd. is one
company which has expanded rapid
ly since the Policy came into effect.
The company started production ten
years ago. In 1980 it had an annual
turnover of Tk. 30 lakh (91,000
Pounds). Since the Policy its turn
over has jumped to Tk. 240 lakh
(730,000 Pounds)."
This is despite the fact that
Ordinance
banned
twelve of
company’s 18 products.
the
the
However
a
report
produced
by
WHO, with the Danish and Swedish
governments, points out that "the
drug policy will change the struc
ture of the pharmaceutical industry.
It seems unavoidable that market
forces will decrease the number of
small
companies."
Of these small
companies, 80%, the report states,
have no quality control to speak of.
If medium-sized companies with good
quality control expand production
and some small companies producing
sub-standard medicines go out of
business little has been lost.
Companies not seriously affected
It was expected that the multina
tionals would suffer as a result of
the
Policy;
the
growth of
local
companies and the banning of some
of their products were bound to
reduce sales. Indeed some compa
nies claimed extreme hardship and
sacked many workers.
In letters
sent to 60 employees (15% of the
workforce)
in
November
1982,
Hoechst
wrote:
"In
view of the
promulgation of the Drug Policy....
30
Year
5.
Company
Pf i zer
sales
Total production of essential drugs
had nearly doubled (by value) by
1983 and the local companies' share
of production
had also increased
(see Table 6).
in Bang 1adesh
May &
Baker
Glaxo
(mi 1 1 ion
F i sons
taka)
Hoechs t
ICI
140
65(83)
1 10
120
1 10
1981/82
207
*
120
80(74)
230(280) 170
1982/83
*
170
150
*
100
1983/84
240 +
1 50
*
- (310) 160
* Approximate, based on union and other estimates.
+ This figure quoted in Pharmaceuticals: merchants of health,
Dhaka Courier, 31.4.84.
Figures in brackets are company targets for the year, where known.
Sources: Annual reports,
information.
interviews,
newspaper articles and other published'
Table 6. Production of essential drugs by value (million Taka) and percentage
of total production before and after Drug (Control) Ordinance.
Mu Itinationals
Value
%
Before Ordinance
%
228
59
287
66
33
55
388
426
8 14
80
75
79
(1981)
First 12 essential drugs
Second 33 essential drugs
Total
After Ordinance
Nationals
Value
(Jan-Oct
First 12 essential drugs
Second 33 essential drugs
Total
1 16
12 1
237
34
67
45
1 983 )
94
145
239
20
25
2 1
Source : Figures supplied by Minister of Health at a press
conference, 28.12.83
Dangerous drugs under
control
Other benefits from the Policy can
not be measured with figures. For
example,
dangerous
drugs
like
Clinmycin
syrup,
Novalgin
drops
and
Orabolin
drops
once
easily
bought over the counter, mispres
cribed and misused, are now diffi
cult to obtain. Drug sellers are well
aware which drugs are banned and
of the penalties they risk by selling
them.
Importers
face
a
fine
of
50,000
Taka
( 1,500
Pounds)
if
caught
bringing
in
unauthorised
drugs.
Undoubtedly
there
is
smuggling, but it is limited and is
generally
of
Schedule
II
or
III
items,
i. e.
irrational
or
useless
rather
than
dangerous
products.
The dangers and difficulties of sell
ing banned drugs are such that
prices
for
these
products
have
rocketed, putting them out of reach
of all but the richest and most
foolish
people,
but
the potential
profits are so high that this will
continue to be a problem.
Worldwide drug policies
are necessary
Given the very clear successes of
the Bangladesh initiative, it is sur
prising that other countries haven’t
followed its lead. The amount of
information available on multinational
and
national
companies’ abuse of
their
role all over the world is
enormous. The UN, WHO and any
number of committees.
Congress
ional hearings and individuals have
castigated the companies for years.
Book after book and report after
report have repeated the need for
control,
given
examples
of
near
criminal
irresponsibility and esti
mates of wastage. Yet few govern
ments
consider
the question
se
riously.
KABLIJI
HOSPITAL
HEALTH CENTRE
The problem in Bangladesh is not
an isolated one, it is one faced by
every
country
in
the world.
In
Britain several official government
reports have re-stated the argu
ments in favour of rationalising the
drug industry and market. In the
US Senator Kefauver and the Senate
Sub-committee
on
Anti-trust
and
Monopoly amassed a huge amount of
evidence against the companies. It
was later supplemented by the Nel
son
and
the
Kennedy
hearings.
Kefauver
"revealed
profiteering,
price-fixing, promotion of ineffec
tive drugs, questionable advertising
and
sales
techniques,
monopoly
trading and suppression of informa
tion."
The
Sub-committee
noted
that, "Human frailty can be mani
pulated and exploited and this is
fertile ground for anyone who wants
to increase profits... the pharma
ceutical
industry is unique in that
it can make exploitation appear a
noble purpose."
The most recent official report in
the UK
is the Greenfield Report
( 1982)
which
estimates
that
the
government could save in excess of
10 million Pounds on its drugs' bill
by abolishing brand names. Others
suggest that "little effort would be
needed to save at least 100 million
Pounds
a
year
on
the
national
drugs' bill... and that with real
commitment
the
NHS
could
save
several times that amount. Savings
would mean that health care could
be improved in other ways." The
UK may think it can afford such
waste, but countries in Asia. Africa
and South America know that they
cannot.
The
pharmaceutical
drug
lobby is so powerful, however, that
even those countries which could
have taken a lead in this matter
have largely failed to do so -- both
in the industrialised and the Third
Worlds.
AND
RURAL
We are a charitable trust operating
a hospital and rural health centre
in
Haryana
about
50
km.
from
Delhi.
This rural facility is also
engaged in several innovative ex
tension programmes to improve the
quality of life of the inhabitants of
the surrounding villages.
We
need
a
husband/wife medical
team
comprising
a
G.P.
and
Gynaecologist.
One of them will be
the project leader.
A couple whose
children are either grown up or in
The Drug Policy in Bangladesh is
not the end of the line, only part
of a long, sometimes tortuous pro
cess. If it is abandoned it will be
because it was too successful in
changing the nature of the pharma
ceutical
industry
in
Bangladesh.
Changes which could, in the long
term, directly improve the health of
the majority. But once government
takes the health of the poor into
account in practice, rather than in
rhetoric,
then it could also take
housing, food and other rights into
account.
Such
ideas are political
dynamite, if implemented, and the
elite may become frightened by the
implications of the Drug Policy.
Every country in the world should
and will eventually have to imple
ment
a policy on drugs.
Health
groups, government ministries and
individuals should all examine the
drug situation in their countries,
press for change and try to educate
the
general
public about
drugs.
The dissemination of accurate infor
mation
is extremely
important
at
this stage, a fact which the Policy's
enemies acknowledge by trying to
distort or suppress its true results.
The more people who are aware of
the situation regarding drugs and
drug companies the easier it will be
for governments to enact sensible
laws
which
protect
their people,
save foreign exchange and increase
the availability of drugs essential to
health.
Pills Policies and Profits - Reactions
to the Bangladesh
Drug Policy by
Francis Rolt is published by War on
Want, LONDON. Limited number of
copies are available from VHAI.
boarding
school
would
find
this
most
satisfying
and
challenging
assignment provided they are inter
ested in rural development and, at
the same time, seeking opportunity
to give expression to their human,
sensitive approach to the medical
profession.
The salary is good and comfortable
living accommodation is provided in
rural setting but the trustees are
seeking a couple who will consider
the chief attraction as being the
opportunity to respond effectively
and meangingfally to the needs of a
rural community.
IN THE NEWS WAS
• Painkiller clothes manufactured by
a Chinese garment factory to cure
back pain, stomach aches and arth
ritis. The traditional Chinese herbal
remedies packed in sachets are used
as
padding
at the
shoulders
of
waistcoats, knees
of trousers and
in belts. These remedies are ex
pected to be effective for two years
and are supposed to heal through
gradual absorption into the skin.
• A herbal drug called
Ashwagandha (withania seminifera) of which
King George Medical College con
ducted
a
clinical
evaluation.The
evaluation has revealed that Ashwagandha can be
used to prevent
stress, to check formation of gas
tric ulcers, cancerous changes in
lungs and thickening of
bronchial
walls. The drug is already widely
prescribed by Ayurvedic physicians
as
a
rejuvenative
tonic for
the
treatment
of
asthma,
marasmus
(softening
of
bone)
bronchitis,
leucoderma,
arthritis,
tumour’,
fever, pain and inflammation.
• Forests of Kerala. According to a
study by Dr. S. Chattopadhay of
the Centre for Earth Science Stu
dies, Trivandrum, in 1905 about 44%
of Kerala's area was under forests
(roughly 17,120 sq.
km). By 1965
the forest cover was
down to 27%
(10,726 sq.
km.)
Now a decade
later, going
by the
guess esti
mates, of some professionals,
the
'natural
forests account for only
between 7 and 10% (between 3,100 &
3,900 sq. km.) of the state's area.
The Union Govt.'s forest survey
of India (Dehra Dun). A report
published by them
(in
1982)
on
"Assessment and delineation of for
ests retaining
primary character
istics"
gives
the area of totally
undisturbed forests "retaining their
original characteristics" in Kerala as
just 151 sq.km or less than 0.4% of
the
state's
area.
This
was
not
based on any independent survey
or analysis but was the sum total of
32
areas identified and reported by the
states.
Filarial
infection
to
which
30
crores of Indians are exposed. Ac
cording to a Madurai Kamaraj Uni
versity Study, presented in Sept.
1984 the
disease is debilitating in
nature causing even blindness and
large parts of the country
are
endemic to it,
yet very little is
known about its parasite.
^Meningitis. According to National
Institute of Communicable Diseases,
there has been a definite rise in
meningitis cases in parts of UP,
Haryana, & M.P., figures are also
pouring in from other parts of the
country. For e.g at the Calcutta
Medical
College
Hospital
more
meningitis cases have been reported
in two months than in the last three
years.
• Quality Assurance Guide prepared
by Organisation of Pharmaceutical
Producers
of
India
(OPPI).
The
research and development committee
of OPPI outlines standard operating
procedures
for
manufacture
of
pharmaceutical
products.
Certain
norms known as 'good manufacturing
practices
*
(CMP)
have been pres
cribed to
ensure that the drug
manufactured is of high quality,
purity, potency and safety.
• Indian
know-how
which set up a
Multipurpose pharmaceutical plant in
Havana. The pilot plant for essen
tial drugs which started operating
on March 18th, is expected to re
duce Cuba's dependence on imported
active ingredients and pharmaceuti
cals.
•
Food
Hawkers
who
received
a
code with guidelines for maintaining
optimum hygienic
conditions from
Indian
Standard
Institution.
The
code provides that no person suf
fering from any skin disease or any
infections
or
contagious
disease
should be permitted to sell food
items.
It also specifies certain cleanliness
procedures
like maintaining clean
short
nails,
washing hands
with
soap before commencing work and
after each absence specially after
using sanitary conveniences.
®
Kasturba
Medical
College
and
Hospital, Manipur. They are intro
ducing a lifetime health monitoring
programme for the 1st time in In
dia.
The
programme
envisages
counselling training and treatment
on a planned basis
through a con
tinuing preventive maintenance pro
gramme. The programme lasts for a
week starting from Saturday,
1st
June,
1985,
and every Saturday
thereafter.
•
Kerala
Agricultural
University
(KAU) at Trichur has launched a
research programme to evolve a low
cost technology for the production
of medicinal plants for ayurvedic
purposes. About 200 of which 160
plants considered ayurvedically im
portant species of herbs have been
collected, identified and transplant
ed,
in the KAU. The programme
also hopes to help in replanting
some of the almost extinct variety
of plant.
* Of the 23 million infants born in the
country every year, only 3 million
may be truly healthy. Of the rest,
7 million are likely to suffer from
minor
forms
of
malnutrition.
3
million are expected to die before
they reach childhood, and 9 million
would enter adulthood
with
im
paired physical stamina and reduced
mental ability
because of severe
malnutrition. Thus only 15% of
the
children
would have full
genetic
potential of growth and physical
and
mental
development.
Of
the
300 million malnourished Indians, 43
million
are
estimated
to
be
preschoolers. 12 million infants are
mentally impaired every year while
another 20,000 infants go blind due
to vitamin A deficiency.
START HERE
A UNIQUE PRESENT FROM THE UNIVERSE
Following
is
excerpted
from
"Start Here," a chapter in Step to
Man ( 1966) by physicist John Platt.
What we need to do to correct the
great psychological strains in our
society today is to cry out over and
over
again.
"Start
here!
start
here!"
We should do it until we
learn to do it habitually, until by
practice we realize again that it is
immediate here-and-now perception
and interaction and creation that
are at the living centre of things,
and that alone can give validation
and meaning to the whirling prob
lems and achievements of our times.
Personal reality is the bedrock
from which confident action arises.
The adoption of an attitude of sub
jective immediacy, a Start Here at
titude, no longer needs to be re
garded as an escape from the world
or
as
something
bordering
on
self-delusion.
It is rather a way of
restoring
psychological
wholeness
acquiring a new single-mindedness
and intensity, and appreciating and
acting
in the world more effec
tively.
I
think
we will
see that the
adoption of this attitude can lead to
a startling and delightful shift in
self-perspective because of its em
phasis on living in the present with
enjoyment
and
spontaneity
and
choice. It can re-emphasize for us
the dynamic and 'becoming' charac
ter of the world and the spreading
circles of relationship and change
by
which our
personal
force in
every desire and gesture reshapes
the future afresh at every instant.
For
example,
if one says
to
himself, "Start here," surely it can
only reinforce his sense of personal
uniqueness,
of
individuality
and
decision.
To Start Here, anyone
can start only as himself, as he is
now.
We are not merely
inter
changeable role players.
Is there
anyone who is not, by his inherit
ance and history,
a very special
person with a very special prepara
tion?
Many of us have trouble believing
in
our
special
potentialities
for
handling our special circumstances.
We are reluctant to insist that we
have
a
different
vision.
Our
novelists, ignorant of the work of
the world, have preached violence,
futility and mechanism until we have
almost
forgotten
our
individual
creative worth.
Start Here is a unique present
from the universe to each of us,
and all it asks in return is our
unique response.
There are many
ways of life that you can never be,
but there is one that you can be,
and are, beginning now.
Almost everyone has met a few
men or
women
who seem to be
shaping
their
lives
around
some
kind of Start Here rule for them
selves.
You know them by their
behaviour:
resourceful,
direct,
productive, easy.
They speak with
confidence, not as quoters or apologizers.
You feel the force when
you are in their presence.
One
might say they have the straight
forwardness
of
animals
—
or
angels.
This
simplicity
and
power
is
characteristic of the well-established
forms of organic life.
The organic
world has learned to act with deci
sion, to say its Yea or Nay clearly
and completely, to go forward with
all
it
knows
from
where
it
is.
"Start here!" is essentially the only
command in evolution — what life
says to the chromosomes in every
cell, what life says to every mind.
God is more like a chromosome or
a thought than a watchmaker.
The
creative principle of the universe is
not external but internal.
All of
the past that we can ever know is
contained in the world at this in
stant.
All of the evolving poten
tialities of the future are contained
in the world at this instant.
And we are the carriers of this
active potentiality as much as any.
The creative principle is inside of
you and me.
A single protein mol
ecule or a single fingerprint or a
single idea of yours implies the
whole historical reach of stellar and
organic evolution.
It is enough to
make you tingle all the time.
(Excerpted
Bulletin.)
from
Leading
Edge
START HERE was the opening
article
of
new
monthly
Holistic
Bulletin. Edited by Sarlu Mishra the
bulletin
scans
frontiers of social
transformation and reproduces the
Leading Edge Bulletin published by
Marilyn
Ferguson,
author
of
Aquarian
Conspiracy.
Annual
subscription
is
Rs.36/.
Please
contact Holistic Bulletin, 9 Kautilya
Marg, New Delhi-11.
SONG
OF
LA WINO
I do not know
The white man’s name for diseases,
I do not know
The names of their medicines,
I cannot measure
The heat of the body
With the white man’s glass rod
Because my hand trembles
And I cannot read it.
When my child is unwell
I see it from his watery nose.
The hair of his body stands up
And his lips are parched,
I see that he is not bright,
I do not read the name of diseases
from books,
I hear him cry
And his eyes water,
I hear the noise from his stomach
The worms complaining;
He is pale
As if he has been playing in ashes.
You hear his chest crackling.
He has no appetite.
And he is aggressive but tired and
week;
He is troublesome.
He wants this thing and that thing.
Then he does not want this thing
And does not want that thing.
Source: p'Bitek, Song of Lawino,
East
African
Publishing
House,
Nairobi,
1966,pp. 158-159.
From Assignment Children
THE
EDITORIAL
CONTENTS
OF BURNS, FALLS
& CUTS
Once
again
we
focus
on
children, this time on childhood
injuries
both
physical
and
emotional.
Editorial
Childhood
Injuries
\
*n
\ India
In the first article we present
what
probably
is
the
most
comprehensive Indian study on
physical
injuries
to
children.
Burns,
falls,
poisoning.
cfrowning
and
traffic injuries.
Principal strategies for control
of injuries are included
In the second part of this
issue an experienced medico social
worker
det
how
to
guide
'ough
your
ch
w holistic
path
.ional
stability through
years.
In
t’
focuses both o»f th. ,
.
■■
well as health',
Emotional Injuries
to Children
Stress
This sectic
strengthened
by
a
contribution
from
the
National
Institute
of
Mental
Health and Neuro Sciences on
emotional reactions to stress in
childhood.
In both the sections you may
notice an obvious urban “bias".
We have not edited out this
bias. You may please make your
bwn adaptations
Management
Guidelines
for health worker
Emotional
Stress and
Children
S. Joseph
new VHAI
President
World Health
Assembly
News from
the States
Reprints of both the sections
If you
are available separately
need copies do please drop a
line.
A.V
his issue of health for the millions
he Voluntary Health Association of
roduced by design.ed
If you would like to be in touch
health
with
the
voluntary
movement contact the address in
your state.
Andhra Pradesh: Mr. D . Rayanna,
MSW Executive Secretary,
AP
VHA10-3-311/7/2
Vijayanagar
Colony, Hyderabad-500 457.
_____
Bihar:
Mr.
Anthony
Kokoth,
Executive
Secretary,
'Bihar
VHA,
Kurja
Holy
Family
Hospital
P.O.
Sadaquat
Ashram, Patna - 800 010.
Delhi:
_____
Ms.
Naseem
Narang
Executive Secretary, VHA Delhi,
A 43/E DDA flats, Munirka, New
Delhi-1 10 067.
Gujarat:
Mr
Kir it
Shah,
Organising
Secretary, Gujarat
VHA, Newman Hall: P B 4002
Ahemdabad : 380 009,
Karnataka: Ms
Neerajakshi,
Promotional
Secretary,
Karnataka
VHA,
St.
John’s
Medical
College
Hospital,
Bangalore: 560 034.
Varghese
Kerala:
Mr
Jose
Kerala VHA,
Program Officer,
Social
College
Rajagiri
of
P.O.
Sciences
Rajagiri,
104.
Kalamassery
Pin
:
683
Madhya
_ ________
Pradesh: Miss. Marjorie
Secretary, MP
Hill, Organizing
‘
MIBE Graduate School,
VHA
P.O. No. 170, Indore : 452 001 .
Manipur:
Fr.
K.C.
George,
Shanti
Bhavan,
Nongmeibung,
Post Box 19, Imphal - 795 001.
Meghalaya:Sr.
Rosario
Lopez,
Secretary, Meghalaya VHA,P.O.
:
Mendal,
East
Garo
Hills,
Meghalaya - 794 002.
Mjzoram: Fr. Thomas Mekkalath,
P.O.
Church,
Catholic
Kolasib, IMizoram - 796 081.
Santra
D.K.
Mr.
Orissa:
VHA
Orissa
Secretary
Christian Hospital, Berhampur 760 001
Distt - Ganjam (Orissa).
Tamilnadu: Mr. John de Britto,
Program Coordinator, TN VHA
No. 13, Second Floor 23, Main
Road : Perambur, Madras : 600
001.
Joseph
M.
Uttar Pradesh :Mr.
Promotional
Secretary,
Singh,
C/O Memorial Hospital
UP VHA,
P.O.
: Fatehgarh Barhpur
209 601.
Enquiries from other states
may be addressed to:
Ms.
Purabi
Pande,
Voluntary
Health
Association
of
India,
r-14
SDA Community Centre,
New Delhi - 110 016 (India.)
___________ ;
■
was compiled and edited by Augustine Veliath
India C-14 SDA
and
Community Centre, New pelhi-1
published
by
CHILDHOOD INJURIES
IN INDIA
high
income
countries.
INTRODUCTION
Almost 50% of the children
born in India do not live to
have
a
sixth
birthday
(Vaidyanathan,
1972) and this
situation is quite common in a
large number of less developed
countries (LDCs). Most of these
childhood .deaths below
age 5
years
are
from
communicable
diseases,
respiratory
and
gastro-intestinal disorders, and
malnutrition
(Agarwal
et
al.
1982)
and
very few
due to
injuries. It is mainly for this
reason that childhood injuries
have
not
been
considerd
a
serious health problem in LDCs
whereas they are recognised as
serious
in
the
highly
industrialised
societies
where
childhood injuries are a major
cause of death.
However,
there
is
some
evidence that while injuries may
not
be
relatively
a
serious
problem
for
mortality
among
young children in LDCs it is
probably
more common
among
young adolescents (Ghosh and
Dhikhpathy,
1966). It appears
that as far as morbidity
is
concerned, injuries may play a
significant role in children's life
if a wider age group than just
0-5 years is considered.
’
A great deal of data and
studies are available for control
of childhood
injuries for the
industrialized
countries
(International Children's Centre,
1982; WHO, 1960; Baker, 1981)
and
because
of
this
many
improvements in the design of
products and the environment
have taken place which have
brought down the incidence of
childhood
morbidity
and
mortality due to injury. Some of
the most dramatic successes in
reducing incidence and severity
of injuries include: increasing
the size of pacifiers to prevent
asphyxiation
(Baker,
1980),
EPIDEMIOLOGY OF
INJURIES IN INDIA
institution
of
flammability
standards
for
children's
sleepwear
(McLoughlin et al.,
1977), the
use of child safety
seats in cars (Melvin, Stalnaker
and Mohan, 1978; Williams, 1981)
and
childproof
medicine
containers
(Done,
1978) .
However,
community
and
government action at redesign of
products
and
equipment
and
enactment of
safety legislation
is
still
not very
common
in
LDCs. In the National Policy for
Children (Government of India),
the problem of childhood injuries
is not mentioned at all.
The present paper
discusses
the information available about
childhood
injuries
in
India,
strategies for control, of injuries
in LDCs and how these might
differ from those followed in the
★ Centre
for
Biomedical
Engineering
Indian Institute of Technology
New Delhi - 110016.
industrialized
CHILDHOOD
Many of the studies dealing
with morbidity and mortality in
childhood
in
LDCs
do
not
include injuries as one of the
causes
(e.g. Agarwal et al.,
1982; Chaudhuri and Chaudhuri,
1962; Fernando, 1964; Grounds,
1964) so it
is not possible to
estimate the prevalence rates for
any country as a whole. The
studies that do include injuries
as
one
of
the
causes
of
morbidity
and
mortality
are
generally based on hospital data
and, therefore, give a limited
picture of the situation since
large proportions of populations
in
LDCs
do
not
use formal
health
services.
However,
aqualitative idea of the kind of
problems
encountered
can
be
obtained
from
spot
studies
conducted
by
various
investigators.
According to a study based on
hospital
admissions
(Gandhi,
1963) morbidity cases and 2% of
mortality cases, whereas Ghosh
and Dhikhpathy
(1966)
claim
that injuries seem to be the
leading cause of mortality and
morbidity
among
adolescents.
These differences
may be due
to the fact that Ghosh included
OPD cases also. Falls, burns,
falls
of
heavy
objects
on
children (Mukhopadhyay, 1981)
and poisoning (Chatterjee and
Banerjee, 1981) are reported to
be the main causes of childhood
injuries. This is very different
from the situation obtaining in
the high income industr ialized
nations where
road accidents,
house fires and drownings are
very
important
(Haddon
and
Baker, 1981).
Childhood
injuries
m «y be
broadly categorised as oc urring
1
at home work or in traffic and
may broadly include:
(i) Burns
(ii) Falls
Poisoning
(iii)
(iv) Drowning
(v) Cuts, scratches, scrapes etc.
burnt by stray embers also. In
the winter this becomes more
common as families keep warm
by
lighting
fires.
This
is
especially true for very poor
families
who
do
not
have
adequate housing. Studies done
in hospitals indicate that there
thrown
among
adults
during
fights (Sinha, 1974) and also of
burns due to firecrackers used
during
various
religious
festivals including Diwali.
Most
studies
mention
carelessness
of adults
and
older children as contributing to
the
high
incidence
of
burn
injuries, but this is in spite of
the
fact
that
responsible
persons were present at the
time of the mishap in a large
number
of cases
(Learmonth,
1975). In most of the studies
mentioned
above
the
child's
behaviour is also mentioned as
an
important cause
of burn
injuries but there is no detailed
discussion of how product or
environment design
may
have
actually
contributed
to
the
problem. Only Learmonth ( 1975)
makes an attempt at estimating
the
magnitude
of
under-reporting and he found
that only 25% of those sustaining
burns attended the out-patient
department
of
a
hospital.
Therefore, the actual magnitude
and spread of the problem is
not really known.
(ii) Falls
Figure 1.
Head injury severity as a function of height of fall
on to rigid surfaces.
(vi) Injuries caused by
Traffic
(vii)
Injuries.
animals
(i) Burns
Burns
in
high
income
industrialized
countries
are
sustained mainly in mishaps in
the kitchen and due to electrical
causes.
Studies
indicate that
burns in the kitchen are very
important in India also partly
because
cooking
is
done at
floor level in a vast majority of
the
households
but
electrical
burns
are
not
very
common
(Sinha, 1974; Learmonth, 1980).
Another problem is that a vast
majority
of families
do
their
cooking on coal or wood fired
stoves
and
so
children
get
2
is
an
increasing
trend
in
admissions due to
burns and
scalds
in
India
(Mukherjee,
1979) but the reasons for this
are not clear.
As
electrification
increases
both in rural and urban areas
there is an increasing incidence
of electrical burns
in
India
(Sinha,
1974)
but
data
regarding
exact
contributory
factors
are
not
available.
Personal
experience
and
anecdotal
information
suggest
that inadequate
insulation and
bad
connectors even on high
power
appliances
may
be
contributing to electrical burn
injuries. There are also reports
of burns
due to acid being
Falls are not a major cause
of
death
among
children
in
countries
like
the
U.S.A.
(Accident Facts, 1982) but they
do
account for a significant
proportion of injuries. Falls also
seem to be an important cause
of
injuries
in
many
LDCs
(Kimati,
1977;
Ebong,
1977;
Pendse et al. 1971; Chandra,
1976;
Mukhopadhyay,
1981;
Ghooi et al. 1976) but none of
these studies gives the details
of
the events leading to the
falls. Obviously
many of the
reasons
would
be
similar
to
those
in
high
income
industrialized
countries:
in
playgrounds, from trees, down
staircases etc. However, there
are situations in India which are
not common in the industrialized
nations: kite flying from roofs,
sleeping on roofs, involvement
of children in agricultural work,
unguarded windows. Falls from
high-chairs and cots is not very
common for the population as a
whole since such furniture is
not used by a large section of
the population. In urban areas,
however, hospitals do get cases
of such injuries from the middle
and upper classes.
i) Poisoning
In the Western countries
idicinal
drugs
have
been
ported
to
be
the
most
mmonly
ingested
products
llowed by
household products
d
pesticides
(Blaszczyk,
ilczyk and Klincewicz,
1980;
10,
1960;
Accident
Facts
82). In India, however, the
ttern
is
different and the
suits
of
ten
studies
are
mmarised in Table I.
It
is
clear
that kerosene
gestion is the most serious
•oblem
as
far as
accidental
iisoning
among
children
in
idia
is
concerned.
This
is
tcause a very large proportion
households in India need to
eep kerosene for stoves and
mps or for lighting wood or
bI
stoves. Since kerosene in
cdia is colourless and is sold in
mstandardized
containers
deluding
empty
soft-drink
titles), it is easy to mistake it
water.
Further,
studies
oiw
that
the children most
re
*cted
are in the age group
3
years
(Chatterjee
and
mierjee,
1981;
ntihanakrishnan
and
ilggopalraju,
1972;
nt hanakrishnan
and
Chitra,
78 J.
A
large
number
of
idiocinal drug poisoning cases
pe;ar
to
be
instances
of
ercdosing particularly in the
lenoothiazine
group
and
rbiiturates
(Chatterjee
and
inerrjee,
1981). A distressing
aturre is that many cases are
nsicdered
to
be
iatrogenic
ara t and Sarkar, 1977) and
e
incidence
seems
to
be
zreaising.
Banerjee
and
lattaecharya (1978) report that
e
incidence
of
medicinal
isoniing
has
increased
in
cent years in India and they
tribuute
it
to
the
easy
ailab'lllty of harmful drugs.
pirim
overdose,
however,
es mot appear to be very
mmom.
Hous.ehold chemicals are also
volveod in a significant number
childihood poisoning cases, as
the VWest, but unlike the West
.isoninng due to oils and seeds
muchi more common in India.
isticidees insect and mosquito
Ilers,
copper
sulphate,
phthal’ene, acids and caustic
da for- cleaning purposes are
e
moore
common
chemicals
TABLE 1
Summary of the results of Ten Studies on Accidental Poisoning
among children in India
(Percentage of case by various causes)
Kerosene
Medicinal Household
Drugs
Chemicals
Seeds
Oils
Misc.
1. Santhanak- 33
rishna ( 1972)
185 cases,
Madras
25
-
17
12
13
2. Sharma 6
55
*
Saxena
(1974)
80 cases,
Jaipur
28
17
6
-
-
3. Barat and
Sarkar (1977)
40 cases,
Bankura
23
15
20
30
-
13
4. Agarwal
and Gupta
(1974) 94
cases, Delhi
40
6
24
1
-
29
5. Ghosh and 39
Agarwal ( 1962)
393 cases,
Delhi
13
34
9
-
5
6. Tak et al. 23
(1979) 61
cases, Udaipur
21
13
43
-
-
7. Chatterjee 44
6 Banerjee
(1981) 84
cases,
Calcutta
36
6
-
—
14
8. Satpathy
30
and Das
*
( 1979)
98 cases,
Rourkela
24
12
27
-
—
24
9
28
-
8
9. Pohowalla 31
and Ghai (1959)
10. Manchanda 38
and Sood (1960)
*
16
11
2
-
33
*Percentages do not add up to 100 in original publication.
3
encountered in India. Seeds and
oils are involved because they
are present in homes as food,
traditional
medicines
or
intoxicants. So is opium.
The above data show
poisoning
patterns
the
are
common (Yip and Paul, 1975).
But
in
India
hospital-based
reports
do
not
document
drowning as a major cause of
mortality or
morbidity among
children. Cordon et al. ( 1962)
do
document
drownings
in
village wells and ponds but it is
surveys are conducted.
(v) Cuts, Scratches, Scrapes
Abrasions and lacerations
are very common in the home
and at play but most cases are
not serious enough to require a
visit to a hospital. Gordon et
al. (1962) report an incidence of
50% for all age groups in their
household survey but do not
give
the
rate
for
children.
Injuries during play and in the
kitchen
are
generally
most
common and in the rural areas
agricultural
tools,
knives and
glass have been recorded as
causing some of these injuries.
(vi) Animals
Gordon
et
al.
( 1962),
Chandra (1970) and Singh and
Sinha (1980) do report injuries
due
to
animals
but
the
incidence is not high. Bites due
to scorpions, snakes and dogs
are also reported
but since
victims
are
not
brought
to
hospitals or clinics it is difficult
to
estimate
the
actual
incidence. It is suspected that
in most cases local traditional
forms of treatment are used.
(vii) Traffic Injuries
significantly, different in India
from those in Europe or the
U.S.A. This is mainly due to
specific cultural practices, low
incomes
and
crowded
living
conditions
in
most
Indian
homes/ In addition, most of the
low income homes do not have
safe areas for storage of unsafe
chemicals
and toxic drugs. As
modern methods of farming are
being
introduced
pesticide
poisoning is becoming much more
common also (Bull, 1982).
(iv) Drowning
Drowning is a very common
cause of accidental death among
children in Europe and the U.S.
where swimming in pools, lakes
or oceans is very common (WHO,
I960).
Similarly,
drowning
in
Singapore is also reported to be
U
not
possible
to estimate
the
incidence. Government statistics
Abstracts,
1978)
(Statistical
total
of
25,711
record
a
but
the
age
drownings
distribution
is
not
given.
A
large number of landless poor
families
live
in
low
lying
flood-prone areas and are much
more
susceptible
to
floods.
Judging
from
reports
of
drownings
in
the
monsoon
season and from the frequent
reports of boats capsizing it is
possible
that
thousands
of
Indian
children
drown
every
year. But these drownings are
generally not due to swimming
as a sporting activity.
Since
most families would
not report
a drowning death to the police
or a hospital if no foul play is
suspected,
it
is
difficult
to
collect
data
unless
household
Road crash fatalities and
injuries among children do not
appear
to be high
in
India
(Pendse
et
al.,
1971;
Mukhopadhyay,
1981;
Mohan,
1983;
Gordon
et
al.
1962).
though some studies of head
injury do report
a significant
proportion
from motor vehicle
crashes (Ghooi et al.,
1976).
This
is again
very different
from the experience in the West
where traffic injuries are the
major cause of
morbidity and
mortality among
children. The
low rates in India are not easily
explainable considering the fact
that a large number of children
are
carried
on
motorcycles,
scooters and bicycles and also a
large number live and play on
road sides.
The low incidence of road
traffic injuries among children
could be
due
to
variety of
reasons: low volume of motorized
traffic,
low
velocities
of
vehicles,
children
of
middle
class and upper class families
may not be spending much time
unsupervised on roads, and it
is
possible
that
very
poor
families do not report
their
children's traffic injuries but
accept cash compensation from
the vehicle drivers instead. In
European
countries
and
the
U.S.A children are hit when
they dart
out
suddenly from
in
between
parked cars.
In
India there are not many roads
where
cars
are
parked
in
parallel with the pavement end
to end along the length of the
road. So children on sidewalks
are visible to motorists from a
greater distance.
Most of the hospital-based
studies
from
India
do
not
mention
injuries
inflicted
by
parents at all. However, this
does
not
mean
that
child
battering
does
not
exist
in
India. It has been reported that
in the U.S.
child abuse is
recorded to be
more common
among
low
income
families
(Haddon and Baker, 1981) but
this
may
be
because
of
reporting
differences as the
high income families may hide
the information better.
It is
possible that in India the high
income
families
hide
the
information,
the
low
income
families do not want to go to the
police and hospital clinicians do
not take time to investigate a
sensitive
matter
like
child
battering
because
of
heavy
work load. Hence, the subject
does
not
get
recognised
or
discussed openly.
data to decide one way or the
other.
The
fate
of
those
children who have to live with
their parents on sidewalks or
temporary shelters
is largely
unknown
and
greater
effort
needs
to
be
directed
at
redressing their problems.
Newspapers in
India very
often report the terrible plight
of children in occupations like
matchmaking,
carpet weaving,
slate
factories,
and
other
occupations where children can
perform the job adequately for
low wages. Children are also
used
commonly
as
domestic
servants, waiters, and porters.
Therefore,
children
sustain
injuries
in
these occupations
which would not be common in
the high-income countries. The
influence of child labour on
injuries among children has not
been investigated in any depth
in India.
PRINCIPLES
CONTROL
Most of India's children live in
very crowded housing conditions
and a very large number in
slums or out in the open. While
we suspect that these living
conditions
may also influence
injury rates we do not have any
OF
INJURY
a. Approach
The
injury
problem
in
developing countries looks so
complex that many tend to throw
up their hands in helplessness.
It is often recognized that the
problem
exists
and
needs
attention. But the most that is
done is to put up posters and
billboards exhorting their reader
to behave more responsibly. The
problem remains unsolved. This
is
partly because there
are
many myths prevalent regarding
the control of injuries. Most
people think that injuries are
mainly a problem for the rich
countries. This is not so. The
data available from developing
countries suggest that in every
sphere
of
activity
the
proportion of persons killed or
injured
is similar to or higher
than
that
in
industrialized
countries. Another myth is that
education, propaganda, and law
enforcement can be the most
effective tools in injury control.
This also does not seem to be
borne out
by
many
studies
around the world. The whole
problem can be best understood
if we are reasonably clear about
the concepts which follow.
(i)
"Accidents" and
are not "Acts of God"
Injuries
It is a vital first step to
realize that the occurrence and
outcome of events which may
cause injury are predictable and
subject in many cases to human
control. Often an injury can be
prevented
even
where
an
"accident"
cannot.
In
a
motorcycle
crash,
the
occurence and severity of head
injury depend on whether or not
a helmet was used and on the
quality of
the helmet.
Fires
and explosions in kitchen are
reduced drastically when safer
cooking
methods
are
used.
Children do not fall out of
windows
which
have
proper
screens.
5
Similarly, even the so-called
natural disasters are not really
"natural". If they were, then
the effects of floods would be
the same in the rich and poor
countries.
It is
rare to see
thousands made homeless in the
U.S., but it is a yearly ritual
in India. Even in India, it is
the poor who seem to be more
adversely affected by floods and
storms
than
the
rich.
Therefore, how a physical event
influences human beings is very
largely
influenced by
human
beings
themselves.
Even
the
occurrence of the physical event
itself is very often a result of
accidents
minimized.
and
(ii)
There
Between
Disease.
are
disasters
Is
No Difference
Injury
and
Injury is a disease that
results from acute exposure of
the
body
to
physical
and
chemical agents. There are no
basic
scientific
distinctions
between
injury
and
disease.
Even the ancient Indian surgeon
Susruta recognized this when he
classified injuries as one of the
four kinds of diseases. When
one drowns one may die because
Further, if injuries are viewed
as diseases, the community may
stop viewing them as events
resulting
primarily
from
carelessness.
Long
ago
we
learned that it does little good
to blame the victim of a disease
for being sick. For example,
when a patient goes to a doctor
with malaria, the doctor does
not blame the victim for not
killing the mosquito before it bit
him. The most effective disease
control measures often consist of
modifying the environment, not
the behaviour of individuals, to
make contracting a disease less
likely. Up to now, our efforts
TABLE II
Comparative Epidemiology of Malaria and Kerosene Poisoning
Pathological
Condition
Malaria
Kerosene
Poisoning
Host
Agent
Vector/Product
1 nteraction
Child
Plasmodium
sp.
Mosquito
Mosquito bite
Child
Chemical
Energy
Kerosene
Drinking
TABLE III
Some Strategies for Control of
Malaria and Kerosene Poisoning
General Principle
Malaria
Kerosene Poisoning
1. Prevent creation of
hazard.
Keep mosquitoes from
breeding
Do not manufacture
kerosene
2. Eradicate present
hazard
Kill mosquitoes by
fumigation, etc.
Do not allow kerosene to be
sold for domestic use (use
alternative forms of cooking
or lighting).
3. Interpose
Use mosquito nets
Store kerosene in childproof
containers
barrier
4. Minimize probability
Take chloroquin
and result of host-agent when in malaria
interaction
infested area
man's
activity.
For
example,
floods
may
be
caused
by
deforestation, faulty design of
dams, blocking up of drainage
in cities, etc. Therefore, man
has a great deal to do with
whether or not accidents and
disasters
take place and how
these
events affect us. We can
design
our
environment
and
products
such
that
the
incidence
and
effects
of
6
Colour kerosene blue so that
can be distinguished from
other consumable liquids.
of the presence of fluid in the
lungs which prevents exchange
of oxygen between air and the
blood. The cause of death in
pneumonia is the same.
Any
infectious
disease
may
cause
fever,
pain,
disability,
or
death.
Injuries do the same.
Therefore, the concept of injury
is coextensive with the concept
of disease. Table II illustrates
this relationship.
at
injury
control have often
been
retarded
by
a
preoccupation with fixation of
blame. This has led to repeated
attempts to prevent injuries by
changing the behaviour of their
potential victims. Such attempts
are usually costly,
not often
successful, and have added
o
the public's sense that Injuries
are an unavoidable evil. But, as
Table III demonstrates, the same
general
principles
used
in
disease control may successfully
be applied to injuries.
(iii)
All
Prevented.
Injuries
Cannot
be
Most efforts to reduce
injuries
are termed "accident
prevention"
campaigns.
We
should be clear that
accident
prevention
is
just
one
aspect----- and not often the most
rewarding
one----- of
a
much
larger
range
of
counter
measures
used
in
effective
injury control programmes. This
is because making mistakes is
very
"normal"
and
not
"abnormal".
It is
normal
for
professional
drivers
to
be
neglect in day-to-day activity.
However,
by
designing
our
products and environment to be
more tolerant of these normal
variations
in
human
performance,
we can minimize
the
number
of
resulting
accidents
and
injuries.
Accidents
result
from
a
temporary imbalance between an
individual's performance and the
demands of the system in which
he is functioning. They can be
prevented
by
alterations
in
either, but most effectively by
focusing on the system, not its
user.
In many areas of public health
we understand this very well.
We know that drinking water
Even
if one
considers
injuries to be a health problem,
very often it remains difficult to
think of all the possible counter
measures because the problem
appears to be too large and
unwieldy. It is always easier to
work in a step-by-step manner.
One
useful
approach
is
to
consider each injury problem as
resulting
from
an
interaction
between
several
discrete
factors, occurring over distinct
phases in time.
This can be
done if we divide all time into
three
categories:
before
the
injury producing event, during
the event, and after the event.
The physical universe can be
divided
into
these
factors:
man,
the
device
under
INJURY MATRIX
FACTORS (SPACE)
Man
Device
Environment
PRE-EVENT
1
2
3
EVENT
4
5
6
POST-EVENT
7
8
9
FIG. 1 INJURY CONTROL MEASURES CLASSIFIED ACCORDING TO THREE FACTORS AND
THREE PHASES
(ADAPTED FROM HADDON AND BAKER, 1981)
distracted during some periods
of their long driving hours; it
Is
normal
for
cooks
to
be
day-dreaming at some point in
the kitchen; it is normal for a
factory
worker
to
make
a
mistake when he thinks of the
hundreds of problems at home;
and it is normal for children to
do the unexpected and
hurt
themselves.
Most of the studies mentioned
above mention "human error" or
"carelessness" as the main cause
of Injuries. Not only is this
incorrect
epidemiologically
but
this approach will not lead us
anywhere.
In short,
we will
never
eliminate
carelessness,
.absentmindedness
and
even
should
be
purified
at
its
source; it
is
unreasonable
to
expect
everyone
to
boil
his
water
before
drinking
it.
Ironically, it is quite common to
create a product or environment
which is likely to cause injury,
warn the user to be careful,
and blame the user if a mishap
occurs. We would never tolerate
a person who introduced cholera
germs in a city water supply
and then asked every citizen to
boil water before drinking it.
But this is what we do all the
time
as
far
as
injuries
are
concerned.
(Iv)
Injury Control Measures
Can
be
Developed
Systematically.
consideration,
and
the
environment, which consists of
everything else. These can be
used to create a 3 x 3 matrix as
shown in Figure 1.
In developing a programme of
injury control measures for a
particular
injury problem,
we
can go systematically through
each cell of the matrix and
think up all possible counter
measures applicable to that cell.
(In classifying an intervention
according to time,
it is
the
point at which an intervention
exerts its effect, not the time at
which it is undertaken, which is
considered.) The usefulness of
the
matrix
is
a
tool
for
generating ideas. At this stage.
every possible strategy should
be
documented
and
nothing
held back because of political or
financial
considerations.
After
all
the
possible
counter
measures
have
been
listed,
injury
control
experts
and
policy-makers can select those
which
are
most
feasible,
effective,
and
acceptable
politically. This is illustrated by
the following example.
stoves which have a low centre
of gravity and wide base. Fix
stoves to the cooking bench.
Equip
pressure
stoves
with
safety
valves
which
are
not
likely to get clogged. Design
stove
nozzles
so
that
the
escaping fluid makes a different
noise when the pressure is too
high.
Use electric
stoves
so
there is no flame.
In
many
countries,
pressurised kerosene stoves are
used
for
cooking.
Not
infrequently
they
explode
or
overturn,
sometimes
causing
serious burns and injuries. The
following
are
some
of
the
possible counter measures which
come to mind:
Cell 5: Design stoves such
that even if there is a fire they
will
not
explode.
Construct
stoves of a material which does
not
produce
sharp-edged
fragments in an explosion. Use
fuel that becomes inert at high
pressure or when spilled.
Cell 3: Do not allow children
in
the
kitchen.
Cook
while
children are sleeping. Do not
have any slippery flooring in
the kitchen. Raise the cooking
surface
above
the
reach
of
children.
Cell 1: Educate cooks about
the dangers and proper use of
stoves. Educate cooks not to
wear
flammable
garments.
Educate cooks not to cook when
tired. Educate cooks not to put
bulky, heavy objects on stoves,
as these cause overturns.
Cell 2: Ban stoves which use
kerosene under pressure. Make
8
Cell 6: Construct kitchens of
flame-retardant materials. Place
no heavy objects on shelves
which can fall in an explosion
and injure the cook. No sharp
corners
and
edges
in
the
kitchen. Sink faucet should be
easily
turned
towards
cook.
Instal
fire
extinguisher
in
kitchen.
Cell
*4:
Make all clothing
flameproof or flame retardant.
Wear
safety
glasses.
Use
a
safety
shower
if present
to
dowse the flames. Educate for
burn minimisation: do not run if
clothes ignite; roll on ground or
smother fire with blanket.
Cell
victim
7: Provide first-aid
and
transportation
to
°
hospital if necessary. Emergency
and
long-term
treatment
and
rehabilitation.
Cell
leak.
8:
Stove
should
Another way of arriving at
possible counter measures is to
use the concept that injuries are
sustained
when
there
is
an
exchange of physical, chemical
or radiation energy between the
human
body
and
the
Baker (1981) where they also
discuss the state of the art on
control of injuries. In another
publication Baker (1981) gives
very useful guidelines on the
community
approaches
to
prevention of injuries and Mohan
not
Contact Time in Seconds
Cell 9: Have first-aid kit and
instructions readily available in
kitchen
or
near
by.
Instal
automatic alarm which sounds in
case of fire.
Establish
burn
centres which specialise in care
of
the
burnt.
Establish
rehabilitation
units
for
the
severely burned.
It is quite obvious that some
of the above suggestions would
not be feasible for
want of
funds,
technology or political
will. The counter measures that
are selected would depend on
the
specific
local
situations.
Figure
2
helps
in
giving
priorities
to
feasible
counter
(measures
in
terms
of
• effectiveness. There is also no
Bpoint
in
suggesting
counter
^measures which are theoretically
feasible
but
cannot
be
iiimplemented.
Source: Adapted from L.A. Marzetta, "A Thermesthesiometer: An
instrument for Burn Hazard Measurement,” IEEE Transactions on
Biomedical Engineering,vol. BME-21(5) (1974) :425—427. Copyright
©1974 IEEE. Used with permission.
Figure 2. Threshold to Pain and
Contact Temperature and Duration.
Tissue
environment.
This
framework
attempts to eliminate the source
of the energy, to reduce the
amount of energy marshalled,
separate in time and space the
source and the human,
place
protective barriers
or
modify
surfaces where energy exchange
takes place. This approach is
best described by Haddon and
( 1982)
discusses
specific to India.
Damage According to
the
situation
In summary, we should have
the
same
attitude
towards
control of injuries that we do
for other health problems. An
epidemiological approach helps in
understanding
the
problems,
and then systemic methods
can
9
be
used
measures
control.
to
for
suggest
counter
effective
injury
b. Biomechanical Considerations.
Biomechanical studies in the
past few years have established
for us some guidelines regarding
the strength (e.g. Owings et al.
1975),
anthropometry
(e.g.
Snyder
et
al.
1977),
and
tolerance
of
children
(e.g.
Snyder,
Foust
and
Bowman,
1977;
Mohan
et
al.
1979).
Guidelines for product design
and safety measures are based
on
such
studies
and
so
children's furniture, toys, and
car seats have been made safer.
For
example,
studies
have
dramatically when the height of
the fall is more than 1 metre,
even thin rugs over concrete
floors reduce the probability of
head
injury in a fall,
hard
mudpacked surfaces and lawns
are much safer than brick and
concrete
paved
surfaces.
Children can exert much more
strength
(especially
when
excited) than we expect them to
and so products have
to be
designed
keeping this in mind
so that toys or furniture do not
fail or give way and thus create
hazardous situations.
c.
Education of Parents.
on
Most of the research papers
childhood injuries in India
of parents about safer ways of
living do seem to have some
effect (Kravitz, 1973) but not if
the contact is limited.
In countries like India where
very
few
children
see
pediatricians,
intensive
education efforts can only reach
an extremely small section of the
population. Therefore, education
and propaganda efforts should
be mainly limited to those items
which can easily be explained
over mass media or by children's
day
care
worker.
Time
and
effort should not be wasted on
general
advice
about
safe
behaviour. On the other
hand,
information
about
specific
actions which are likely to be
implemented
and advice about
choice of safe toys and products
is likely to be more effective. It
is
also
very
important
that
decision makers, manufacturers
and
voluntary
groups
be
educated about what community
actions can result in a safer
world for children.
STRATEGIES FOR CONTROL OF
INJURIES
shown that it is 'not possible for
adults to transport children in
cars safely in laps (Mohan and
Schneider,
1979)
and
rules
regarding
mandatory
use
of
child
seats
are
also
being
enacted in many regions around
the world (Williams, 1981). The
Consumer
Product
Safety
Commission of
the U.S.A, has
also been able to set technical
requirements
for
toys
and
guidelines have been formulated
for safe design of cots, high
chairs,
and
playground
equipment. A detailed discussion
of the subject is out of the
scope of this paper but some
general
guidelines
can
be
mentioned.
The
head
10
probability
injury
of
children's
increases
reviewed above, mention parental
education as one of the most
important
measures
*
for
peventing
injuries
among
children.
Though
these
suggestions
are
very
well
intentioned there is
mounting
evidence around the world that
this approach has limited impact
even in industrialised countries.
It
appears
that
exhorting
parents to be careful has little
effect
(Uershcwitz
and
Williamson, 1977; Riesinger and
Williams, 1978) but giving them
information which helps them in
selecting
a
safe
product
or
Performing
a
one-time
action
which
results
in
a
safer
environment is more likely to
succeed (Spiegel and Lindaman,
ZiL:'- Ml,,er' et al. 1982). In
addition, continued -counselling
The
above discussion
has
shown that childhood injuries in
LDCs like India have a different
pattern from those in the high
income countries. Many of the
childhood injuries in India are
partly due to very low incomes,
inadequate
housing
facilities,
and culture and region specific
practices
(e.g.
opium
poisoning). It is also true that
the outcome of injuries in India
may be worse than in the ^high
income
countries
because
of
inadequate
medical
care
and
wide
prevalence
of
malnourishment
and
undernourishment.
Therefore,
many
of
such
problems
will
reduce
with
economic
development.
However,
we
should not be complacent and
depend too much on this factor
alone as economic development
can be accompanied by increased
incidence
of
injuries
due
to
electrocutions
and
road
accidents
unless
counter
measures are instituted now.
there would be no stray embers
or sparks.
In proposing counter measures
in India the following factors
have to be kept in mind:
(iii) This would be the right
time to introduce flat pronged
electrical plugs in India before
use of electric power is much
more wide spread. Flat pronged
plugs are much safer because
children
cannot
insert
their
fingers into the wall sockets.
(i)
Actions requiring greater
family expenditure are not likely
to be very fruitful.
(ii) It is
implement
regulations,
rural areas.
not very easy to
standards
and
especially
in
the
(iv) Much stricter control
should
be
exercised
over
manufacture of fire crackers and
(iii) Mass media
campaigns
which give simple and specific
instructions about safer ways of
using products
and warnings
about
unsafe
products
would
reach a larger number of people
than hospital based programmes.
At present there is very little
information on what strategies
are
certain
to
succeed
and
which
would
be
doomed
to
failure in a country like India.
In
the
absence
of
such
information only some tentative
suggestions can be made for
injury
control
and
the
effectiveness of such measures
must be continuously evaluated.
(a)
Burns:
makes
(i)
it
Cooking on the floor
easier for children to
numbers by the urban middle
classes,
it is very important
that
furniture
manufacturers
and
users be educated about
principles
of
safe
design
of
these products.
In this case
standards evolved in the U.S.A.
would be appropriate in India
also and would not raise the
cost of the product.
(ii)
Municipal
housing
standards should require that
all
windows
in
new
housing
should be provided with guards
and
programmes
started
to
retroflex old houses; railings on
terraces should not be less than
100 cm
in
height;
staircases
should
provide
landings
or
turns at descents of 2 metres to
avoid falls over greater heights.
(iii) All play areas should
have soft surfaces or lawns and
brick
or
concrete
surfaces
their use by children restricted
to the safest varieties only.
(v)
Use of flame retardants
in
clothing
should
be
made
mandatory.
(vi) Cold water treatment of
burns
should
be
given
the
should be banned.
Safe and
inexpensive
designs
of
playground
should be widely
disseminated
among
architects
and townplanners.
(iv) Flying of kites
roofs should be banned.
interfere
and
cooking
at
a
higher level increases the risk
of hot objects falling on top of
them. Safer designs have to be
investigated
which
can
be
adopted
at
low
cost in
new
housing projects.
(ii) Stove designs which
are safer should be promoted.
For example, new efficient wick
stoves are safer than pressure
stoves. Cooking methods using
solar energy in the future may
reduce incidence of burns as
from
widest
publicity
using
all
available
media
sources,
first-aid classes and community
organisations.
A
majority
of
people and even some medical
practitioners are still unaware of
the effectiveness of this simple
and inexpensive method of burn
control.
(b)
Falls:
are
(i) As cots and high chairs
being
used
in
greater
11
(c)
Poisoning:
corners
is
dangerous
for
everyone
and
parents
be
persuaded to buy only those
designs
which
have
rounded
corners and edges.
(i)
Kerosene
and
methyl
alcohol sold for non-industrial
use should be dyed in some
shades of blue. Technology for
this is already available. The
possibility
of
making
these
fluids taste even worse should
also be investigated.
(ii) Stricter
control
on
dispensation of medicines have
to
be
instituted.
Health
agencies, both government and
voluntary, must educate medical
practitioners
and
the
public
both about the dangers of the
overdose
and misuse of the
various drugs on the market.
Childproof
containers
suitable
for illiterate populations should
be developed.
(iii) Household
chemicals
should
be
sold
only
in
childproof
containers.
The
containers should be such that
even if left open, only small
amounts
of
chemical
can
be
dispensed at a time.
(iv)
Public
education
campaigns are necessary against
those oils and seeds which are
used
traditionally
for
healing
purposes but have been proved
to be harmful. Alternative cures
should
be
popularised.
For
example use of water instead of
kerosene for treatment of burns.
(f) Animal and Insect Injuries:
.
(i)
Stray dogs
eliminated
from
areas.
solve the problem once and for
all.
(e)
Cuts,
Bruises:
Scratches
and
(i)
Standards
for
safe
design of toys,
specially for
minimum
sizes
of
items.
elimination of pointed parts or
sharp corners and safe paints
are
already
well
established.
The government and community
should
put
pressure
on
manufacturers
to adopt these
measures.
In
principle,
toys
should be so designed that even
if the child falls on them there
should be no serious injury.
(ii) Traditional razor blades
should be phased out. The new
"twin-track"
blades
are
very
(g) Traffic Injuries:
(i) Motorised two-wheeler use
should be discouraged with the
intention
of
phasing
out
manufacture of such vehicles by
2000 A.D. Provision of safe and
convenient public transportation
will go a long way in achieving
this.
be illegal to
in the front
Drowning
(i)
Stricter laws
use of swimming pools.
regarding
(ii)
Control of deforestation
to reduce flooding of rivers,
building
of
dams
for
flood
control and provision of land to
poor people who have to live
on dry river beds, would be the
most-effective ways to prevent
drowning during the monsoon
season.
(iii) All wells should have
walls or hedges around them.
Eventual
elimination
of
wells
with tubewells and pumps would
12
(ii) Simple and safe methods
of treatment of insect, snake
and
animal
bites
should
be
widely publicised.
(ii) It should
transport children
seats of cars.
(v)
Pesticide poisoning is a
serious concern now, but no
countermeasures have yet been
particularly
successful.
Education and clear labelling will
have to do in the absence of
better ideas.
(d)
should be
residential
safe, because even if a child
handles
them
without
supervision
there
is
no
possibility of deep cuts.
(iii)
Manufacturers
and
designers should be made aware
that
furniture
with
sharp
ACKNOWLEDGEMENT
Mr.
Sunil
Kumar collected
much of the information used in
this paper.
(iii)
Buses
should
be
designed with entry and exit
procedures
such
that
the
probability of falls is minimised.
(iv)
Fronts
of
buses,
trucks
and
cars
should
be
designed such that they
are
less menacing for pedestrians,
especially children.
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15
EMOTIONAL INJURIES TO----
CHILDREN
INTRODUCTION.
Personality is a word showing
the ways
in which a person
deals with others and lives her
life.
Each
individual
develops
her own personality using the
powers
and
strengths
with
which
she
was
born.
They
develop through interaction with
the people and events of life,
and by personal reflection and
conclusions. Emotional wellbeing,
feeling happy and satisfied, is
closely
connected
with
personality and its development.
Emotional health flourishes when
the person feels secure, happy,
precious
to
someone.
With
enough
emotional
health
a
person
is able to tackle the
challenges of daily life rather
successfully.
Very closely connected to the
ability to cope, to solve one's
problems
and
be
happy,
is
creativity. Creative persons can
use
time
happily,
and
well.
They
can
be
appropriately
fearful, sad, angry, delighted,
happy, etc., and
can be alone
for
a
while
and
not
feel
uncomfortable because they have
learned the use of the powers
they
have,
in
living.
This
power to be creative and to
cope is awakened in us when we
are introduced to and involved
in activities that are a little
complex and sometimes a little
exciting along with the routine
and familiar.
Therefore it is important that
parents
-and
children
have
space in their homes and time in
their day for themselves,
for
experiencing the little things of
nature,
and
culture
and
enjoying quietly, even to make
little mistakes and learn from
them. The paragraph on time
budgeting at the end will give
some hints on how to work this
into one's life as a habit, in
this way
growing retains its
fun
side,
work
becomes
a
challenge and enjoyable.
16
The sense of having achieved
leads
one
on
to
risk
and
experiment
again
for
fresh
insights. Such type of persons
will successfully live in the 21st
Century. Will you be one? Will
you help your baby to become
one?
It is important to know that
anxiety is an integral
part of
life and that
it can play an
important role in human growth
and development. Anxiety
can
push
a
person
to
change,
adapt, - find new ways.
The
first
anxiety-producing
experience is thought to be by
some, the adjustment demanded
of the
unborn child for living
in the restricted space of the
uterus after the fifth month of
pregnancy. In traditional India
that was the time the Pandit was
called
for
the
ceremony
of
blessing the mother and unborn
★Personnel
Development
Depar tment
Holy Family Hospital
Okhla
Road,
New Delhi 1 1 0025 .
child and reading the Gita to
them for peace. That is the time
from which the limbs have to
fold,
the
head
to
bow
and
backbone
to
curve,
to
fit
experience more than the others
and hence one remains weaker
than the rest, the one to buckle
and break down under stress in
later life.
The second anxiety-generating
experience is said to be the
total
change
from
the
safe,
rather passive, existence in the
womb to the world of space and
time,
of
individual
life
and
responsibility
at
the time of
birth. Love and care, holding
and contact, are precious and
important for the new born.
Then, in the early months of
life,
satisfaction
of
survival
needs means life and failure to
take care of these needs causes
some
anxiety,
unpleasant
feelings.
The infant uses its
only way to deal with this, it
takes the initiative, it cries to
get help. Hopefully, this taking
of responsibility for self will
continue all through life.
The
but
infant's
intense
anxiety is
and
not
diffuse
to
be
lightly passed over. All human
life
is a series of occasions
when new
experiences crop up
demanding action,
adjustment,
initiative,
habits,
skills,
learnings. Only in this way can
anxiety be overcome and some
satisfaction
felt,
otherwise
"cop-out"
habits,
passiveness
etc. can be laid. So, your baby
has a variety of satisfactions
and
frustrations.
If
the
presence of a safe and loving
person can be felt at the time of
a new experience, it is likely to
be satisfying, even rewarding.
Growth
and
development
flow
from
successful
resolution
of
anxiety-producing
experiences
also. Fear is something learned
and comes after the experience
of anxiety. It is important that
children have the freedom to
voice their fears so that the
appropriate
guidance
can
be
given.
Growth and Development.
I.
The Pre-School Years.
Part
INFANCY:
Your
newborn
is
a
highly
intelligent
person
capable
of
engaging in communication from
the very first moment due to
extra-ordinary learning power.
At
birth
all
the
perceiving
abilities are well-formed under
genetic control and influence.
They develop according to their
use and stimulation to and from
the
environment.
This
development
has
far-reaching
effects on motor behaviour and
cognitive
growth.
The
best
environment you can provide for
your baby is one where there is
possibility of
regular
loving
and communication routines. The
formation
of
skills
for
interaction
with
people
are
easier
in
infancy
and
gets
harder as time goes on. It will
not be helpful to leave your
baby alone for long periods of
time
or
to
have
an
ever-changing line of people be
the caretakers. Such a situation
will
interfere
with
the
awakening, the using and the
developing,
of
communication
skills.
Infancy
begins
officially
at
birth,
and
ends
with
the
development of language ability.
At
birth
your
baby
enters
abruptly
into
an
environment
almost
opposite
to
the
safe
existence in the womb. As most
infants are well able to cope
with
this
change,
so
will
yours. The experience of being
loved, accepted, cared for, can
take care
of any trauma that
might
arise
in
the
birth
experience.
In
the
first
six
months
you
can
supply
experiences that
are
likely to
give
your
baby
feelings
of
satisfaction,
e.g.
somewhat
regular feeding,
even feeding
on demand in the beginning.
loving,
cuddling,
attention to
crying reasonably soon to find
out
why.
Babies
cry
from
discomfort, hunger,
loneliness,
fright,
to
make
contact.
It has been noted that babies
who do not have their basic
needs for food,
security and
comfort taken care of, get the
feeling and understanding that
they are obstacles to others.
This
can
slow
down
their
development. There could well
up
in
the
baby
some
uncomfortable feelings likely to
be interpreted as: "I must not
feel, I am not wanted here, I
must not have needs since they
disturb others". In verbal and
other
ways
you
can
supply
experiences
that
have
the
message: "You have every right
to be here, your needs are all
right with me, I attend to them
willingly and like it, I am glad
you are my baby girl (boy), I
like you, I like holding you,
you do not need to hurry".
After six months your baby will
have a need to explore and do
things. As you attend to needs
your
own,
baby’s,
other
people’s
there
could
come
occasions
when
your
baby’s
wishes
do
not
coincide
with
yours. There can arise blocking
messages like: "do not bother
me, do not imitate,
do not do
things,
do
not
think
for
yourself, do not be curious, do
not be spontaneous and real". If
you are aware of this possibility
you
can
sometimes
supply
experiences having the opposite
messages like: "You don't have
to do tricks to get my attention,
loving, stroking. It is all right to
do things honestly and get my
approval, and support".
In the first three years
some
very
important
developments
take place and they have an
influence on the rest of life.
Normally
these
developments
happen without difficulty. You
do not need to dwell on the
problems that might be.
You
need to concentrate on the fact
that your baby is a person who
is
growing
in
ability
to
communicate, understand, assert
self, be independent, begin to
relate more widely, like you.
THE TERRIBLE TWQs.
It can be a terrible time for the
17
adults, who are running after
the baby, who now enjoys the
experience
of
being
free,
everywhere,
and
into
everything.
A
positive
self-image, the feelings of being
worthwhile
and
of
self
confidence
being
to
be
laid
through experiences of approval
and recognition. These feelings
are very important for moral
development, which is surely a
foundation stone needed for life
in the 21st Century. For your
baby,
what is good and bad
gradually become one with the
experience
of
reward
and
punishment.
In the beginning, good and bad
are
associated
with
and
determined by material things
and
the
feelings
going
with
them, their presence or their
lack. Only gradually does the
selfish motive creep in. With the
population growth and shortage
of goods on the increase, the
people of the 21st century will
require
a
high
degree
of
sharing ability, selfishness will
be detrimental to the person in
many ways. So it is the time to
label things by their function so
that when you stop your baby
from some activity there is a
positive meaning to it,
e.g.,
“The spoon is to stir with, it is
not for digging". Parents who
have cultivated
the habit of
giving reasons for YES and NO
to themselves, each other and
family etc., will naturally do so
for their child as well. Your
child will now begin to fear
separation from the familiar.
18
Illness gives rise to unfamiliar
feelings,
separation
is
very
much feared by the small child
who is ill. Stay around, or in
sight or hearing if your child is
ill, or have someone whom
the
child trusts take turns
with
you.
Many young mothers work. That
is good for them and sometimes
necessary. It is important for
you
to
know that substitute
mothers, or caretakers, can be
helpful and beneficial for your
child, if the right environment
is present. Remember that there
is some direct influence from
any adult in close contact with
the child on its development;
also
of
elimination,
training
experience,
feeding
habits,
speech
opportunities
and
models, experiences that allow
testing and exploring of reality.
Many children have ambivalent
feelings at this time. They love
the presence of, and interaction
with,
trusted
adults.
They
dislike them
for any control
they may exert. Unsatisfactory
relationships between caretaker
and child can increase into poor
relating ability in adulthood.
The
need
to
explore
the
environment
and
receive
information grow rapidly after
the age of 18 months.
Your
habit
of
giving
reasons
for
permission and control will be a
great help to your child now.
Added to this will be your habit
of setting safe and clear limits
within which your child is free
to explore and choose as it is
the age of accident proneness.
The
result
of
deliberately
crossing limits set needs a little
explaining, to your child,
so
that
self
discipline
and
creativity are helped to grow.
Although it may appear to the
contrary, your child still likes
being held and loved, in fact it
is a deep need in all of us
humans.
The blocking message
that could be picked
up by a
child of this age are:
"don't
think,
don't
have
needs
different to mine,
don't have
problems
different
to
mine".
Helpful message that could be
given are: "I am not afraid of
your anger, I am happy you are
growing up, it is all right for
you to think and feel at the
same time, you don't
have to
look after me when you want to
do something, I will inform you
if I want to be included,
you
can be sure about what you
want."
THE TRUSTING THREEs
At
this
age
there
is
a
tremendous
growth
in
your
baby's skills and abilities. Your
child now has the power to
rebel, to be independent, to say
no and enjoy it.
If dialogue
between you - the parents breaks
down,
there
is
the
possibility that your child will
learn to play one parent against
the other to have her own way.
This is not good for any one of
you. It is very important that
your words and examples teach
your child the right
use of
power. Provide opportunities for
getting rid of frustration and
aggression in play and activity.
You
can
provide
hammering
toys, allow some digging etc.
Positive control will prove more
helpful to your child than the
negative
sort.
"You
may
sit
quietly and listen like the rest
of us grown ups
if you
wish"
or "go play
outside", will be
more effective than: "Don't jump
around and
make a noise, we
want to listen to the music".
Children at this age glory in
accomplishment through physical
activity, in play, mastery over
things
with their hands.
1°
minutes a day with an interested
adult
doing
such
physical
activity
will
prove
most
beneficial. Remember that soon
your
child
will
be going
to
nursery school, or playing with
other children for several hours
away from home. Other adults
will occupy important places in
your child’s life from now on.
The contact with a
home - a
safe and happy place to be with loving adults who regularly
interact and have time for one,
is
a
valuable experience for
your
child.
Those
daily
10
minutes will not be too much
once you realize the benefits
they hide. Besides, they give
you
opportunity
to
share
adulation
and enjoy being a
child yourself.
THE FRUSTRATING FOURs
At this age the greatest task
for your child
will be to learn
how
to
spend
energy
well.
Deepening curiosity and ability
to undestand help your
child
grow in the power to reason,
communicate,
manipulate,
do
things. Copying adults becomes
an
important
part
of
your
child's life.
Be aware of the
example you may be giving. You
can
help your child get ready
for
the
world of
school
by
using the senses to explore the
world together. The activity of
these
10 minutes changes now,
e.g.
take your child to the
bazaar
with
you, buy
some
vegetables,
say
brinjals.
On
coming home allow your child to
touch
the
brinjal,
feel
its
smoothness
and
rough
sepals
and stem, introduce
her to the
colours inside and out,
allow
her to feel
the difference in
texture of the whole and when
cut up, smell it, taste it. Then,
after
cooking,
explore
the
difference
in
touch,
smell,
colour, taste. You can find a
million ways to open up the
world
of senses
to your child
through ordinary tasks of daily
living.
THE FASCINATING FIVEs
This is the age when your child
will experience much security
and happiness in family customs
and
rituals.
Control
of
the
body becomes a task for your
child again. The schedules
of
school and home
need to be
integrated. It is the age to talk
and reason, to help your child
know what is expected of
her
at home, in the school, in the
neighbourhood. You may need to
help your child make friends,
give in to others sometimes, get
along with people outside the
home, rest when tired, ask for
food when hungry. Adults help
children adjust to one another
by staying outside their petty
quarrels. Adults help by being
good
listeners.
When
the
problem is understood they will
be able to make a response that
helps
the
children
see
the
problem. In this way adults will
not
side with
one or other
party, or inadvertantly lay guilt
or blame on young shoulders.
Consistent
discipline
is
most-important.
This
means-clear limits within which
there is freedom to express,
choose and define consequences
of crossing the limits known
before-hand.
Parents need to
keep the promises they make to
their children, so do not make
rash ones either for reward or
punishment. In this way your
child will not get punished by
surprise, and at the same time
will
be
helped
to
lay
the
foundations of personal values.
Blocks to full development can
come
from experiences whose
messages the child takes to be:
"feel bad about what you do, or
say,
or
choose;
don't
be
powerful,
let
others
shield
you, give in to others always,
don't be warm and loving, be
careful, don't risk yourself". It
is
possible
to
give
helpful
messages that can say to the
child: "You can be powerful and
still need me, you can express
your feelings and not always
hide
them,
you
can
make
mistakes and learn from them, it
is all right, you do not have to
be or act dead & sick to get
love and attention, you can ask
for what you want".
19
SUMMARY.
Most parents and children do
well. A few things need some
attention and
a little planning
so that the basic experiences
required for development in the
21st century are assured.
1.
Security: The experience of
belonging
to
someone
is
important - first to a person,
then a family, and gradually to
wider groups. Part of loving
your
child
is
giving
good
example,
clear
and
firm
guidance,
being
available
at
predictable times of the day,
some
positive
stroking,
and
providing reasons for giving or
withholding permissions. If you
allow your child to do mostly
what she wants, there can arise
the feeling "No one cares or
shows how, why bother". Stand
firm
with
decisions
made.
Parents who do not spend time
talking
to
each
other,
can
confuse
their
child
by
contradictory
messages.
The
experience
of
growing
acceptance in the family circle,
with
definite
rights
and
responsibilities builds feelings of
security and importance.
The
experience of having been loved
in
the
early
years
of
life,
strengthens
the
sense
of
acceptance.
2. Adaptability:
This
means,
learning to live in the world as
it is and to modify it with least
injury to self
and others. It
does
not
mean
just
passive
acceptance
of
everything.
Therefore reasons
are to be
supplied. Older persons are the
most
powerful
forces
in
the
child’s reality, the controllers,
providers,
guides. Your child
needs times of the day to do as
she wishes, and this needs to
be
guided.
Adaptation
is
achieved
by
awakening
and
sharpening
of
listening
and
questioning
abilities.
Parents
too, need to be good listeners.
Since children ask questions to
fill
time,
show
off,
parrot
others, get attention, sometimes
to know, make an effort to find
out
and
listen
before
you
answer. All you may need to do
is nod, remain silently listening.
make a statement, ask another
question.
Sometimes
you
will
need to give answer and give
information.
Be careful
about
child
with
overloading
your
experiences,
information,
and
that
will
as
blocking
to
too
little.
development
as
is - answer
Another caution
truthfully. Once a child finds
out
that
an
adult
has
not
answered truthfully, trust and
confidence can be deeply shaken
in all adults. It is quite all
right to say "I do not know,
let's find out together"; or, "I
will find out and let you know"
or it may have to be something
like
just as you cannot drive
the aeroplane at this age so you
will not understand it now. I
will explain more as you grow".
Occasionally
have
your
child
along as you do things, it gives
opportunity for her to learn,
store information and builds the
feeling
of
belongingness
and
importance.
3. Self-Expression:
This means
freedom to show individuality. It
involves
the setting of clear
limits within which the child is
free to do and to choose. It also
includes
allowing
choices
in
routine things in the day, e.g.
"do you wish
to wear pink or
yellow today?" "You are to eat
all of your lunch, but you can
choose which you will eat first
- the dal, vegetables, chapattie.
After that
you may have a
banana". Time for day-dreaming
20
is helpful to a young child, and
adults need to understand that
the boundary between fact and
fantasy is
rather hazy for a
pre-school child - so regular
weekly or daily time together
for stories and experiences is
very helpful. Play with other
children also helps
a lot. Our
village children profit immensely
from opportunity to make things
in clay, or devise play things
from stones, sticks and leaves.
Their proximity to home at all
times allow them to handle flour
in its dry and kneaded forms to
experience
and
make
thingsUrban children can be given
similar
opportunities
in
the
home, and the sand pits and
other
manipulating
things
in
children's
parks.
Time
spent
regularly
with
the
child
to
explore the results of choices
made help her develop wisdom
and insight,
and the daring to
attempt again. Failure needs to
be
understood for its positive
aspect to balance the feelings of
shame
and
guilt
that
might
accompany
unsuccessful
attempts. "It is true
you did
not come first in the race, you
tried hard and that is what I
like. You do not have as long
legs
or
the
practice
like
Shyama, that will come for you
also.
There
is
nothing
bad
about not coming first if you
have tried your best. How do
you feel about it now?"
4.SUCCESS:
Experiencing
success
in small and greater
things is an important part of
life and growth. It must involve
a
little
conflict.
Both,
authority and conflict are an
integral part of life. Achieving
some
independence
and
constructive
management
of
conflict
are
equally
essential
parts of life and development.
Your growing child meets limit
and
authority
in
the
daily
things
of
life in
the home,
school and neighbourhood.
Shielding your child from all
responsibility is not helpful
to
her.
Some
experience
of
ownership is essential if your
child is to understand sharing.
Begin with a small box. Respect
the things your child may put
into it, she has the right to
own
little
things
and
to
experience others respecting her
ownership
them.
Simultaneously
with
ownership
should go occasions when your
child is asked or involved
in
sharing things of others. You
may share something of what
you
have,
say,
a pencil,
a
rubber band, a beautiful feeling
or a sight. On occasion you may
ask your child to share with
you.
The experience of
not
ALWAYS having to share
what
one has, is important. Praise,
approval,
positive
clear
guidance, all help a lot.
Kindly let us know if this has
helped
you. It is meant for a
city, not a rural setting. Any
suggestions for Part
II,
the
school going years, will be most
welcome.
Should you care to
contribute to our printing costs,
we will be most grateful.
TIME
BUDGETING
I. The 24 hours of the day can
be portioned out
to include all
the essentials
for
personality
growth.
Eight
hours
go for
rest/sleep/relaxation,
taken
in
continuation or spaced out in
the day. Along with this allow
20
minutes
a
day for doing
something you enjoy. This will
change with the seasons and
with your mood. Include things
that
are
passive;
reading,
listening
to
classical
type
music,
active;
playing,
gardening, creative work, card
making, etc - so, it is naturally
a time you look forward to.
2. Normally
parents
perform
well. They are successful. So
will you be.
Relax and enjoy
your role of parent. Your baby
is not an object in your house.
Your
baby
is
a
valuable
member
of
your
home
and
family. You do not merely have
a child, like you have a pair of
slippers. You are related to a
person,
you are "mother" or
"father" of your child. By the
year
2000
A.D.
60% of our
people will be below the age of
30 years. Infants of today need
their parent's help and example
to grow into wise adults ready
for their time.
3. Eight hours will be spent in
work without much effort. With
this include exercise equal to 20
minutes of walking. This is most
important since the body is the
marvel
of
engineering
and
regular exercise helps keep off
21
weakness
in
heart,
blood
pressure,
joint
ailments,
constipation etc.
4. 20 minutes should be spent
in
management
time,
i.e.,
mother and father talking about
the things of the home and the
children.
This
helps
smooth
running of the house, flow of
information and the chance of
the parents to gradually see eye
to eye on important things of
the
home and children, or just
talk about them. In the long
run it will help the children see
their
parents
having
equal
authority in the home and so
they will not need to manipulate
one against the other, to have
their way.
5. Till the children are 10-12
years of age each parent needs
to spend 10 minutes daily with
each child alone. As your needs
and the child’s needs change,
from
time
to
time,
but
for
several weeks keeping it at the
same hour helps formation of a
habit. The habit of opening up
to and enjoying mother/father,
of living in intimacy and sharing
secrets, new knowledge etc., is
formed and important.
6. Since our spiritual power is
the most important ingredient of
us it needs to be kept in good
condition.
Ten
minutes
spent
with COD are essential. What
name or face or shape Cod has
for you, is not important. Find
a time when you can be quiet
and
alone
for
10
minutes,
breathe
gently
in
and
out,
review the previous 24 hours
and thank God for 5 or 6 things
that
happened.
Thanksgiving
from the heart achieves for us
the same as peacefulness and
happiness of rest and hobbies.
Then look for one occasion when
things went well between you
and another(s) recognise your
part in that event. Some gift of
personality however small, made
it so, keeping quiet, helping,
etc.
Make that a
prayer of
thanksgiving
also.
When
you
have knowledge of small things
you do well you will not be
easily stressed, and you will
spontaneously
recognise
and
reward small things in others
that are good. This habit will
pass off on to the children,
they will grow what has been
recognised and increase
that.
Then
discover
one
occasion
when things were not so good
and recognise your part there
also. 99% fault may be the other
party’s, 1% will be yours. That
too can be made into a prayer
and it helps us to get spiritual
strength
for
giving
all
discipline.
EMOTIONAL CHILD ABUSE :
The invisible plague
Nobody knows the number of
those afflicted. But awareness is
growing
among
mental
health
experts
that
the
youngster
deprived
of
attention
and
affection
may
be
even
more
damaged
than
one
who
is
battered.
"The bruises don’t show on
the outside- so, there are no
statistics on how many children
are victims", says Dr. Elizabeth
Walkins at St. Roosevelt Hospital
in New York.
According to authorities on
child
development
emotional
abuse results in nothing less
than the systematic destruction
of a child’s self-esteem. The key
word is systematic.
Emotional abuses are prompted
not by children’s misbehaviour,
but by their own psychological
problems.
22
"Perfectionist"
parents
may
display irrational expectations.
through education and example
and domination and cruelty.
Emotional child abuse may be
at least as devastating as those
of physical abuse.
Questions to ask yourself:-
Dr. Jay Lefer, a New York
psychiatrist
,
refers
to
the
"four ’D's" of emotional abuse,
deprivation,
distancing,
depreciation
and
domination.
The parents may use one or all
of the four 'D's to play out
their
own
psychological
conflicts.
According
to
Dr.
Lefer, "When a child
is being
emotionally abused, the problem
cannot be successfully treated
in
isolation.
Once
a
parent
realises
something
is
wrong,
this
can open up the whole
matter of how the family works.
And other family members can
be brought into the therapeutic
process.
There
is
a
big
difference
between
domination
(2) Do I see characteristics in
my child that remind me of how
much I dislike someone else in
my family?
(1) Am I constantly angry at my
child?
(3) Do
I compare him
other people's children?
with
(4) Am
I
indifferent
when
someone else praises my child?
(5) Do I often feel ashamed
my child?
of
If the answer is 'yes' to the e
questions,
you
may
need
professional help.
Source:
1985.
Reader’s Digest-July,
STRESS MANAGEMENT
GUIDELINES FOR
HEALTH WORKER
Psychological
to
man
lead
stress.
factors injurious
to
physiological
Franz
Alexander
showed that
emotional stress is accompanied
by
internal
physiological
process of an adaptive nature.
These are generally under the
control
of
the
Autonomic
System.
Prolonged
emotional
stress
causes
chronic
disfunction
in
the
body’s
response.
These
pathological
responses cause,
in the long
run, tissue damage accompanied
by symptoms. In this way, all,
or most, illnesses are said to be
physical
disorders
caused by
chronic
emotional
stress
accompanied by disease (that is,
absence of ease)
due to living.
'Stress' can be simply
defined
as the rate of wear and tear in
the body. General stresses can
result from reaction to noise
pollution,
air-pollution,
food
adulteration
and
pollution,
clothes
pollution
(polyesters)
over-crowding,
pressures from
having
to
meet
deadlines,
constant
competition,
financial
difficulties, death,
violation of
law,
interpersonal
relationships,
also
from
inexplicable variations in one's
eating, sleeping or play habits,
even muscle tension, spasm or
from overuse of muscles. Any
change or adaptation that taxes
a
person's
physical
or
emotional adaptation system can
be termed stress producing for
that person.
Stress can be of an injurious or
non-injurious type. The latter
invites
to
successful
or
creative
adaptation.
It
is,
therefore, important that Health
Care Delivery Systems include
in
their
services
information
about
prevention of injurious
stress. People need to know and
to understand the relationship
between
their
behaviour,
attitudes and the systems of the
body.
1*
*s
the
in
neuro-physio-socio-factors.
For
example,
disfunctional
eating
habits
are partially the result
of stress and its effect on the
digestive process. Stress draws
off blood from
the digestive
process
when
it
is
needed.
Under stress breathing becomes
shallow
and
irregular
and
interferes with oxygen supply.
It is important to know that
deep muscle relaxation
induces
physiological changes that help
restore
health
when
it
is
disturbed due to stress. The
five pillars of health need to be
explained.
According to Hans Seley,
the
Pioneer
of
psychosomatic
medicine, the major diseases of
adaptation can be schematized.
- Diseases of adaptation lead to
derailment
of
the
adaptive
system, which in turn leads to
faulty response to stressors.
Over-response
creates
over-defensiveness leading to
excessive
pro-inflammatory
corticoids, and so to arthritis,
allergies, asthma etc.
Under-response
creates
under-defensiveness leading to
excessive
anti-inflammatory
corticoids,
so
to
ulcers,
infections etc.
Specific factors that are to be
examined with the patient are
Loss, Injury and Frustration.
Loss
can
be
of
values,
objects, persons, ideals, dreams
shattered,
home,
country,
prestige etc.
Injury
can
be
real
or
imaginary,
it
will
be
accompanied by pain that causes
inability to engage in, or use,
familiar things or relationships.
Pain can also result from loss of
familiar and loved persons, or
objects.
Frustration
conflict
due
can
to
come from
conscience.
blocking of needs, desires, from
fear
that
is
real
or
even
imaginary,
from
immobilisation
due to loss and injury, or from
restriction put by society.
SCHEME
TENTATIVE
THERAPY.
FOR
MAKING
ASSESSMENT AND
In the first six months of life
the human need is for feeding,
approval,
stroking—physically
and psychologically—response to
crying which is the baby's way
of calling for attention in its
helplessness. If this
has been
inadequate it will show in some
degree of denial of reality in
the style of
life. The probable
damaging messages that could
have been picked up at that age
are:
don't
be
here,
don't
bother
me,
feel
bad
about
having
needs as they disturb
me.
Signs to
be read. The person
will
show
great
dependency,
feelings of inadequacy due to
real
or
imagined
causes,
helplessness,
all
forms
of
attention getting, guilt, anger
which, on analysis, turns out to
be
a
cover
for
fear/helplessness,
stored
up
rage
now
becomes
chronic,
hyper
or
hypo-reflexia,
nervous - irritability,
chronic
colitis,
great susceptibility to
infection,
blocked
genital
feelings etc.
Therapy will include helping the
person
achieve
balance
with
special attention to :
i.
accepting,
understanding,
enjoying the right to be in the
family group they are in, at
present and making meaningful
relationships.
ii.
acknowledging
personal
needs
and
feeling
ease
in
fulfilling the legitimate ones in
appropriate ways.
iii.
understanding and accepting
23
large part of the waking hours,
yet there is always more to
learn and remember. Disruption
in achieving this can result in
the
person
constantly
discounting self, not comfortable
about personal successes. The
damaging messages that could
have
been
picked
up: don't
think,
don't have needs and
activity
different
to
mother/father/others, don't have
problems
different
to
mother/father/others.
maleness and femaleness—one's
own
body—with
its
basic
functions and needs.
Six to 18 Months: The need is
to explore and be
involved in
activity basic to daily
life. It
is
the
time
when
projection
comes
easily,
for
some
it
persists unduly into adulthood
and can be the sign pointing to
damaging messages taken at an
earlier age. The messages could
be:don't bother me, don't bother
others, don't imitate, don't think
for yourself,
you are always
wrong, don't be curious, don't
be real, don't be intuitive- it
always
leads
to
the
wrong
thing.
SIGNS
TO
BE
READ:
The
person will reveal a lot of fear
about a variety of things which
on analysis turns out to be a
cover for
anger, physical and
mental
activity
will
be
very
high,
as
also
risk
taking,
curiosity,
there
will
be
heightened adrenal stress with
behaviour that
may
be stuck
in
fright,
flight
or
freeze,
sensory motor
impairment easily
happens, perceptual problems of
eyes 8 ears, asthma, migraine
etc.
Therapy will help the person
achieve balance specially in :
i. getting approval from others
by open straight behaviour, not
24
by illness or tricks.
ii. becoming involved in doing
things and also sometimes asking
for help in doing things that
are
pleasant,
build
relationships.
FROM 1 1/2 TO 3 YEARS : The
greatest need is to handle time
well,
also
limits,
and
information. Thinking occupies a
Signs to be read:
There will
be
a
feeling
of
isolation,
separation
from
others
in
general,
inconsistency
in
behaviour
with
big
swings
between rebellion and obedience,
there will often be scenes over
control issues, strong sense of
shame,
guilt.
The
person is
usually very tidy, and clean,
there
could
be
uncomfortable
discharges of energy, seizures,
tension can also be released in
the
rituals
surrounding
constipation,
diarrhoea,
neck
muscles often get stiff, central
and
autonomic
systems
easily
disturbed.
Therapy will help the person
achieve balance specially in :-
i. expression of anger or other
feelings in appropriate ways.
Therapy
includes
achieving
balance by stressing:i. acceptance of personal power
while having needs like others.
Pride in a few things well-done.
ii.
expression
of
feelings
appropriately and not in veiled
ways, open giving and receiving
verbal or non-verbal approval.
iii. asking for love, and not to
get it by being sick, scared or
by pity from others.
ii. permission to self to grow up
and enjoy life, to change, to
think and feel for oneself, to
have some simple hobbies.
habit
of
iii.
cultivating
the
taking care of one's own needs,
sometimes
without
including
others
and
making
decisions
also.
iv. learning to trust personal
abilities and not always doubt
personal needs, abilities, plans
unnecessarily, learning to plan,
to
look
at
alternatives
and
consequences before deciding.
problems connected with caring
and hurting issues they will
be
many,
easy
swings
of
behaviour towards being unwell,
going mad, having breakdowns,
there is much hostility that is
turned
inwards,
unresolved
rage,
many
inhibitions,
situations in daily life ending in
fights,
circulatory
problems,
chest pains, palpitation, raised
or lowered metabolic rates.
The
6
to
12
Years:
is
considered to be generally a
unifying period. The need is for
experience in doing things with
appropriate
guidance
and
approval so as to have small
successes
and
learn
constructively from failures. It
is the time for struggling to
incorporate
values
and
structures of life. The damaging
messages that cguld be picked
up are: 'don't think just do as
you are told', 'do things by
habit', 'do not innovate', 'don't
ask
questions',
clarifications,
'don't struggle', 'don't organise',
you always do it
wrong, 'don't
ever
exclude
anyone
or
anything close to you', 'don't
make mistakes'.
Therapy
stress: -
to achieve balance will
Between 3 and 5 Years
of age
a person needs to have external
information,
proper
feeding,
safe limits within which to be
free,
experience
of
using
personal powers to explore, be
creative in little things, achieve
success and failures
that
are
learned
from.
The
problems
revolve
around
exploration,
adaptation.
The
damaging
messages that could have been
picked up are: be sorrowful,
eat your heart out quietly, long
for things, for love, approval,
but don't ask for them, wait
patiently
till
given,
be
depressed not silly and gay or
enthusiastic, don't be powerful,
don't be warm and loving, watch
out
always
and
don't
trust
others easily, believe in magic.
Signs
to
be
read:
Look
f6r
25
i.
You can plan and think
before acting, then mistakes will
automatically become less.
ii. You can choose to do many
things you want to; once you
h»ve found out the limits and
cbnsequences, you do not need
to always include others. You
can take initiative in things not
done by you before.
and integrating the values and
lessons
learned till now. The
need is to experience choosing,
taking
consequences,
making
successes, learning new roles.
The personal
identity emerges,
so, the problems centre around:
a. crisis of work or using time
productively, i.e., working from
choice
not
compulsion
or.
d.
internalising
values
and
customs, rules 5 regulations of
family and society, politics, etc.
e. arriving, however vaguely,
at the meaning of one’s life,
some
awareness
of
one’s
non-physical
powers
and
abilities.
The
be :
damaging
messages
could
Don't succeed, don't grow up
and
leave,
remain
mummy's/daddy’s
baby,
mother/father
will
look
after
you,
don't work yourself too
much.
Signs to be read. Opposite sex
distribution
of
fatty
tissue,
sense of muscular
binding in
the
thoracic
area,
acne,
allergies, allergic reactions to
persons can be revealed in talk
and
unresolved
interpersonal
problems,
obesity,
dysmennorrhoes,
involutional
depression/reaction,
allergic
reactions.
Therapy will include attention to
the
problems
voiced
or
detected first - then to the
following:
i.
giving permission to enjoy
growing up, owning one's body
and enjoying being the sex one
is.
ii.
taking
care
of
personal
needs
in
appropriate
and
satisfying ways.
iii. talking
about and sorting
out
feelings, desires, dreams,
plans.
iv.
discovering
and
being
proud
of
the
many
things
lovable in self, the successes
already made.
iii.
It is all right to disagree
specially if you have reasons’ for
doing so.
iv. You do not have to suffer
to get what you want. Sometimes
you may have to admit wanting
things you cannot have.
13 to 20 Years:
The adolescent
period is a time
when a lot of
energy
is
spent
in
unifying
26
resignation to circumstances.
b.
crisis of authority or finding
out when to depend and when
be
independent
and
make
meaningful relationships.
c.
crisis
of
sexuality
or
becoming
used
to
same
or
opposite
sex and one's
role
among them — be they younger,
older or of same age.
NORMALLY WE ATTEND TO THE
PRESENTING PROBLEM.
ONLY
IN THE COURSE OF THERAPY
THE OLDER PROBLEMS MAY BE
SURFACED
IF
NEEDED.
HUMANS ARE ABLE TO MAKE A
CHANCE IN SELF FROM ANY
POINT
CHOSEN.
ONLY
PERSISTENT
PHYSICAL
PROBLEMS NEED PROBING TO
SURFACE
FEELINGS
FROM
EARLIER TIMES.
P-Y.
EMOTIONAL STRESS AND N"" NS
CHILDREN
Unlike adults children respond
to situations around them or to
their own conditions, with little
attempt to control or hide their
reactions. This spontaneity of
their responsiveness on the one
hand
endears
them
to
their
elders, but on the other, causes
them to be easily
disturbed in
the
face
of
unpleasant
circumstances or illness. A few
children
may
manifest
psychological
disturbances
similar to adults, but many of
them have disorders
that are
unique to certain age ranges.
Placed
under stress, a child
can react in any of a large
number of ways. Nor are these
ways
mutually
exclusive.
For
example,
a
child
who
has
suddenly been removed from the
security of family life by the
loss
of
parent
may
be
emotionally sad,
irritable and
may begin to wet his clothes in
the night despite having gained
bladder control earlier. Another
child who has been punished
severely at school may begin
refusing to go to school, eating
excessively
and
shying
away
from friends.
Children,
in
many instances,
fail
to
make
a
connection
between a traumatic event and
their
disturbed
behaviour.
Indeed, quite often they may
not recognise their responses as
being deviant at all. Common
stresses to which children react
are usually in
the immediate
environment.
Thus,
parental
disharmony,
divorce
or
separation,
bereavement
especially of a parent, illness of
any family member, or illness of
the parent himself are commonly
reported
precipitants
of
childhood
disturbances.
Any
significant
happening
in
the
school or in the child's group of
friends
can
sometimes
bring
about
an
emotional
reaction.
Catastrophes
which
affect
an
entire
community
are
also
powerful
causes
of children's
problems, especially when large
numbers of the community are
killed,
disabled
or
uprooted.
Children in such situations are
prone to develop a precocious
understanding
of
devastation
caused by such violence, become
grimly realistic and more easily
break down when
faced with
stress in the future.
Recognising
children
who
have a problem entails finding
out
whether
the
particular
'disturbed'
behaviour
is
appropriate to the age, whether
it leads to a disability or when
it is against social expectations.
Thus a 10-year-old child with
nocturnal
bed
wetting
is
considerd disturbed, but a twoyear-old is not.
Some
commonly
encountered
reactions
of
children,
under
stress, include:
1.
Disturbance
functions:
of
bodily
The
appetite
of
this
child
markedly changes. Usually there
is a sudden reduction with loss
of interest in food. Less often a
voracious appetite may appear
or
food
hatyts
may
become
erratic.
The
child
despite
having
gained bladder control,
begins to wet his bed at night.
Sometimes there may be soiling
of clothes.
Sleep
disturbances
appear.
Intermittent sleep with bizarre
or frightening nightmares may
occur. Sleep may be marked by
excessive restlessness, shouting
or
talking.
In a few cases,
sleep is delayed so that the
child lies in bed for a long
while
before getting to sleep.
Seldom he may rise very easily
and fail to get back to sleep.
2.Disturbances of feelings:
Children show a wide variety of
disturbances in their subjective
feelings. The child may complain
of feeling some abnormal moods
such
as anxiety,
fearfulness,
misery or jealousy.
In
many
instances,
however,
subjective
feelings
have to be
inferred
from observing the child and
later can be corroborated by
him.
Thus
an
anxious
child
becomes
fidgety and
trembles
when spoken to. A depressed
child
may
be
fearful,
avoid
27
company
and
might
not
be
interested in games or studies.
Shyness
may
develop
in
a
hitherto
friendly
child.
Yet
another
manifestation
of
emotional disturbance is that of
irritability
and
anger.
Often
such
irritation
seems
unprovoked or arises on very
trivial provocation.
In severe emotional disturbances
the
child
may
become
very
withdrawn and even keep quiet
for days on end.
The child
might show problems in relating
folks at home and may become
increasingly isolated.
3.Conduct Disturbances:
Mainly involves aggressive and
destructive behaviour. The child
resists
any
attempts
to
discipline him, defies elders and
sometimes indulges in physical
violence. In addition to these,
the
child
makes
repeated
attempts to destroy things in
his
environment,
such
as
household
articles.
The child
seems to act before considering
the consequences of his act.
Such children tend to lie, steal,
tease or bully their companions,
family
members
or
even
strangers, and they easily get
into quarrels. Sometimes sexual
misconduct may occur. Children
play
truant
from
school
and
their
school
performance
deteriorates.
4 .Illnesses
others:
Modelled
after
Children
are
more
suggestive
than
elders
and
often
mimic
everything about their elders
including
their
illness.
This
must
not
be
thought
of
as
mischievous or
imaginary and
discussed. Thus, a child who
develops dyspnoea, may believe
his
own
breathing
to
be
impaired, especially when large
numbers in the community are
complaining of a similar problem.
Quite
often
psychological
complaints such as depression' or
sleeplessness can also be picked
up in a similar fashion. Not only
elders, but neighbours', friends'
or schoolmates' maladies can also
find their way into a child's
mind.
TREATING DISTURBED CHILDREN
It
28
is
of
utmost
importance
to
convey
with
tact
to
the
responsible
elders
that
the
child's disturbance can be the
manifestation
of
their
own
problems. It is only with the
cooperation of the family that
effective
treatment
can
be
brought about, as children are
often
only
the
pointers
to
general disturbance within the
family, e.g. marital disharmony
leading to child's school refusal,
from
fear
that one or both
parents may suddenly leave.
At
the
outset
it
is
important to convey to the child
patient
that
it
is
for
his
improvement that the doctor is
concerned,
rather
than
to
comply with the needs of the
distressed parents or elders.
Interviews with children work
out better when initial focus is
on an area of little disturbance
(e.g.,
a
conduct-disordered
child may be asked about his
favourite game).
Assuring the patient that
you
are
on
his
side,
all
through, is necessary and this
can be made obvious in subtle
ways like always speaking to the
child alone before meeting the
parents for a detailed narration
of
disturbed
behaviour.
Impartial observation can be fed
back
to the
child,
and his
expectations and needs must be
listened to before a judgement is
passed on these.
Working
with
disturbed
children calls for patience and
keen observations as they can
make symbolic gestures of great
value, e.g., aggression directed
at pictures of dolls of a certain
sex
could
give
a
lead
on
disturbed
relationship
with
a
parent of that sex.
Children
understand
a
system
of
rewards
and
punishments
fairly
well
and
these can be undertaken with
care, after parents have been
counselled on the need for a
united approach to disciplining,
and their position of advantage
in
being
available
to
the
emotionally disturbed child to
ventilate
his
feelings.
Punishments must not be in the
forms
of
harm
but
can
be
deprivations of certain pleasures
e.g. favourite food or favourite
pastime.
A
consistent
warm
non-judgemental
attitude
helps
in dealing with many disturbed
children.
The severely disturbed
or withdrawn patients may also
benefit from meditation after an
adequate
diagnosis
has
been
made.
Dosages
should
be
adjusted for the body weight of
the child.
S. JOSEPH
NEW
VHAI PRESIDENT
Dr.
Samuel
Joseph,
M.D.,
Medical Suprintendent of MGDM
Hospital,
Kangazha,
has been
elected
President
of
VHAI
Executive board at the annual
general
meeting concluded
in
Dehradun.
Dr. S. Joseph was president of
Kerala VHAI. He has served in
the boards of VHAI, and the
Christian Medical Association of
India.
He has also been the
editor of CMAI Journal.
Dr Joseph who set out to start
a specialist Cardiac Centre now
heads
a
large
community
health
programme
participated
actively by various communities.
The other office members are:
Vice President: Mr. G.D .Kunders
(Karnataka)
Secretary:
(A.P.)
Dr.
D.B.I.
Victor
Mr.
Korah
Joint
Secretary:
Mathan (Gujarat)
Treasurer:
Sr.Lucia
(New Delhi)
Panikulam
Other members are Fr.Anthony
Swamy (Tamil Nadu), Fr.John
Noronha
(W.Bengal),
Dr.E.B.
Sundaram (U.P.), Dr.Bhartendu
Prakash
(U.P.),
Mr.M.Zaman
(Bihar) and Mrs.Anthya Madiath
(Orissa) .
29
WORLD HEALTH
ASSEMBLY
The
38th
World
Health
Assembly concluded its work on
May
20,
1985,
on
a
background
of
earnest
pleas
made
by
its
President,
Dr.
Suwardjono
Surjaningrat,
and
by the Director-General of the
World
Health
Organisation
(WHO), Dr. Halfdan Mahler, to
concentrate
efforts
on
the
attainment of health for all by
the year 2000.
The
Assembly
displayed
renewed faith in the potential
for people's development and the
dynamic role of strategies for
health for all in ensuring it.
The Assembly also decided to
strengthen
WHO
support
to
countries
cooperating
among
themselves,
for
health
development
on
their
own
initiative
and
to
involve
non-governmental
organizations
more than ever before, to attain
the goal of health for all as a
social
contract
between
governments, people and WHO.
Technical Discussions
The Technical Discussions on
the topic of "Collaboration with
non-governmental
organizations
in
implementing
the
Global
Strategy
for Health for All"
were held under the general
chairmanship of Dr. Maureen M.
Law (Canada). There were 566
participants, many representing
national
non-governmental
organizations;
representing
Indian
voluntary
sector
were
Dr.
Hari
John,
Dr.
John
Vattamattam
and
Augustine
Veliath. Dr Lata Desai of SEWA
also
participated
in
the
discussions.
The
overriding
conclusion which emerged out of
the Technical Discussions was
that
a
growing
partnership
between
governments
and
non-governmental
organisations
was an inescapable necessity for
the attainment of health for all
by
the
year
2000.,
It
was
generally agreed that the time is
most opportune for intensifying
30
such a partnership, based on
mutual
understanding,
identification
of
appropriate
roles,
complementarity
of
actions,
mutual
learning
by
doing
and
full-fledged
cooperation. WHO has a crucial
role in promoting, fostering and
strengthening
such
a
partnership.
T echnical_______and_______economic
cooperation
among
developing
countries
Action to build up a critical
mass of "Health For All" leaders
was supported by the Assembly
as
suggested
by
the
Director-General.
A
comprehensive
strategy
for
leadership
development
is
required
and
all
concerned
including
Member
States,
international
organizations
and
bilateral,
multilateral,
non-governmental and voluntary
agencies,
were
ubged
to
concentrate
on
activities
strengthening
technical
and
economic
cooperation
among
developing
countries
(TCDC/ECDC) .
strategy for
health
the year 2000.
for
all
by
Prevention
of
disability
and
rehabilitation of the disabled
Emphasis was placed on the
prevention
of
disability,
particularly
through
the
Expanded
Programme
on
Immunization
(EPI),
and
by
strengthening
environmental,
occupational
and other
health
programmes. Member States were
also
requested
to
increase
opportunities
for
the
participation of disabled persons
in
community
life
and
in
decision-making;
to
expand
education,
training
and
job
opportunities
for
disabled
persons;
to
facilitate
their
acceptance
by
the
general
population;
to increase public
information and education so as
to prevent disabling accidents;
and to remove all barriers which
prevent disabled persons from
leading
socially
and
economically productive lives.
Prevention
of
deafness
hearing impairment
and
Women, health and development
There was general concern
about
the
slow
progress
in
realizing the objectives of the
UN
Decade
for
Women,
particularly
regarding
high
maternal
mortality
rates,
the
frequency and severity of the
repercussions on women's health
of certain practices, inadequate
conditions of domestic work or
paid employment, the frequency
of nutritional anaemia, and the
prevalence
of
adolescent
marriages and pregnancies. The
Assembly felt there should be
greater
concern
for
the
protection of women's health and
suggested
"inter
alia"
information
and
education
campaigns
to
intensify
the
participation of women - who
play a key role in health and
development
in
the
implementation
of
the
global
Deafness is estimated to afflict
70 million people in the world,
and hearing impairment affects
at least eight per cent of the
population in every country.
Most
of
the
hearing
impairment results
from causes
that can be prevented at the
primary
health
level.
Great
advances
in
technology
in
otolaryngology
and
audiology
have also been achieved. Aware
of these facts,
the Assembly
requested
the Director-General
of WHO to "assess the extent,
causes
and
consequences of
hearing impairment and deafness
in all countries".
Proposals for strengthening
measures
of
prevention
and
treatment of hearing impairment
and deafness are to be made to
the 39th World Health Assembly-
Childbearing and maturity
Premature
pregnancies
in
immature
adolescent
women,
have
disastrous
world-wide
consequences
especially
when
they
occur
in
a context of
poverty,
illiteracy,
undernutrition,
and
an
unhealthy environment. WHO is
requested
to
increase
its
collaboration with Member States
in
providing
programmes
for
adolescents based on primary
health care, with an emphasis
on information,
education and
guidance. The same resolution
urges
all
Member
States
to
advocate
the
delay
of
childbearing until both parents,
but especially the mother, have
reached maturity.
Onchocerciasis:
programme area
an
extended
The Assembly celebrated the
tenth
anniversary
of
the
Onchocerciasis
Control
Programme
(OCP).
Onchocerciasis,
or
river
blindness, affects several million
people
in
Africa.
OCP
at
present covers seven countries:
Benin,
Burkina Faso,
Ghana,
Ivory Coast, Mali, Niger and
Togo. It will be extended next
year to four more
countries:
Guinea, Guinea-Bissau, Senegal
and Sierra Leone.
Over 90 per cent of the
present
programme
area
is
under effective control and the
riverine lands which had been
deserted by the population have
now
been
declared
safe
for
resettlement
and
agricultural
production.
Malaria control
The
spread
of
malaria
jeopardizes
health
and
development in many developing
countries. To prevent a further
deterioration of this situation,
the
control
of
malaria
is
essential, with full and active
community
participation.
It
should
be
integrated
into
national
primary
health
care
programmes.
The
Assembly
therefore urged Member States
concerned: 1) to undertake
an
immediate
appraisal’
of
the
malaria situation and of existing
control strategies, 2) to plan
antimalaria
activities,
utilizing
appropriate technologies, to be
integrated
into
PHC
programmes. WHO continues to
support
research
for
malaria
vaccines.
Chronic
diseases
non-communicable
Member
States
are
called
upon
to
promote
studies
on
population behaviour with the
aim
preventing
and
controlling
cardiovascular
diseases, lung cancer, diabetes
mellitus and chronic respiratory
and
other
non-communicable
diseases.
The
Assembly
also
requested the Director-General
to foster and support community
studies
aimed
at
the
joint
control
of
a
number
of
risk-related
non-communicable
diseases
related to styles of
life.
This resolution was passed
bearing in mind that information
is accumulating which points to
a number of features common to
several
non-communicable
diseases, such as their origins
in, and aggravation by, tobacco
smoking
and
other
lifestyle
factors. The adverse effect of
smoking on health was stressed
on a number of occasions.
"Health for All" and "Sports for
All"
Mr
Juan
Antonio
Samaranch,
President of the International
Olympic Committee (IOC), told
the Assembly that the IOC and
WHO had initiated a collaboration
to make the year 2000 a year of
victory
for
health
and
well-being everywhere.
the
World
Leon Bernard Foundation
and
Prize - Professor
Senault (France).
Medal
Raoul
Prizes
awarded
Health Assembly
at
A.T. Shousha Foundation Medal
and
Prize
Dr
Mohamed
Hamad Satti (Sudan).
Child Health Foundation Medal
and Prize
Professor Perla
Santos Ocampo (Philippines).
Dr. Anant Menaruchi (Thailand)
was awarded the Medal of the
Jacques
Parisot
Foundation
fellowship
for
his
research
project on the methodology of
community-based
sanitation
programmes.
THIRTY-EIGHTH WORLD HEALTH ASSEMBLY GENEVA 1985
Dr H. Mahler, Director General of the World Health Organization
presenting his report to the 38th World Health Assembly.
WHO PHOTO
Dr.
Jesus
Azurin
(Philippines), Dr. David Bersh
Escobar
(Colombia),
and
the
Rural
Society
for
Education,
Welfare
and
Action
(India)
shared
the
Sasakawa
Health
Prize which was awarded for the
first
time
in
recognition
of
innovative
work
in
health
development.
31
NEWS
FROM THE STATES.
MADHYA PRADESH
The Bhopal tragedy dominated
the annual general body meeting
of
Madhya
Pradesh
VHAI
concluded
in
Raipur
on
February
9.
Many
voluntary
health
agencies
among
them
members of MPVHA were there
at the disposal round the clock.
Mrs.
R.G.
Masih
of
Padhar
Christian Hospital reported how
her hospital adopted villages in
Bhopal, surveyed them, formed
village mohalla committees and
provided relief.
Dr. Mahashabde, the president
of
MPVHA
himself
an
ophthalmologist, also shared his
experience in Bhopal.
He
said
while
the
victims
suffering
is
intensified
by
insecurity and fear, those who
want to do good were prevented
from doing so as they did
not
know
what
exactly
to
do.
Respiration
problems
and
problems of eye coupled with
insecurity
and
sorrow
of
alienation are the predominant
problems.
The meeting then discussed the
theme "water and sanitation".
Ms. Christina De Sa from VHAI
also
participated
in
the
discussions.
THE ORGANISING SECRETARY
REPORTS ON THE PAST YEAR
The year from mid February
1984 till February 1985 has been
a
year of advances,
and of
standstills,
of
some
achievements, and also of some
failures.
It was gratifying to
32
know, from group discussions at
the
Annual
Meeting
that
members feel we have broken
down some of the walls dividing
institutions
from
each
other;
that we have helped members
understand what and why of
Community
Health
based
on
people's real participation; that
many have found our training
workshops
useful
in
their
programmes.
We recognized the need for more
growth
in
working
with
government,
for
more
communication
among
members
and
between
this
office
and
members.
T wenty-three
new
members
joined our Association during
1984. Many of these come as a
result
of
the
work
of
our
Honorary
Secretary,
Sr.
Prabha. Our total membership
now is
135, of whom 3 are
Associate
members
living
in
other
states.
We
very
much
regret
that it has not been
possible to visit all the members
each
year, as we would wish.
We have lost two old
members
this
past
year,
through the
closure of their programmes.
More
of
our
members
have
become
actively
engaged
in
Community Health, with Village
Health Workers, School Health
programmes,
Tuberculosis
Control
programmes,
small
savings schemes for women. In
a number of areas our Catholic
members have formed
Diocesan
Health Teams, in order to work
more effectively
together.
Members in Satna Diocese have
made
remarkable advances
in
several different areas of health
and development since forming
their Diocesan team. The people
of regions like Jhabua and Satna
are
beginning
to
take
some
financial responsibility for their
programmes,
in
small
ways.
Padhar, Pushpakunj and RAHA
are taking up
new programme
in
development
as
well
as
health. Indore Eye Hospital and
Padhar
Hospital
have
been
active in relief and on-going
health
programme
in
Bhopal
after the gas tragedy.
KERALA
PRESIDENT: Dr. C.T.Varghese
Mission
Director,
St Gregorios
Hospital
Parumala P .O ., PIN-689 626.
VICE-PRESIDENT: Sr. ALOSIUS
St. Joseph's
Administrator,
Mission Hospital
Kothamangalam
Dharmagir i,
PIN-686 691.
SECRETARY: Mr. P.O. GEORGE
Administrator,
Jubilee
Mission
Hospital
Trichur, PIN-680 005.
TREASURER :Dr. K.C. MAMMEN
Director,
M.O.S.C.
Medical
Mission Hospital
Kolencherry,
PIN-682
31 1
Sri.
P. R .Rajagopal,
Advocate,
Secretary,
P.N.P.
Memorial
K.V.M.S. Hospital, Ponkunnam
Sri. Tharyan Mathews, Formerly
Social Coordinator of Christian
Welfare
Centre,
Malappuram,
and
Dr.
S.
Joseph,
M.D.,
Former President of Kerala VHS,
M.G.D.M.
Hospital,
Kangazha,
are
the
other
members.
Family generator
The
Nanjing
Farm
Machinery
Research Institute of China has
produced
a
new,
tiny
turbogenerator that can make
small
mountain
brooks
or
irrigation ditches
to generate
electricity.
According
to
the
I nternational
Development
Research Centre Reports,
it's
the size of a large thermos
bottle and weighs 25 kgs. It
can operate on streams with a
flow of water moving at a rate
that
would fill an average pail
in, half a second. Chen Furong,
a
flower
grower,
uses
a
turbogenerator driven by water
from a nearby reservoir to light
his three-room cottage, operate
a TV, a rice cooker and a water
pump
and
heat
his
64-square-metre
hothouse,
formerly
heated by coal. He
estimates that the minigenerator
will pay for itself in six months.
The Research Institute's chief
engineer says the unit was built
primarily for peasant families.
Installation is simple. All that is
needed is a concrete support for
the generator, a few lengths of
pipe and some running water.
National Child Labour Projects
Society
The
Ministry
of
Labour
proposes to set up a
National
Child Labour Projects Society.
To
start
with,
projects
are
proposed to be taken up for
75,000 children working in the
carpet
industry
in
Mirzapur-Bhadohi area of Uttar
Pradesh
and
about
40,000
children working in the match
industry of Sivakashi in Tamil
Nadu.
The objective of the projects
is to significantly reduce the
incidence of child labour and to
improve working conditions and
terms of employment of children
who must work in the transitory
phase. A comprehensive package
of
service,
mainly
by
upgradation and improvement of
existing schemes, are planned.
As
per
the
project,
the
employers would be required to
contribute,
to
enable
the
project agency to give to each
child worker one square mea1
each day.
The Ministry
take a number
had decided
of projects
to
in
areas
where
there
is
a
concentration of child labour,
after studying the reports in
different parts of the country.
Regarding minimum age for
employment
of children it has
now been decided that in view
of the wide
repercussions, the
matter should
be considered in
detail
and
finalised
in
the
Indian Labour Conference, likely
to be
held in the first week of
August 1985. While considering
Gurupadaswamy
Committee
report, the Government felt that
time was not yet ripe to accept
the recommendations regarding a
uniform
age
for
entry
into
employment for children. Later,
at the
State Labour Ministers
Conference, it was decided that
the
entire question of minimum
age for entry into employment
as well as the need and the
feasibility of a comprehensive
legislation
regarding
child
labour, should be gone into by
a group of Labour Ministers.
The
Report
of
State Labour
Ministers was considered in the
J-abour
Ministers'
Conference
held recently.
For private circulation only
Immunization World-Wide
Every year, five million children die and five million more are disabled by
diseases which can be immunizedagainst for $5 per child. (UNICEF)
PERCENTAGE OF THE WORLD’S CHILDREN
IMMUNIZED IN THE FIRST YEAR OF LIFE
Measles
Polio
DPT
Percentage of
pregnant women
immunized against
Tetanus
42
21
<5^71
14
39
•
*
N/A
81
■
g; 70
16
146
N/A
BCG immunizes against Tuberculosis
DPT (3 injections) immunizes against Diphtheria. Pertussis (whooping cough) and Tetanus
Tetanus Toxoid (2 injections) given to a woman in pregnancy immunizes her child against Tetanus
m the first month of life—the most dangerous period
To compare the immunization figures in the different regions more easily
turn the
chart sideways, so that the names of the regions, Africa,
Americas, South-East Asia etc., read from left to right at the bottom of the
instance, BCG
chart. Some rather surprising comparisons' will be seen. For
immunization against tuberculosis is 77 per cent in Europe but 80 per cent in
the Western Pacific. With a figure of 39 per cent for measles immunization.
the Americas are the fourth out of six regions.
these
comparisons.
T oo
from
much
however
Should
not
be deduced
T uberculosis does not pose a great threat in many European countries;
similarly measles
is hot a killer-disease in the United States as it is in many
countries of the developing world. Where the disease is not dangerous the
need for immunization is clearly less urgent.
4
figures and wonder why the
The reader might however consider the polio
*
higher. He might ask himself
percentages are not all around 81 - or even
what he can do to bring this figure up to near• 100 per cent for his own
country - by the year 1990.
HEALTH FOR THE MILLIONS
VOLUNTARY HEALTH ASSOCIATION OF INDIA
nw
*%
AUGUST 1985
Volume XII
THE EDITORIAL EYE
Curative Medicine, the dramatic gift of health to the ill has always
been recognized and rewarded both with material rewards and a
piacc in posterity. But health as such has never been thought wor
thy of this honour. That is. till now. This year, the awareness that
good health is basic to good life, appeared as awards for the pro
moters of good health, and reaffirmed our faith that Health is a
winner.
•
Dr. Zafar ull ah Chowdhury of Bangladesh was awarded the
Magsaysay Award for Community Leadership.
*
“Baba” Murlidhar Devidas Amte was awarded the Magsaysay
Award for Public Service.
•
Dr. Hari John received the National Council for International
Health Award for her outstanding work at Dccnabandhupuram, Tamil Nadu.
*
The Government of the Federal Republic of Germany award
ed Dr. E. Bockcis of the German Medical Welfare Organization
“Action Mcdcor” for his contribution to the essential drugs
programme.
•
Dr. Ruth 1 larnar received a Doctor of Divinity degree from the
Christian 'rheological Seminary of Indianapolis. Indiana, USA,
for her lifetime service as a missionary in India.
♦
SEWA-RURAL received the Sasakawa Award from WHO for
its work in Jhagadia, Gujarat.
♦
The Norwegian Nobel Committee awarded Peace Prize. 1985
to the International Physicians for the Prevention ol Nuclear
War.
*
The Right Livelihood Prize, or the Alternate Nobel Prize went
this year to Lokayan, a Delhi based organization.
•
Dr. James S. Tong delivered the Dr. B.L. Kapur Oration xii
under the auspices of the Indian Hospital Association.
Lt. Col. Kulbushan, a New Delhi based businessman, invited
ideas from all over India. The award winning ideas that relate to
health arc reproduced here on page 18
Now for the Last Word
The present editor is taking up another assignment. To all those
who tolerated the delays and the errors, sincere thanks. To all those
who occassionally wrote to say a word of appreciation, gratitude.
And to all those who practiced what we “preached” through the
Health for the Millions, may your tribe increase!
Beyond The Blue Book
A Commitment To People
The Man With The Little
Oil Can—Baba Amte
Celebrating Vulnerability
A Life Time Of Service
Right Livelihood
Guiding Destinies
A Push For Peace
A Single Card For The Instant
Detection Of Malnutrition
'WT'
CONTENTS
Diarrhoeal Diseases:
Combatting The
Longterm Effects
Audio-Visual Folio
Award Winning Ideas
A Legend Comes Alive
Drug Action Alert
Books
The Cold Chain
News From The States
COMMUNITY HEALTH CELL
326, V Main, I Block
Koramcngala
Bengal ore-560034
India
BEYOND THE BLUE BOOK
James S. Tong
Kind friends.
Today we arc engaged in creating
history. We are in an historic year. We
are celebrating a peak event in this
never to be forgotten year of 1985. We
are entering a new era.
A new life nourishing vision is en
shrined in a beautiful blue book recent
ly published by the Government of In
dia, Ministry of Health and Family
Welfare. It contains India’s message
and pledge to the World Health
Assembly. 1985. It's title tells its
message: “Collaboration with NonGovernmental Organizations in Im
plementing the National Strategy oi
Health for All." This was the thrilling
theme of the World Health Assembly
Technical Discussions at Geneva, May
10-1 1, 1985. With India as one of the
leading proposers, the concept was
unanimously praised and approved by
the World Health Assembly.
Related to our subject India’s blue
book states: “The National Health
Policy — envisages a constructive and
supportive relationship between the
public and private sectors in the area
of health... In particular, active communi
ty participation and involvement of Non-
Governmental organizations in a massive
health education effort is urgently needed”
... Pages Ref. 43 = 12-13-14). “The
Government and the voluntary organizations
are fully convinced of a need of partnership
for meeting effectively the health needs of
the people. ’ ’
Our Government has called the
whole world to witness this new
energising policy statement. It has
been written by Government with the
participation of the Voluntary Sector.
Our Government has presented it as
their policy statement to the World
Health Assembly in Geneva, May.
1985.
I am officially the voice of the Indian
Hospital Association and the Voluntary
Health Association of India. But bv
spiritual affinity, my voice is the voice
of an immense volume of the Voluntary
Sector throughout the country.
In the name of the Voluntary Sector
of health service. I do encourage all the
Governments (central and local), to
begin today to encourage and welcome
a spirit of partnership with the Volun
tary Sector, as we both strive towards
the fabulous goal of health for all by the
year 2000.
1 also urge the Voluntary Sector to
respond generously. Thoughtfully.
however, on this occasion. I invite
Government to take the initiative. 1 am
conscious that this is the opposite of
what is normally done. Generally the
Voluntary Sector appear as clients
before the Government, and wait for
replies. For most affairs that is all right.
but now. wc arc entering a new culture.
To launch this new adventure, our
results will be wider and far more effec-
live if the stronger partner will ap
proach the weaker.
In speaking of Government. I mean
all the complex of Central. Slate,
District. Municipal and all the other
levels or sections to which our topic
may apply.
SOME CONDITIONS
FOR SUCCESSFUL WORKING
TOGETHER OF GOVERNMENT
AND THE VOLUNTARY SECTOR
Credibility
Before we can hope for effective
working relationships, it is necessary
to have a basis of credibility and
mutual trust. The altitude of the Volun
tary Sector towards Government is
that Government is an ambivalent
force. It is sometimes helpful and
sometimes harmful. Of course the
Voluntary Sector believes in Govern
ment. knows that it is a necessary
feature of civic life, is loyal to Govern
ment. and has a disposition to forgive
delects. Still, there is in the VoluntarySector considerable experience of
This text of the B.L. Kapur oration is reproduced
with permission of the Indian Hospital Association
from Hospital Administration.
1
grants delayed or promised and not
given, of contracts broken, of materials
purchased by Government and the
bills not paid, or paid after one or two
years, after many trips and pleadings.
and getting the intercession of impor
tant people. Once the Voluntary Sector
have several experiences like these, and
hear of many more from others, they
are likely to say “it is better for us to
do it alone and not become involved
with Government.”
One relevant factor is that the Volun
tary Sector have traditionally had in
ternational relationships. Some fun
ding was available to them from other
countries. Now at this time when
Government is urging the Voluntary
Sector to expand their activities, the
same Government is restricting.
limiting and carefully scrutinizing
every item of funding coming from
abroad for the Voluntary Sector. In
these days when we are promoting the
concept of the globed village, the restric
tions on the Voluntary Sector regar
ding foreign assistance, naturally
causes the question to rise, “how do we
stand with Government?” Of course.
we all agree that foreign money ought
not to be used for bombing cities and
airplanes, and gunning down
statesmen. But it is true that Govern
ment imports enormous sums of
foreign money. It seems to the Volun
tary Sector that what is good for the
people’s Government, should be good
for the people themselves. Still.
whatever the difficulties. I still urge and
recommend that we do our best to try
lo work together.
Some Practical Possibilities
of Cooperation
It remains now for both Government
and the Voluntary Sector to inquire, in
a spirit of dialogue, in what ways
cooperation may be practical. Can we
think of a few projects in the health field.
in which we could begin very soon, and
generate some experience of success in
working together. There is one that I
particularly recommend. That is that
we should work together in getting out
our hospital and health centre
directories.
Need of Accurate Directories
In the past we have gone on the prin
ciple that Government is Government
^and Voluntary is voluntary, and never
the twain shall meet. One result of this
2
passing each other by without speak
ing is that the Directory of Hospitals in
India, published by the Ministry oi
Health and Family Welfare on page 7.
claims that there are 1.017 voluntary
hospitals (erroneously printed 11.017).
The Directory of the Voluntary Health
Association of India lists 1,355
hospitals (338 more). The Government
Directory stales also on page 7 that
there are 55.958 hospital beds in the
Voluntary Sector. The VHAI Directory
claims 1.18.672 beds in the Voluntary
Sector (62,714 more). By working
together we could come to the same
number in both directories.
Further, the Government Directory
lists as hospitals, health institutions
beginning with even 1 bed. So several
hospitals arc listed with 1.2.3.4. etc..
beds.
The VHAI Directory lists as hospitals
only those with 6 beds and up. Those
with 5 beds and less are classed as
health centers. Another feature of a
Government Directory is that while it
proudly lists even one bedded clinics as
hospitals it does not list the so called
nursing homes at all. though many of
them have a considerable number of
beds, impressive lists of doctors and
nurses, and plenty of modern hospital
equipment. Presumably the so called
nursing homes are not classified as
hospitals because they are not called
hospitals and perhaps also because
they charge a fee for service.
While speaking of nursing homes, I
should like to suggest that the word
nursing home could reasonably be us
ed for long term or mild care institu
tions where the characteristic service
offered is nursing, and not doctoring.
But any institution having beds and
professional health personnel and
hospital equipment is justly classified
as a hospital, irrespective of what fee
they charge or by what name they call
themselves.
The recognition of nursing homes as
hospitals would make an astonishing
increase in our total hospital statistics.
Another observation on the Govern
ment Directory of Hospitals is that
while it lists so called hospitals of one.two or three beds, it docs not list the
approximately 6000 primary health
centers at all. These are in various sizes
and conditions, but many of them have
6 to 10 beds and a couple of doctors
and other staff. So the question arises.
when does a health center become a
hospital?
Our VHAI Directory endeavours lo
list all health centers. By recalling
these features we praise the separate ef
forts that both Government and the
Voluntary Sector have made. The
discrepancies invite both the Govern
ment and Voluntary Sector to joint
endeavour.
If Government and the Voluntary
Sector are to begin to work together.
the first thing is to find out who the
Voluntary Sector arc. 1 recommend
that both Government and the Volun
tary Sector set to work to bring out new
and more accurate directories. The
Government may do theirs and the
Voluntary Sector may do theirs.
However, before starting the work, let
us sit together and decide on a jointly
recognized definition of a hospital, a
health center and a nursing hOnie.
JEven if the definitions we are able to ar
rive at are somewhat arbitrary, they
will be of considerable value if we can
agree on them.
Both the Government and the Volun
tary Sector health institution addresses
should be compiled in such a way that
the statistics of both directories agree.
it is also important that we have a
directory of Voluntary Sector health in
stitutions, different from the directory
of Government institutions and dif
ferent from the directory of the other
private commercial hospitals and nur
sing homes. This way the Government
as well as the rest of us can know who
the Voluntary Sector are and what they
are doing. The Voluntary Sector is a
notable portion of our national wealth.
It seems to me that future hospital
directories should have complete ad
dresses with postal zone numbers, so
that anyone who desires, may write to
them.
Grants
One of the long standing traditional
ways of Government cooperating with
the Voluntary Sector is by grants. This
arrangement in principle is praisewor
thy both in theory and in practice. In
theory, because the service paid for by
the grant is usually what Government
would be expected to provide totally at
its own expense should there not be
any voluntary institution to manage it.
The voluntary institution can provide
the administration. This saves the
Government much detailed work
related to recruiting, planning, super
vising of personnel, inspecting and
reporting. The system of grants has
also the sanction of experience, dating
back through all the decades of recent
history.
Related to primary health care, in
Tamil Nadu a combined GovernmentVoluntary
system
has
been
worked out. and is called the mini
health center. It was designed and
tested by the famous Dr. K.S. Sanjiyi
of Madras. The mini health center is in
charge of a voluntary society. It is ex
pected to have about five personnel.
one of them a doctor. The latter may
be part time. The operators are allow
ed to charge something from the pa
tients. though as it is a village service,
there is not adequate income from this
source. The Government gives a grant
amounting to half the cost. The volun
tary group manage for the balance.
Contracts
MINI HEALTH
CENTRE
A couple of hundred of these are func
tioning in Tamil Nadu. This system is
w’orking quite well, though I hear that
one of the weaknesses is that the grants
do not come on time. For a small agen
cy depending on the grant for
sustenance, regular delay in receiving
the grant, can quickly force it to close
down.
The Ministry of Health and Family
Welfare has a book listing and describ
ing present grants available. Whenread through, they look impressive.
Some of them are working adequately
well. A topic for dialogue with the
Voluntary Sector is whether the pro
cedures for getting the Government
grants could be simplified.
The Voluntary Sector has the oppor
tunity to compare procedures for get
ting grants with other agencies. For ex
ample. there arc several funding agen
cies in about the same class as Oxfam.
Even though the ultimate approval has
to come from Oxford, we never think
of the Oxfam procedure as difficult.
Whether the response is yes or no.
there is no undue delay in getting the
reply, or in getting the grant. There are
grants for voluntary institutions
originating even from foreign Govern
ments. For example. Sweden.
Switzerland and others. It never occurs
to us that their procedures are cumber
some. or that there is any doubt about
reliability once the project is approved.
My belief is that in India the grant
system has great potential for
stimulating primary health service in
the Voluntary Sector. The realization
for this potential will depend on facili
ty of procedure for getting the grants,
and on dependability of delivery after
the grants arc sanctioned.
It would-be possible for the Govern
ment by contract to engage a voluntary
society to develop a limited tribal or
other neglected or remote area. The
projects could be economic, educa
tional and health related. Some con
tracted projects of this nature have
been started in tribal areas of Ra
jasthan. It would be of interest to
Government to inquire how those pro
jects are succeeding. In principle,
perhaps we could think of their
duplication. Secular companies seem
to be very greedy about getting Govern
ment contract. There is less en
thusiasm in the Voluntary Sector.
Some sections of the Voluntary Sector
would welcome encouragement in this
area.
Purchasing
Under the heading of purchasing, I
have in mind mainly educational
materials related to primary health
care. Things like picture books, flash
cards, posters, slides cassettes and
video tapes.
One way for developing the purchas
ing relationship, would be for the
Voluntary’ Sector to produce these
items and make them available to
Government for purchase on a non
profit basis. We have some experience
of this model. This model is usable on
an occasional or casual basis. However.
it is not practical to recommend this
model for large scale use. The main
reason, based on our experience, is the
difficulty, delay and sometimes im
possibility of getting bills paid by the
State Governments.
A more effective way to develop the
relationship of purchasing in the in
terest of health for all would be for
Government to produce all these
materials in all the languages, and
make them easily available to the
general public and the Voluntary Sec
tor at subsidized rates. Government
never has any difficulty about gelling
payment from the Voluntary Sector.
Moreover. Government is accustomed
to thinking in terms of large volumes.
that tend to exceed the imagination of
the Voluntary Sector.
Tax Relief
Our Voluntary Sector hospitals and
health centers often urge me to get for
them in all that pertains to rates of
3
taxes, licenses, water and electricity,
the same status as Government
hospitals. The rationale for the request
is that voluntary hospitals and health
centers are set up on a legally non
profit basis. They are expected to cater
to the poor, and to the extent possible
make it possible for them to appear
more as a public service institution.
and less like a commercial institution.
The mere necessity of remaining in ex
istence. forces the voluntary hospitals
to charge fees for service that gives the
impression that they are commercial
ventures.
It is not physically possible to run a
non-profit hospital on a fee for service
basis, in which there is professional
competence and modern technology,
and expect it to appear to the public as
a charitable hospital. Some relief of tax
ation on the part of Government would
help it to appear a little more
charitable. They all earnestly desire not
only to give the impression, but actual
ly to be charitable. This cannot become
possible unless there is some kind of
public subsidy.
The voluntary hospitals serve the
public the same way as the Govemhospitals do. Therefore, they deserve to
be recognized and treated as in some
manner pertaining to the public health
system of the country, and should not
be classed indiscriminately with com
mercial hospitals.
Mechanism for Cooperation
When we propose a more effective
4
cooperation between the Government
and the Voluntary Sector, the sugges
tion quickly arises that to bring this
about, some kind of mechanism will be
needed. Just what is needed or what
will work we may not be able to foresee
in advance. We may have to experi
ment to see what will succeed.
Manifestly the first thing that is need
ed is a declaration of intention on the
part of Government that they genuine
ly want to develop better working rela
tions with the Voluntary Sector. Once
there is a directive will, some practical
way Will be found. Once it becomes
known in the Voluntary Sector that
there is a welcome in the Ministry, and
a genuine interest in their proposals.
the Voluntary Sector will respond with
growing confidence. It may be that a
mere attitude change giving a basis for
mutual trust is all that is needed. There
really may not be any need of a special
committee or council. In Delhi, the
Ministry calling the Voluntary Sector
for an occasional meeting has proved
helpful.
The kind of attitude change that is
needed is in the direction of Govern
ment treating the Voluntary Sector less
as a child and more as an adult, or we
may say, less as a client and more as
a colleague.
Presently the typical approach is foi
the Voluntary Sector to hand in a peti
tion to the Ministry. For some time on
inquiry, they will be told that it is under
consideration. Eventually they will get
a yes or no reply.
Another example may be that an
order may come that all private volun
tary and commercial hospitals must
register in the same list. That no
distinction will be made on the grounds
of being legally non profit, or legally
oriented to profit. This sort of an order
can happen without any dialogue at all
with the Voluntary Sector.
These are both examples of parent
child relationships. The Government
assumes the role of parent and yields
to the petition of or commands the
Voluntary Sector as a child. The parent
assumes that power is synonymous
with wisdom, or that might makes
right.
Still, it may be good indeed if there
could be one person in the Ministry
who could be specially appointed for
liaison with the Voluntary7 Sector. Such
a person should be one who has arisen
from or who is familiar with the Volun
tary Sector. This person could be the
first to welcome visitors or petitioners
from the Voluntary Sector, lie could
read over their draft proposals to see
whether they are correctly written. If
it is not. to guide them how to design
their paper so that it will be more like
ly to be understood, or to lit in
with Ministry policy. This could
lead to so much more effective co
operation than for the petitioner to
be told a few months later that some
necessary item is missing, or some re
quirement not correctly understood.
When everything is in order, the liaison
officer could advise the visitor about
which officer or department to
approach.
The liaison officer, of course, would
ee concerned with more than petitions.
be would be one to sympathetically
receive ideas or tentative proposals,
lalk around them, and give encourage
ment or guidance if he finds real value
n them.
On the part of the Voluntary Sector.
would be reasonable to expect that
Inose who are dealing with similar
topics such as family welfare or com
munity health should club together, so
fnat too many individuals or institu
tions do not come to the Ministry with
tne same topic, and possibly not agree
ing in their suggestions. The Voluntary
sector will do well to come to some
iroup agreement among themselves
in serious proposals before ap
proaching the Ministry.
HE SOURCE OF
SUCCESS IN THE
VOLUNTARY SECTOR
S AVAILABLE TO ALL
It is generally recognised that the
Voluntary Sector has notable success
m creating a helpful response in the
community. I suggest that whatever
success they may have is not because
Hiey are voluntary, but because they
Lire concerned. The Voluntary Sector
mas no secret formula.
Whatever they have is openly
available to anybody willing to partake
•if it. Being in Government service does
u.ot close people off from being concern
ed. Any team in a Government health
center who would like to be concern
ed may become so, and the same suc
cess will be theirs as may be had by the
Voluntary Sector. It is absolutely ceraain that the Voluntary Sector has no
monopoly on being concerned.
Everybody in the Voluntary Sector.
me same as everybody in the Governnent sector is subject to the very same
miversal law of entropy. Entropy
means the tendency to run down, to
eecome lethargic, lazy, selfish,
sreless, disorganised, and ultimately
m be reduced to casually scattered
material, like rubble on a hill side. A
ealue that both Government and
•oluntary Sectors hold in common, is
mat we are all equally human.
However, people in the Voluntary
eector. to keep entropy at bay. have
various kinds of renewal exercises like
-n annual retreat, a monthly review, or
■ney set aside some time for meditation
and realization of their purpose in the
universe, or they may have someone to
conduct for them an occasional motiva
tion seminar.
I highly recommend some similar oc
casional or annual exercises for the
staff of the Government primary health
centers. Such exercises could renew or
rouse enthusiasm, and from them
radiate out among the community. En
thusiasm is contagious. If the Primary
Health Center staff have it, the people
round about will catch some of it.
Some leadership seminars could be
held for the PHC staff, oriented to help
ing them to animate the village people,
encouraging and enabling the com
munity to do as much as they can to
maintain and improve their own
health.
OPPORTUNITY FOR A
PARADIGM SHIFT
The Voluntary Sector in the health
field is still heavily chained and limited
in movement and expansion by
adherence to an ancient culture. The
Voluntary Sector needs liberation from
the inheritance of their medical
ancestors. Due to the scientific
knowledge we now have related to
health, we need a total paradigm shift
in our attitudes in the direction of
greater emphasis on the promotion of
health. There was a time when the
human race did not know fire. When
they discovered fire, there was a total
shift in their way of living. There was
a similar shift with the discovery of the
wheel. Again for printing and electrici
ty. Such great and sudden changes in
culture arc called a paradigm shift.
Some similar shift upwards, outwards
and forward is now available to all of
us. but especially in the Voluntary Sec
tor. due to new knowledge now
available regarding maintenance, im
provement and enhancement of
health. We know now that much of this
kind of knowledge can be acquired and
communicated by all of us. but the new
opportunity has a special significance
to the Voluntary Sector, because this
new vision can live and thrive largely
on enthusiasm with no cost or low cost,
and very easily acquired technical
knowledge. I refer to the immense
value for the extension and improve
ment of health that is available in mass
health education and the inspiration to
live up to what we know about it.
REMEMBER WHAT THE
BLUE BOOK SAYS
“’The National Health Policy ... en
visages ... active community participa
tion, and involvement of nonGovernmental organizations in a
massive health education effort...”
When we think of the boundless
scope for promoting health through
health education, mind boggling new
opportunities open before us. We have
the whole educational system of the
country through which practical health
can be taught and lived—health
teaching for health action with em
phasis on what to do rather than what
to memorize. We have a plethora of
temples, mosques, churches and
gurudwaras. All of them can be
motivated to leach the knowledge and
practice of health. All round good
health is evidence of spiritual
achievement.
All kinds of organizations and
associations can be encouraged to look
for some aspect of health learning or
practice that is appropriate for their
spirit or activity. In every post office.
the girl who sells stamps, could also
sell a few important Government
publications concerning scientific child
care and health maintenance. This way
health literature will be easily available
to the community. One or two pages in
every ration book could contain the
essential child survival messages, like
breast feeding, weaning, nutrition.
growth monitoring, diarrhoea manage
ment, and immunizations.
Once the paradigm shift has caught
5
on. the imagination will come up with
endless novel ideas.
For our three hundred million people
below the poverty line, health rather
begins with food and clean drinking
water than with tablets and tonics.
Food must be cither grown or earned.
This points to the need of having either
land or a job. Thus, for those whose
hunger and consequent ill health
arise from exploitation, the provision of
health must begin with actions that arc
strong enough to demand social and
economic justice. Thus, social justice
workers are also health workers.
There arc also agricultural, economic
and all kinds of development projects.
All development projects should have
a health component. Opportunities like
these seem endless for expanding the
concept of health beyond the tradi
tional limit of healing of illness. This
opens up immense possibilities for the
Voluntary Sector and for community
participation. For all of us to seize this
fresh horse and race with it will create
a great leap forward, truly a new
paradigm shift.
ARE DOCTORS HEALTH
TEACHERS? OR DOES THE
URGENCY OF THE PARADIGM
SHIFT DEMAND THAT WE TURN
TO OTHER SECTIONS OF
SOCIETY FOR THIS URGENT
FUNCTION?
Again I come back from another
angle to the message of the Health
Ministry blue book. “The National
Health Policy... envisages... a massive
health education effort...
There is a significant language
peculiarity related to the word doctor.
In Latin from which the word comes.
the word doctor means teacher. The
word for physician is medicus. In all
the other disciplines, such as a doctor in
economics or literature, we easily
presume that such doctors are teachers
or at least familiarly associated with
universities or research projects. But
popularly we do not think of a medical
doctor as a teacher. Of course they
teach their own kind, but with regard
to their public image, we do not think
of doctors as health educators. Wc
think of them as practitioners. They
are said to practice medicine. Only a
rare few earn their living by teaching
health. The reason is that there is no
6
money in health. The big money is in
disease. As the Voluntary Sector is not
primarily motivated by money, the
new knowledge that we now have
about health preservation can be ab
sorbed by natural leaders among the
people, and communicated by them to
all our millions, including the illiterate
millions.
I invite the Health Ministry' and the
health professions to rise to this oppor
tunity and cooperate with the Volun
tary Sector and encourage them to
become teachers and inspirers of
health. Teaching without inspiration
has little value. Here is an illustrative
example: the Health Ministry and
Medical Professions have brought
about Lhe law that cigarette advertising
should include the words “smoking is
injurious to health.” That teaching has
scarcely any value because it lacks in
spiration. Since those words have been
put, cigarette smoking has increased in
India, by 5% per annum. The same
Government who put the words there.
is purringly happy with the increased
tax income.
Concurrently with financial hap
piness. one day a successful surgeon.
for a fee much less than the cost of a
page of advertising, will insert a
tracheostomy lube into the cancerous
throat of the Marlboro man. This is the
outcome of knowledge without inspira
tion. It is time for us to begin to com
pare the promotion of health with the
sacredness of a religious vocation.
This said; I acknowledge a new
spirit blowing in the wind. There are
prophet doctors today as there have
been in the past. This vigorous new
spirit is appearing especially among
the young doctors. A few days ago
there was a convention of young doc
tors in Patiala symbolizing this new
spirit.
Anger is rising among them against
the tobacco and all industries, in
cluding lhe pharmaceutical, to the ex
tent that for ugly gain, they deceive
and exploit the people, including the
poor, to the detriment of their health.
There are husbands, who by spen
ding on cigarettes, deprive their babies
of needed food. I invite the women s lib
movements to stir up leadership
among women less privileged than
themselves.
In silent meditation on lhe
sacrcdness of life and its preservation.
I urge the Government and lhe private
commercial and Voluntary Sectors to
pause and ask ourselves whether we
are willing to separate ourselves from
all systems and practices that arc
harmful to or restrictive of health.
and reveal health truth to our people.
Let us together strive to have
a lifting influence on ourselves and
other people towards a more abundant.
more radiant, more creative life, that is
health. That is the Paradigm shift. We
have the power to effect it. But do wc
have the inspiration?
Frankly, there is a lethargy in all of
us, public, private and voluntary. The
whole public and all of us share the
blame for not living in the manner that
promotes the more radiant glow, the
more happy heart, the more abundant
life that is described by word health.
However, there is little progress in
blame. Progress will come from our
grappling with the thrilling opportuni
ty of the paradigm shift now within our
power.
. I stand here in the honour you have
given me. I call upon all of us. the
public, joint and private sectors, both
commercial and voluntary, to embrace
the new renaissance, the new birth, the
renewed life now available to all ol us
in a new radiance, a new joy, a new
energy and a new happiness bursting
from the idea of health for all. Health
is our birth right: health in all its
aspects, physical, environmental.
psychological, social and spiritual.
United we stand, divided wc fall.
There’s work and reward for all oi us.
A reasonable standard of health is
available for the taking. Starting from
this day 1 urge all of us solemnly to
resolve that together in our land we shall
create health.
JAI HIND
A CCTOTOTTOAT TO
PEOPLE
lness. The transition from the
stereotyped health center to a com
pletely integrated development project
has been slow, difficult and not unmixcd with tragedy.
PARAMEDIC—THE KEY MAN
The Ramon Magsaysay Award for
Community Leadership was, this year,
awarded to Dr. Zafrullah Chowdhury
of Bangladesh “for engineering
Bangladesh’s new drug policy,
eliminating unnecessary phar
maceuticals and making comprehen
sive medical care available to ordinary
citizens’’.
The
founder
Director
of
Gonoshashthaya Kendra (People’s
Health Center). Dr. Chowdhury’s in
volvement in social and political issues
dates from his student days. Though in
England at the outbreak of the 1971
war. he soon returned to Bangladesh to
work with the freedom fighters. After
the war, his field hospital moved from
near the Tripura border to Savar, as the
Gonoshashthaya Kendra (G.K.).
G.K. has, since its inception, been the
focus of numerous controversies and of
admiration. An outstanding example of
demystified, decentralized, people cen
tered health programmes, the group of
doctors wno started the Kendra, found
that the entire system of health care as
imported from the West and superim
posed on a different culture, could not
do much lor the people except treat il
Thu person around whom the whole
concept ol “alternative health care ap
proach" of G.K. revolves is the
paramedic. Most of the paramedics are
unmarried girls who usually have
some education. They work with senior
paramedics lor about six months. The
other health personnel including doc
tors conduct regular classes for them.
The paramedic has to work with the
departments of agriculture, family
planning, pathology and family welfare
alongwith learning diagnostic and
curative operations. She eventually
runs her own out-patient clinics, ex
amining patients and prescribing sim
ple medicines. She has to visit a
population of 3000 (approx. 3 villages).
CONOSHASHTHAyA
This is just one aspect of the work
done by the paramedic. The brutal
murder by the local power lobby of
Nizam, a paramedic in Shimulia il
lustrates the more important aspect of
the changes the G.K. is attempting.
Nizam had been helping the villagers
to organize a well-run sub-center and
a local credit cooperative, both to the
detriment of the local quack and the
landlords. The murderers, even though
identified, have never been brought to
justice. This has been a constant
reminder to the personnel of G.K. of the
powerful and oppressive forces in
society.
G.K.’s openness to new ideas is clear
ly shown by their being one of the first
to use Depo-provera. the controversial
contraceptive for women- Yet, when
there were doubts about the safety of
this contraceptive, and its side-effects.
G.K. was the first to stop using it. and
also urged the Government to abandon
its use. with little success.
KENDRA
7
OPPORTUNITIES FOR SUCCESS
The G.K. is also a Held training cen
ter for medical students. This training
exposes them to the harsh realities of
ill-health and almost always convinces
them of the inadequacy of medical
education as it is taught today in deal
ing with the problems of rural
Bangladesh. G.K. also offers a three
month training in Held work to UNICEF
workers. Besides this, G.K. has also
training facilities for women at its
Narikendra. Alongwith fundamental
literacy, women are taught metal work.
carpcnt ary, sewing, shoe-making and
baking etc. The courses help the
women understand the reasons for
their own under-development, and
what to do to bring about the changes
required. Trainees at the Gonoshilpalaya (People's Workshop) pro
duce at competitive prices hospital
beds, simple operation tables,
revolving chairs, grills, window frames.
agricultural equipment etc... They are
divided into two categories—skilled
and unskilled worker... Gono Paduka
(People’s Shoe) a joint cooperative of
skilled workers—has a display shop
near the canteen.
In 1977 was started the Gono Patshala (People’s School). Most of the
children of the area had been unable
to attend school earlier, as their time
was taken in contributing towards a
livelihood. Understanding this. Gono
Patshala has classes for five days a
week instead of six. The older children
and teachers hold classes at the village
for those children unable to attend
school. The older children get a couple
of hours of vocational training, so that
in two to three months they are capable
of making effective contributions. The
school children are also involved in
poultry farming.
The people’s farm (Gono Krishi
Kamar) is organized to expose those
not involved with agriculture to the
skills and the problems of the farmer—
the low level of technology, Lhe hard
manual work, the exploitation of and
under payment for his vital contribu
tion. Every staff member of G.K. is
compelled to put in his daily quota of
work irrespective of his official status.
Many workers resent this, not having
understood the nature of relationship
between health and the occupation of
the people. This has led to a larger tur
nover of the G.K. staff. Reforestation
8
and fish cultivation are also being pro
moted by the Kendra.
LIFE OR DEATH?
By far, the most important new ven
ture of G.K. has been into the phar
maceutical industry. The problem of
obtaining good inexpensive drugs leads
the group to think of having its own
drug producing unit. Bangladesh, India
and other Third World countries, have
been the-dumping ground for the
multinationals. As in these other coun
tries, less than half the production was
of essential medicines, deliberate mi
sinformation. unethical advertising
and marketing practices lead to an un
naturally big demand for non-essential
drugs. G.K. entered this field in 1978.
to produce essential drugs under
generic names lor low profits, which
arc used back for the expansion of the
factory.
Dr. Chowdhury has since the begin
ning. been involved with the Govern
ment's policy on health. The Govern
ment's health care system, at least
theoretically, puts more emphasis of
health care on health workers than on
doctors. This influence is apparently
growing. For the Drugs Policy Or
dinance was passed soon after G.K. had
organized an international conference
of Drugs and Pharmaceuticals. Dr.
Chowdhury, in his personal capacity as
well as a member of an eight-member
Expert Committee, met with and con
vinced numerous people about his
stand. Though, this ordinance met
with tremendous conservation and
criticisms from most of the developed
world, and many loop-holes were found
for reintroduction of some nonessential drugs, a beginning has been
made, and an example sei. As Dr.
Zafrullah Chowdhury himself says. “If
drug policy is implemented fully in
Bangladesh, not only the people of
Bangladesh will gain, but also the peo
ple of the Third World nations. The
onslaught of Drug Manufacturers’ pro
paganda through mass media and
advertisement has caused many peo
ple to make the choice of spending 2-3
*
days
income to buy unnecessary
medicines”.
THE MAN WITH THE LITTLE
OIL CAN—BABA AMTE
“I don't want to be a great man. I
want to be a man who goes around
with a little oil-can. that’s my ideal in
life”.
“Baba” Murlidhar Dcvidas Amtc and
his little ’’oil-can” have helped
thousands of ostracized, ill-treated
human beings to find a new dignity in
life. Baba Amte was awarded the
Ramon Magsaysay Award this year lor
Public Service.
divine lightning
Born a brahmin, by profession a
lawyer. Baba broke his bondage with
tradition, caste and family, when as
President of the Warora Muncipal
Scavengers Union, he responded to the
challenge of the striking workers by
clearing lavatories himself. 1 k* tore up
his licence to practise law and decided
to set up a commune where he invited
the untouchables and other social out
casts to join him. “One doesn't set out
to do social service simply for the sake
of doing it ... there comes a moment ot
divine lightning that touches your
darkened heart and is gone alter il
luminating it forever.” Baba’s “divine
lightning" struck him al a traumatic
encounter with a leprosy patient one
night. 1'his made him realize that a
horizontal programme, which would
9
pervade every strata of society, has to
be devised” to combat the evil of
leprosy. Today, Baba has organized a
massive project toward this end.
Baba started his project with six
leprosy patients. Rs 14/- in cash, a lame
cow. and a little forest land.
Anand wan-—Forest of Joy—is not the
last resort of the leprosy patient; it is
the starting point in his life of dignity.
Today it is a sprawling 450-acrc com
plex with a total budget of Rs 1.5
crores. How did this change come
about?
‘...nothing but an awakening of the con
sciousness can explain...structures strong and
functional built without architects, engineers
and contractors, weavers without fingers...a
man who cannot walk managing the in
dustrial training center moving on a tricycle
fabricated with in-house talent and
materials...a master tailor who cannot use
his hands, training tailors..."
WORK BUILDS,
CHARITY DESTROYS
From the beginning Baba has
detested charity. ‘Work builds, chari
ty destroys.’ Against much opposition
from the medical profession, Baba
enrolled as a student at Calcutta’s
School of Tropical diseases to gain a
rudimentary knowledge of the disease
he planned to grapple with. Around
this lime the whole of leprosy treat
ment was revolutionized by the
discovery of DDS. Baba taught the
patients—particularly those not yet
deformed—the need to take regular
medication. He exhorted them to de
pend on themselves and their own ef
forts. To this end. training in various
activities were provided.
Today. Anandwan, Ashokwan and
Somnath are self-sufficient. The latter
two communes are run by noncontagious and cured leprosy patients.
While the programme does receive
some funds from the government and
other funding organizations, most of its
requirement is generated from the pro
ject itself. The projects virtually feed
themselves. They produce much more
than the government figures for the
same acreage of land elsewhere in
Maharashtra. Most of these earnings go
toward the running of the non-profit ac
tivities ol the programme. However.
each person is allowed to earn a small
income for himself. This income comes
from kitchen gardens, fruit trees, and
maintaining small herds of goal and
sheep. These men who were cast out
of their homes now send back money.’
10
Besides leprosy patients, there arc also
other physically-handicapped persons
working at Anandwan. Besides
agriculture, dairy and poultry, works
of carpentery. leather, printing, tailor
ing. knitting, spinning, weaving, wood
carving, painting, welding, construc
tion. electrical fittings and digging of
wells are undertaken. Anandwan also
has a post office and a bank. The pro
ject has also founded the Anand
Nikctan College of Arts. Science. Com
merce and Agriculture al Warora.
besides schools for the blind, deaf and
leprosy affected children. Gokul is a
home for orphans.
Sandhiniketan—House of Opportuni
ties—further cements the residents'
motivation to work. Sandhiniketan of
fers training in various productive ac
tivities. As a result, as a UNICEF report
put it. “nothing but an awakening of
the consciousness can explain ... struc
tures strong and functional, built
without architects, engineers and con
tractors. weavers without fingers... a
man who cannot walk managing the
industrial training center moving on a
tricycle fabricated with in-house talent
and materials... a master tailor who
cannot use
tailors...”
his hands, training
CHILD—AGENT OF CHANGE
Alongwith the rehabilitation of
leprosy patients, Baba is also concern
ed with the uplift of the Madia-Gonds.
tribals from the heart of Maharashtra.
Hemalkasa, the center, is an offshoot
of Lok Biradari Prakalp (People’s
Brotherhood Project) started by Baba
in the early 70’s. This project is being
managed by Baba’s son and daughterin-law. and their team of workers at the
base hospital at Hemalkasa and six
sub-centers. Besides providing health
care, the project aims at helping tribals
fight corruption and exploitation
through education and developing the
children as agents of social change.
These children then assume full adult
responsibility and after training as
barefoot doctors at the hospital, return
to the’ sub-centers to continue their
work. They arc assisted by cured
leprosy patients. Inspite of his bed
ridden state (Baba suffers from a
debilitating and disabling spine pro
blem and cannot sit even for short
periods). Baba travels widely to all
parts of his projects and personally
meets everyone possible. His house is
an open house to anyone from the
projects.
REAPING REWARDS
This work has brought in awards
from all over the world. In 1971. he was
awarded the Padma Shri by the
Government of India. In 1978. he was
awarded the FIE Foundation Award.
The next year, he received the Jamnalal Bajaj Award. Last year. Baba was
awarded the Damien Dutton Award
“for his outstanding contribution to the
rehabilitation of leprosy patients in In
dia” and the Nagpur University made
him an honorary Doctor of Letters.
These awardsand honours have not
made any difference to him. Rather, he
looks upon them as milestones driving
him on to further achievement. At 71.
Baba’s ambition still remains being the
‘man with the little oil-can’.
CELEBEATOM® WOLbMEKABOLOTY
This year's National Council for In
ternational Health Award had been
presented to Dr. Hari John, for her
work in the Community-based Health
Care Programme in Deenabandhupuram, Tamil Nadu. Dr. John and
her husband, also a doctor, went into
community work with a set of
preconceived notions:
•
•
•
sophisticated medical education
and an over-reliance on technology
is better than anything indigenous;
ill health and poverty are not inter
related;
outside inputs managed by profes
sionals can change the ill health
patterns in the community.
With time and patience on the part
of the community, their working with
the patern of the programme changed.
Through trial and error, they learnt the
meaning of community participation in
all levels of programme implementa
tion, the true cause of ill health in com
munities. the need to make the com
munities sell-reliant.
In her speech delivered at the NCIH
Conference in Washington. USA.
Dr. Hari John analyzes a community
programme and her present approach
to community health.
Never has it been as important in
Third World countries to fight oppres
sion and confusion—never has it been
so urgent to say things clearly about it
because never has time for acting or
perishing been so short. From this
urgent and vital necessity, comes forth
an alternative approach—not merely
alternative to health care, but to. life
itself as millions know n—which by
definition proposes to create a con
sciousness for liberation—liberation
from patterns imposed by imperialism.
liberation from centuries of oppression
by the ruling elite.
It is now. in these decisive years, the
most vital task because it is a matter
of surviving not merely as people, but
as cultural beings. This struggle pro
poses not just to illustrate misery—
because that is of no interest to the peo
ple who know it well and suffer it in
their daily lives—but to denounce the
structures of exploitation and power
that cause this misery.
To create a consciousness for libera
tion involves a struggle against several
enemies ol the people: against several
aspects of an effort io deform them
now. as previously over the centuries.
Oppression has taken many forms
and it is painful to note that medicine
and medical care have been used as in
struments of oppression for a long time
now. With the introduction of'western'
medicine into the Third World.
medicine based on an individualistic
perception of human beings—the
Cartesian model of the body and the
germ theory of illness—a clinical
curative approach to health care
emerged. Capitalism transformed
health care into a commodity and
health care became individualized and
purchaseable. The majority of the rural
poor who live below the poverty line—
continue to suffer greatly under a
system whose priorities are not those
of the poor—unjust allocation of funds.
inequitable distribution of resources
and inappropriate priorities have all
contributed to this state of affairs.
Obviously, a linear expansion of the
present model of health care delivery
will only add to the existing waste and
make the ultimate solution to our
health problems more difficult.
The new approaches that have
emerged over the last decade, have all
relied not only on community par
ticipation but on people’s power to
achieve justice in health care—to lake
health care away from the profes
sionals and to vest it with the com
munity. indeed with each family, thus
breaking the stranglehold that the
medical profession in collusion with
transnational drug companies has on
them.
At the core ol this approach have
been Village Level Health Workers—
usually semi-educated poor women.
often from the landless outcaste sec
tions of Indian society—the most op
pressed of the oppressed.
This brings to my mind an incident
11
J read about an American woman—an
ordinary citizen will) ordinary educa
tion and ordinary capabilities, who.
some years back infiltrated a high
security nuclear power station to
demonstrate that such installations are
virtually defenceless and therefore.
constitute a great threat to mankind.
What prompted this ordinary woman
to stand up and be counted? What
made her face steclhelmetcd riot
police? What gave her the courage to
confront the system?—She was mere
ly celebrating her vulnerability.
Likewise, every time they go out in
to a society dominated by males, by the
educated upper classes, by the. higher
castes, by centuries of oppressive tradi
tion to deliver health care, these health
workers arc celebrating their
vulnerability.
When illiterate landless women go in
a procession to protest against police
brutality, they arc celebrating their
vulnerability.
Every lime landless agricultural
labourers militantly surround govern
ment functionaries, demanding drink
ing water pumps, they are celebrating
their vulnerability.
We have had the privilege of par
ticipating in this exhilarating process
for the past eighteen years. Their
courage makes us just a little bit more
hopeful of an eventual structural
change in our society—a society where
people can live in dignity and equali
ty. The call “Health for All by 2000
AD“ will descend from the realm of
rhetoric and look achievable to some
extent not because of high technology.
not because of sophisticated medical
education, not because of high inputs
and not because of centralised plann
ing but because of the motivation and
involvement of ordinary people, who
though marginalised, arc no longer
willing to lie supine and accept it as
their fate, but have a spark of dignity
in them and a concern for others that
often ignites into a movement. It is this
movement that we have facilitated in
the past decade and it is these people
you are honouring with this award.
Though, alternatives as we envisage, ex
clude profit, star complex, competition.
awards and international recognition.
This thinking of alternatives must
not limit itself to denouncing or to the
appeal for reflection. It must be a sum
mon for action. It must appeal to our
people's capacity for tears and anger.
enthusiasm and faith; we must par
ticipate in the effort to remove them
from the slumber and confusion to
which oppression and misery have
submitted them; we must contribute to
shaking away the apathy which failure
and frustration have sown in popular
consciousness. Someday, somehow, we
shall overcome.
A LIFE TIME OF SERVICE
This year the Christian Theological
Seminary of Indianapolis. Indiana in
the United States of America recogniz
ed the importance of health promotion
by conferring the Doctorate of Divini
ty on Dr. Ruth Harnar, for lifetime ser
vice as missionary in India.
Working with the Mid India Board of
Education, as Director of Nursing
Education, she helped develop
graduate programmes for nurses. She
developed a curriculum, and an ex
amination system for general nursing
education. Though periodically revis
ed and updated, this is still in use.
One incident stands out in Ruth's
mind as the spark that ignited her in
terest in community work. A man
brought his motherless daughter to the
health center where she was, the child
was malnourished. The father wanted
her health to improve. He had heard of
12
milk powders but did not know how
to use them. He had been feeding the
girl the powder as it was. He now
wanted to leave the child at the health
center so that she could be looked after
properly. He was a very regular visitor
to the health center, taking keen in
terest in his daughter’s growth. One
day. he came to take her back as her
mother would now be joining him and
would look after the girl. Alter almost
a year he brought his daughter back.
She was malnourished and almost
blind with xerophthalmia. And all this
because the hospital staff had not taken
the initiative to teach this interested
father about nutrition. “Here we have
these families who insist on staying
with patients, and we have missed the
time for helping them find out what are
the local resources, what is available.
and educate them on the best ways of
using these resources”.
Ruth joined VHA1 in 1974 and
started training programmes for
trainers of community health workers
along with Sr. Anne Cummins.
Gradually, their experiences were
codified as a training guide “Guide for
Training Village Health Workers”.
As her involvement with communi
ty health increased, so did her interest
in training curricula for ANMs.
Alongwith the M1BE. she evaluated the
ANM (raining course and recommend
ed a curriculum change. She also
assisted with the monitoring and
evaluation of the initial phase of the
programme of cooperation between
the Comprehensive Rural Health Pro
ject. Jamkhed. and the Swiss Develop
ment Corporation. This programme
relates to training supervision and
follow up of community health guides
in the thirteen talukas of Ahmcdnagar
District in Maharashtra. The women
chosen are married, have their homes
in the villages, and have Vll class
education. They have a one year (rain
ing in community health work atJamkhcd. following which they have to
appear for the Maharashtra Stale Ex
amination. This course is now
recognized by the Maharashtra State
Nursing Council. Though not yet
recognized by the state government.
many village health guides attached to
primary health centers have shown
considerable interest in this course.
Ruth also designed and conducted
workshops on teaching methodologies
for nurse tutors during her decade with
VHAI. Her continuing interest in Nur
sing Education, to improve its quality.
to increase the community health con
tent is now indicated by recognition
WHO has given the nursing Pro*
fession. Since leaving VHAI. Ruth has
assited the Indian Nursing Council and
the WHO help make more relevant the
General Nursing curriculum, by in
cluding examinations in community
health nursing every year, and in
cluding community health com
munication skills as a subject. Her ex
periences in the field of nursing educa
tion is now available in a book she has
written with Prof. Betty Lehman. Nur
sing Education in India: Its Relevance in pro
vision of Primary Health Care. This report
to the USA1L) comprises the
quintessence of an extensive and ex
haustive study of what is being done in
the field of nursing education in India
RIGHT LIVELIHOOD
This year, the Right Livelihood Prize,
also known commonly as the Alternate
Nobel Prize was awarded to Lokayan.
a Delhi based organization, alongwith
Peter Vergas—a noted Hungarian en
vironmentalist. and Pat Mooney and
Carl Fowler—International Genetic
Resources Group. Canada.
This prize is given to “support,
recognize, and honour those working
on practical and exemplary answers to
the real problems facing the world to
day: the danger of war. the effects of
ecological disasters, material poverty
in the Third World and spiritual pover
ty in the Industrialized countries.”
Lokayan (Dialogue of the People), has
been an intellectual initiative to promotive, active and sustained exchange
among activists from non-polilical
organizations and concerned citizens.
This movement is sponsored by the
Center of the Study of Developing
Societies and is carried out with the col
laboration of a large network of in
dividuals and organizations.
Lokayan forms the forum for ex
change, in a series of dialogues in
various regional contexts as well as
across regions on major issues. It also
brings together activists, professionals
and concerned citizens to a common
platform to probe into the major issues
affecting the country, particularly the
oppressed and the exploited. The
results oi such meetings arc widely
publicized and circulated, in an at
tempt to end isolation and fragmenta
tion that divides the various
movements for change at present.
bulletins which carry an ongoing
debate on intellectual and ideological
issues, commentaries on concepts and
the actual work of projects, and infor
mation on relevant literature. They
also have a research and publication
wing to bring out the results and con
clusion that their work in various
aspects of social development have
defined.
Through all this the Lokayan net
work “has energized directly and in
directly. a variety of individuals engag
ed in action movements on behalf of
the people... with a view to moving
towards a new crystallization of issues
and answers relevant to our time and
society and to the global context in
which we are placed.”
ACTION MEDEOR
The Government of the Federal
Republic of Germany awarded Dr. E.
Boekels, founder of Action Mcdeor for
his most significant contribution to the
essential drugs programme, the
“Bundesverdicnstkrcuz 1c Klassc”. Aclion Mcdeor is based in Tocnis-vorst.
W. Germany. A detailed write-up on
Action Mcdeor appeared in a previous
issue of Health for the Millions.
UNION CARBIDE ACCUSED IN
WATERMELON DRAMA
Watermelons tainted with pesticide
have been linked to an outbreak of a
severe iluc-likc illness among scores of
people in the western USA. Now the
pesticide manufacturer. Union Car
bide. and the melon growers.in Califor
nia arc at logger-heads over who is
responsible. Traces of the pesticide.
aldicarb sulphoxide, which is sold by
Union Carbide under the brand name
Temik, have been found in melons
from four California growers. At least
100 people—and possibly as many as
300—were affected within an hour oi
eating the melons. Union Carbide has
actused the growers of Flagrant
misapplication of the product'. A war
ning label lists the crops it can be used
for and watermelon is not one ol them
The melons tend to accumulate residue
in amounts that could be harmful. But
the glowers maintain that Union Car
bide is al lault because the product can
stay in the soil much longer than ex
pected. The company says Temik will
degrade within 100 days. (New Scien
tist. UK. II .7.85)
13
GUIDING DESTINIES A Report on Society for
Education, Welfare and Action—Rural
i
SEWA-RURAL started out to
* provide health care where it is
needed, at low cost
• provide health education
♦ develop integrated plan lor com
munity development through com
munity participation
* catalyze and organize youth
forums for action-oriented develop
ment programmes
• develop systems for rural resource
management
• provide appropriate training
* to plan and develop projects which
could be replicated elsewhere in
India.
The organization strives to achieve
these objectives through planned scries
of programmes conducted in the
backward, tribal and poor areas of
Jhagadia in Gujarat.
SEWA-RURAL believes that while
prevention is better than cure, curative
medicine is the better entry point. The
KMA Society. Jhagadia. gave the
organization their maternity home, at
their inception. Since then, this has
become the Kasturba Hospital, and is
the operating base for the organization.
The project instituted OUT REACH
programmes of health care in ten
villages. This is under their Communi
ty Health Project. This project is
managed through a three-tier
approach.
SEWA-RURAL manages six anganwadis in the area under the 1CDS
scheme. Village level health care is
maintained by CHVs. Dais and anganwadi workers with support by weekly
visits ol the CHP team. Direct contact
with people and periodic reviews with
workers at all levels is their approach
to continuing education and helps
them understand local problems
thoroughly. A special TB center has
been started for people suffering from
this disease, as this is the prevalent
disease in the area. The services are
low cost and free for the needy.
In addition to the present push on
health services. SEWA-RURAL is ac
tive in the following areas as a part of
comprehensive community develop
ment.
★ the organization administers a
training programme for internee
doctors, nurses. CHVs. Dais and
anganwadi workers;
★ an agro-cconomic project with
community participation has been
initialed at Uchedia:
★ a pilot rural product-marketing ex
periment for eventual resource
management is under evaluation;
a detailed economic and education
programme for participative com
munity development is on the
anvil.
SEWA-RURAL believes:
® no amount of political will will be of
any avail unless the masses of In
dia are well educated, well fed and
well cared for;
• that comprehensive community
development is possible only
through community participation;
• that equipped with man making
character building education, in
dividuals as well as communities
guide their destinies;
o that participative attitude can be
inculcated through involvement.
motivation and imparting comihunity consciousness;
© individuals develop by doing ser
vice to others.
These beliefs led SEWA-RURAL to be
the recepient of this years Sasakawa
Award, presented to them by WHO. on
behalf of Sasakawa, a shipping agency
□f Japan. They, along with two other
award winners received this honour for
their contribution to community
development.
★
A Push for Peace rgvQP____
With Bob Geldof, the Irish singer who organized Live Aid benefits for Africa. Ronald Reagan and
Pope John Paul II as the most favoured nominees for the Nobel Peace Prize, it came as a surprize
when the Norwegian Nobel Committee named the International Physicians for Prevention of Nuclear
War (IPPNW) as this year’s award winners. The IPPNW was founded five years ago, to publicize the
dangers of nuclear war. The founders are two cardiologists—Dr. Bernard Lown, a professor at the
Harvard School of Public Health and Dr Chazov. director-general of the National Cardiological
Research Center in the Soviet Union. This prize was awarded to an antiwar group on the eve of the
Geneva Summit in order to encourage the U.S.-Soviet arms talks.
"There is' no way, we can
solve today, the health
problems of the world. We
ire spending today $ 900
billion on the arms race.
That is more than $ 30,000
tach second. That's about S
? million every minute.
rhal‘s $ 120 million an hour.
rhe biggest achievement of
4
medicine in this era was the
elimination of small-pox.
The elimination ofsmall-pox
cost less than two and a half
hours of the arms race. We
can wipe out malaria. We
can wipe out diseases that
claim human lives even as we
talk now. There were 220
children who died during the
last few minutes (hat we
talked. There were 220 who
were maimed during these
few minutes by diseases that
we know how to cure and
prevent. Saving the lives of
these children would cost a
mili-second of the arms race.
We are already living in the
rubble of World War III. "
Dr. Bernard Lown
"We have faith in human
reason. Because if we go on
like this, the only thing we
can expect is the total
annihilation of mankind."
Dr. Chazov
A SINGLE CARD FOR THE
INSTANT DETECTION OF
MALNUTRITION
Malnutrition can now be detected in
stantly in your growing child. KGAT
card—a simple, small portable and
easy to use for interpretation of an
thropometric measurements in terms
of malnutrition by any literate mother
or health worker has been devised by
Dr Umesh Kapil and Dr Mahesh C.
Guptet of the Institute of Health and
Nutrition. New Delhi (India).
It is very easy to operate. Just adjust
the age of your child (up to 60 months)
on the respective window of the KGAT
card, you will get instantly the
minimum expected weight (in kg.).
height (in cm) and mid upper arm cir
cumference (MUAC in cm). And if these
values are less than the critical values
(which arc also shown simultaneously
against each parameter i.e.. weight,
height and MUAC), it warns that your
child has severe malnutrition. Alter
natively. by adjusting the height (in
cm) of your child on the KGAT card.
you get the instant minimum expected
weight for this height along with the
critical value which indicates severe
malnutrition.
If your child’s nutrition status is bet
ween normal and severe category of
nutrition, it means he is suffering from
mild to moderate degree of malnutri
tion (figure). Feed your child extra food.
whatever he may be presently eating
and monitor his weight with the help
of KGAT card.
Various criteria used to interpret an
thropometric measurements in terms
of malnutrition are shown in the Table.
The reference values for various
parameters used in KGAT card have
been taken from WHO. Monograph
Series No. 53 (D.B. Jelliffe, Assessment
of Nutritional Status of the Communi
ty, 1966). Except in ease of MUAC.
these have been derived from the Har
vard Standards (Stuart and Stevenson.
1959). Amongst the indices based upon
weight and height, the weight for
height detects wasting (acute malnutri
tion) while height for age measures
stunting (chronic malnutrition).
Weight lor age and MUAC arc non
specific indicators of acute, chronic or
acute on chronic malnutrition.
The field testing of this tool was done
in a group of 20 educated mothers in
an urban clinic of Delhi and it was
found 100 per cent acceptable. The
degree of agreement between educated
mothers vs qualified MBBS doctors was
95-100 per cent. The field testing of this
card are being tested at three centers.
’’This card can even be used by
health workers and their supervisors in
ICDS blocks and we arc now planning
to develop this tool in regional
languages’’, said Dr Kapil and Dr Gup
ta. Several eminent scientists feel this
simple card as an extremely useful
guide for helping millions of literate
nutrition-conscious mothers in India to
monitor the health and nutrition status
of their children.
For further information, please contact:
N.C. Jain
Asstt. Research Officer
Division of Publication & Information.
Indian Council of Medical Research.
Ansari Nagar. P.B. 4508,
New Delhi-1 10 029 (India).
Table, Criteria used to interpret anthropometric measurements in terms of
malnutrition.
SI. No.
Parameter
Cut off point for
categorising malnutri
tion (as percentage of
reference standard.)
Normal
Severe
01.
Weight for age
80
60
02.
03.
04.
Height for age
Weight for height
Mid upper arm circumference
(MUAC)
95
90
85
70
Reference
critericn
used
i) Indian Academy
of Paediatrics
ii) Welcome Group
J.C. Waterlow
in WHO
Monograph
Series No.
62.
15
DIARRHOEAL DISEASES:
COMBATTING THE LONG
TERM EFFECTS
Treating the whole child
The immediate effects of diarrhoea are so devastating that its long-term effects
and association with related conditions are sometimes overlooked. We report on
the link between diarrhoea and nutritional blindness or xerophthalmia.
Lack of sufficient vitamin A in the
diet causes blindness in thousands of
children in developing countries. In
Bangladesh alone, some thirty thou
sand children become blind every year
and at least half of them die.
Throughout the world the number of
children blinded by xerophthalmia is
probably half a million each year. Lack
of vitamin A also puts millions of
children at greater risk from diarrhoeal.
respiratory and related infections. Blin
ding malnutrition results from the
combined effects of poverty and ig
norance. It is, however, a problem
which can be greatly reduced and. in
time, eliminated. As death from diar
rhoea can be prevented with oral
rehydration therapy (ORT), blindness
caused by xerophthalmia can be
prevented by an increase of vitamin A
in the diet. The success of both these
interventions is heavily dependent on
effective community health education
Stages In the Development of
Xerophthalmia
Xerophthalmia is caused by an ex
treme shortage of vitamin A in food in
take. Many of those affected die from
the associated malnutrition, increased
susceptibility to common Infections and
a lowered immune response. Even mild
degrees of vitamin A shortage can
damage the body’s protective epithelial
surfaces which line intestinal,
respiratory and urinary tracts as well
as covering the eyes. ’Night blindness’.
difficulty in seeing in a poor light, is a
first sign of vitamin A deficiency. Af
fected children become clumsy in the
It is always very important to
remember that blindness is often
precipitated by infections—particularly
diarrhoeal diseases. These rob the bodyof already scarce reserves of vitamin A.
Prompt and comprehensive treatment
of these illnesses will save both lives
and sight (see below).
Treatment of xerophthalmia
(W.H.O. 1982)
Bltots spot* are foamy patches near the lateral
side of the Iris.
dark and. where xerophthalmia is com
mon, communities recognize this con
dition and often have a traditional
name for it. Unless vitamin A Intake is
increased, the condition may get
worse, especially where children suffer
from diarrhoea and other infections.
Night blindness is followed by con
junctival xerosis; the covering of the
eye I ‘'comes dry. rough and wrinkled
insceaa of remaining smooth and
shiny Bitot’s spots can often be seen—
these are foamy patches near the
lateral side of the iris, the coloured part
of the eye. The next stage is particular
ly serious as it affects the cornea, the
clear area over the iris through which
objects are seen. It also becomes rough,
and eventually opaque. Finally, the
cornea becomes soft (keratomalacia)
and the eyeball may perforate. Even if
corneal ulcers heal there will be severe
scars and, if the eye collapses, vision
is lost. Nevertheless, all of the early
stages of eye damage described can be
reversed by effective treatment.
Vitamin A
• Immediately
200,000 IU by mouth
O Day 2
200,000 IU by mouth
• Day 14
200,000 IU by mouth
— earlier H eyes
women
Diarrhoea and vomiting: 100,000 IU wafer solu
ble vitamin A by intra-muscular in|ection If
available.
Under 12 months: '/a the dosage.
The Link with Diarrhoea and Measles
Blindness becomes an immediate
risk among ill-fed children when infec
tions like measles and diarrhoea occur.
Measles can be prevented by im
munization: and the WHO/UNICEF
emphasis on effective immunization
programmes should reduce this par
ticular danger where the measles virus
can directly attack eyes already
weakened by a mild degree of
xerophthalmia. Repeated attacks of
diarrhoea are closely associated with
the onset of xerophthalmia.
Diarrhoea contributes to nutritional
blindness in serveral ways. During the
disease, food intake is limited and ab
sorption decreased. Diarrhoea occurs
more often and more seriously jn
malnourished children who have very
poor stores of vitaminA in the liver.
A study in Bangladesh showed that
at least half of the children who had
serious xerophthalmia had suffered
from diarrhoea in the previous month.
In
Indonesia,
children
with
xerophthalmia were five times as like
ly to have had diarrhoea in the last
week as children without signs of
vitamin A deficiency.
Dealing with Xerophthalmia
Children most likely to develop
xerophthalmia are those who are
already malnourished with grossly in
adequate intakes of energy, protein and
fats as well as of vitamin A. However,
a recent study in Indonesia showed a
high frequency of vitamin A deficien
cy In children who were not
malnourished. Vitamin A deficiency
is a complex problem of more than just
food intake. In the long term, better
feeding of young children is the way to
control the problem. In the short term,
regular distribution of vitamin A sup
plements to children-at-risk is useful
and comparatively inexpensive. The
cost of a therapeutic dose of 200.000
International. Unit (IU) of vitamin A is
approximately two US cents and will
be effective for up to four months since
vitamin A is stored in the liver. Among
severely malnourished children, the
supplements need to be given more fre
quently, as, for example, in feeding pro
grammes for young victims ol famines
like the one affecting Africa.
Treatment guidelines
The following guidelines for treat
ment are important:
© Examine the eyes of all children
with diarrhoea. In all areas where
xerophthalmia is common, be sure
to see the eyes of every child who
comes to a clinic. This includes
those who are crying and those who
are sleeping. Too many children go
blind ‘behind closed eyelids’.
• Make sure all children with diar
rhoea receive effective oral rehydra
tion without delay. This will pro
mote appetite and intestinal ab
sorption of food. Any associated
respiratory or other infections
should be appropriately treated. Re
feeding should start as soon as
possible following rehydration.
Breastfeeding should be encourag
ed and practical advice given about
Improving the diet to include some
vitamin A rich foods. Some govern
ments are fortifying foods with
vitamin A—such as the long
standing sugar fortification pro
gramme in Guatemala.
o If the eyes show signs of
xerophthalmia, follow the WHO
recommended treatment schedule
(see box). All damage to the eye can
be cured up to the stage of severe
corneal damage.
• All malnourished children with
measles are at high risk of blind
ness and this can develop within a
few hours. Give vitamin A in the
recommended dose unless the
child has received a large dose
within the last four months.
To on® gloss of water, add ono pinch of salt and
Breast-feeding to Protect Sight
The unborn child gets vitamin A
from its mother through the placenta.
If the mother’s diet is inadequate, the
new-born starts life without a sufficient
store of vitamin A in its liver.
Premature infants are particularly at
risk and babies may even be born with
obvious xerophthalmia. Young
children cannot store much vitamin A
and need to have a small but regular
supply in their diet. In those countries
where vitamin A deficiency is most
common, babies depend mainly on
breastmilk for their supply. The
highest concentrations occur in col
ostrum (the substance secreted by the
breasts during the first few days after
delivery). In societies where it is not the
custom to allow babies to have col
ostrum, a valuable early source of
vitamin A as well as other protective
substances is wasted. The amount of
vitamin A in breastmilk gradually
decreases but is always higher than in
cow’s milk.
Breast-feeding therefore protects
against xerophthalmia, although
breastmilk from a poorly nourished
mother may be low in vitamin A and
may also be insufficient in quantity to
prevent a degree of malnutrition.
Where the average diet is known to be
vitamin A deficient, mothers can be
given a megadose (200,000 IU) by
mouth after delivery and this will raise
the levels of vitamin A in their milk for
at least 3 months. Too much vitamin
A can, however, harm the unborn
child. Doses greater than 10,000 IU
should never therefore be given to a
pregnant woman, or one who is
breast-feeding but who may also have
On® scoop of sugar or (aggory
Glvo tho child ono glass of this drink after each
watory stool.
an early pregnancy. Even without
vitamin A supplementation of the
mother, the risk of xerophthalmia for
children under two who arc not breast
feeding is nevertheless 6-8 limes
greater than for those receiving
breastmilk.
Continued on Page 22
17
AUDIO-VISUAL FOLIO
QASOOR KISKA
The racing ambulance on a dark
night spells Casuality. The matter is
serious since a six-month old child
suffering from acute diarrhoea
resulting from bottle feeding, dies in
spite of every possible treatment.
The shocked parents Ramesh and
Savitri watch their dreams crashing
before their eyes and the looks they ex
change in grief seem to voice the ques
tion arising in their minds ... ‘Qasoor
Kiska’.
The film trace the story right back to
the rural setting, where an expectant
Savitri awaits the arrival of her
newborn with much happiness and
glorious dreams of the future. The day
arrives finally and the father Ramesh
rushes home to his village from the ci
ty to see his newborn. With him comes
the dreaded feeding bottle in all it’s
gleaming form and attraction. Thus the
villain—the bottle is introduced in the
joyful life of a normal, healthy baby
who would have been otherwise nor
mally and safely breast-fed.
The crash of their dreams shakes
them and incites the film makers to
probe deeper into the problems relating
to unsuccessful breast-feeding. Dr. R.K.
Anand, a leading Child Specialist of
Bombay who himself is a crusador for
the cause of promoting breast-feeding
talks about the problems and their
solutions and makes an appearance in
the film. Several actual cases were trac
ed out and genuine questions asked by
mothers were put across to Dr. Anand
who answers them in a reassuring
way.
In this campaign, the film makers
have presented the evidence in favour
of breast-feeding in a way that most
sceptical or half hearted mother should
find acceptable. We have come to the
conclusion that with the right advice
and encouragement, almost every
mother can breast-feed happily and suc
cessfully for as long as she and her
baby wants.
"This 18 minutes colour film very ef
fectively portrays the importance of
Breast-feeding in Child’s Development
and dispels many of the fallacies that
prevail in our society in this regard.
This ultimately comes out with the
message that breast-feeding is the on
ly way to ensure good health to child
and restoration of a good physique for
the mother".
S.Y. Quraishi
Deputy Secretary to the Govt, of India
Ministry of Social Welfare.
"The general shift from breast
feeding to bottle feeding not only in ur
ban areas but increasingly in rural
areas is alarming. In that sense, this
film is timely as it lucidly conveys the
danger of this shift and scientifically
explodes many of the myths common
ly associated with breast-feeding."
Mrs. Laj S. Deshmukh
Executive Secretary
Indian Council of Social Welfare.
Prints are available. For details,
contact:
Voluntary Health Association of India,
C-14, Community Centre.
S.D.A.,
New Delhi-110 016.
AWARD WINNING IDEAS
RUBBISH DISPOSAL
A solution to many of our problems
lies in the removed of rubbish. The non
performance of the municipal services
clearly amounts to collective murder.
They must be provided with modern
equipment and any dereliction of duty
on their part must be severely
punished.
CLEANLINESS COMMITTEES
Cleanliness Committees should be
formed in every locality to co-ordinate
and supervise the work within their
areas. They could be able to get the
help of the municipality and police
whenever required. Spitting, piling up
of litter and all such activities should
be made punishable by law. If the
government enforces cleanliness, the
country would make great progress.
CLEANLINESS DAY
Let the second Saturday of October
every year be observed as ‘Cleanliness
Day’ throughout the country, when no
garbage should be allowed to remain
anywhere. On this day every citizen
should participate in a cleanliness cam
paign in his neighbourhood with
dedication, enthusiasm and pride.
Cleanliness Committees and civil oflicials should organize competitionslo
generate awareness and enthusiasm
for cleanliness in every citizen. Prizes
should be awarded for the cleanest
areas.
EATING PLACES
Totally unhygenic conditions prevail
at most way-side dhabas and
restaurants. Thousands visit these
every day. If hygenic standards are en
forced at public eating-places there will
be no overcrowding in the hospitals.
PREVENTION OF DIARRHOEA
An experiment in one of the worst
slums in Dhaka showed that washing
hands with soap before meals and after
going to the toilets reduced the in
cidence of diarrhoea by more than 80
per cent. This message should be pro
pagated through imaginative cam
paigns through the mass media.
ANTIBIOTICS
Human bcings are getting resistant
to antibiotics by drinking milk from
animals which have been given a
course of antibiotics. Children are the
worst sufferers. The administration of
antibiotics to animals without the
prescription of a veterinarian must be
banned by law with heavy penalties for
defaulters.
DONATION OF ORGANS
PREVENTION OF CANCER
Cancer is curable if detected in the
early stages. The early signs of cancer
should therefore, be well-publicized
through various media.
For rural areas a paramedical stu
dent and a technician team, equiped
with dyes and stains worth about Rs.
300/- with training to identify symp
toms and dysplastic cells in affected
tisements. Government must adopt
more active measures to curb cigarette
smoking to safeguard the health of its
nationals even if it means a loss of
revenue.
One in every four Americans carries
organ donor cards' on his/her person
declaring that the doctors could use
any of the organs for transplant in case
of his/her death. This movement
should be urgently popularized in In
dia with the help of the mass media.
SULABH SHAUCHALAYA
There is only one way to prevent the
use of vast areas in cities, towns and
villages as open toilets causing ex
tremely unhygenic conditions. The
highly successful sulabh shauchaluyu
type of latrines should be introduced in
all such areas. These arc inexpensive
and can be brought into use m a short
time.
PAY-TOILETS
The municipal urinalsand toilets in
various towns are terribly dirty and few
would like to visit them. The services
of unemployed youth could be utilized
to keep these facilities clean, tor which
they could charge a small fee from
every user as fixed by the municipality.
cases, can prove most beneficial. In
cases of suspected cancer they can
direct the patient to the nearest cancer
center with a pamphlet containing
OPD timings and other related
information.
CIGARETTE SMOKING
In spite of the known hazards of
smoking, massive advertisement cam
paigns continue to project smoking
cigarettes as a pleasurable pursuit of
the young and ambitious. The warning
about its being injurious to health is
becoming more and more in
conspicuous in the manner i ,s
displayed on the pack and tn the adver-
BLOOD DONATION
There is a tremendous disparity bet
ween actual requirement of blood and
its supply. This is mainly due to the
totally unwarranted apprehensions in
the minds of potential blood donors
which should be removed through
campaigns in the mass media. The
penal code should be amended to
reduce proportionately the period of
sentence for prisoners who donate
blood. College students. Government
employees and others should be
rewarded with commendation badges
which they can display on their dress.
PROFESSIONAL ETHICS
Efforts must be made to control the
propensity of some members of the no
ble profession of medicine to engage in
195
The laws must be amended to enable
people to rush to the help of accident
victims without the fear of being
harassed by the police and from legal
consequences.
profiteering, caring little for their pa
tients. The general practitioners giving
unnecessary injections and antibiotics.
gynaecologists unnecessarily removing
the uterus, the vicious ciiclc of referrels. costly investigations and abetting
the nefarious practices of multi
national drug firms and other activities
need to be curbed.
To uphold the traditions of this pro
fession a beginning could be made with
the abolition of the capitation fees for
admission into medical colleges, follow
ed by stringent action against errant
doctors. Excessive and unnecessary
specialization leading to more ‘super
quacks’ should be curbed.
NATURE CURE
ACCIDENT VICTIMS
It is sad to see accident victims lying
unattended, waiting for death, with a
crowd looking on. It is the fear of legal
consequences that keeps good people
from offering assistance. Even reputed.
well-equipped private hospitals turn
down such cases, directing them to
Government hospitals. In most cases
immediate medical attention could
have saved their lives.
Antibiotics do not cure disease but
only suppress the symptoms and give
temporary relief. There are side-effects
also. Ayurvedic and homeopathy are
sometimes helpful, but even these
medicines are foreign bodies and can
be harmful in a case of wrong
diagnosis.
The nature cure system is a gift of
nature in which food, sunlight, mud,
water etc., are used in a manner that
'removes toxins, the symptoms disap
pear, the body becomes clean and cure
is permanent.
Government should encourage
Nature cure clinics for training,
research and treatment of patients.
THE PROMOTION OF
NON-SMOKINGSUMMARY OF GOALS
GOAL: 1
Involve the public In the pro
motion of non-smoking
Seek support from sectors
and groups. Seek to involve
the public. Commit
substantial funds and form
a task-force to promote
GOAL: 5
non-smoking.
Monitor results.
GOAL: 2
Promote the right to breathe
smoke-free air In enclosed
public places; promote non
smoking as the norm
Surveys indicate over
whelming public support
for this.
GOAL: 3
Educate children to be life
long non-smokers
Educate school children to
be lifelong non-smokers;
prevent addiction to
cigarettes. Make it an of
fence to sell cigarettes to
children.
GOAL: 4
20
Assist smokers who wish to
give up smoking
GOAL: 6
Make ‘stop smoking'
courses widely available.
Involve institutions.
worksites, health profes
sionals, volunteers, com
munity groups.
sumers on tar yields and
additives.
GOAL: 7
Further restrict, and with
public support, eventually
ban any encouragement of
cigarette sales by advertis
ing or sponsorship.
Promote non-smoking in the
work-place
At worksites, encourage
non-smoking on the job,
and non-smoking work
zones. Educate about the
hazards of smoking, and
restrict exposure to
substances which increase
those hazards. Offer stop
smoking courses.
Introduce improved health
warnings and reduce the tar
Increasingly restrict and even
tually ban the promotion of
cigarettes
GOAL: 8
Adopt a taxation policy that
encourages non-smoking
Tax cigarettes so that,
relative to other prices,
they cost more, and smok
ing is discouraged.
GOAL: 9
Finance the promotion of non
smoking from cigarette tax
A tax levy may be
necessary.
Require improved health
GOAL: 10 Establish a council for non
warnings on packets and
smoking and health
advertisements. Permit the
Establish a Council to
sale of only medium and
oversee the comprehensive
low tar cigarettes. Provide
promotion of non-smoking.
more information for con-
A LEGEMD
Once upon a time there was a man.
He was a healer of little children. One
day he realized that the medicines he
was.giving these little children were
not all safe. Some of them were very
dangerous. They were dangerous not
only to little children, but also to the
bigger people. A terrible giant was
making these medicines and enticing
people to take them. The medicine
caused many problems—blindness.
paralysis, loss of bladder control. But
the people did not blame the medicine
nor the giant for their troubles—they
did not realize who was responsible.
The man did realize, and decided to
take on the giant. The man was Dr. Olle
Hansson; the giant—Ciba Geigy and
the medicine—Mexaform.
Dr. Hansson was professor of
Paediatric Neurology in the University
of Goteberg, Sweden. Since 1965, he
had single handedly fought against the
unethical practices of pharmaceutical
companies. He fought against Ciba
Geigy’s "denial of facts”, e.g. absorp
tion of the drug, association of mex
aform like drugs with SMON (Subacute
Myelo Optic Neuropathy). Dr Hansson
stood as a witness on behalf of the
SMON victims in the Tokyo Court.
where SMON case was fought for eight
years. His contribution as an expert
who was willing to take the side of the
people against one of the most power
ful multinationals is exemplary. He
had the courage to stand against the
medical establishment which con
tinued to perpetuate the lie that SMON
was caused by virus and was a genetic
disorder of the Japanese. It was his ef
fort alongwith that of other socially
conscious lawyers, doctors and jour
nalists that led to the banning of mex
aform in Japan in 1971.
In Sweden, his el forts led to the
diagnosis of 43 cases of SMON.
In 1976. Dr Olle Hansson proposed
a boycott of all Ciba Geigy products for
continuing sales of their products—
mexaform and enterovioform in the
Third .World countries. Doctors from
Sweden. Denmark, and Norway joined
in the protests. By 1981. Ciba Geigy
had lost 25 percent of their market in
Sweden. And by mid 1982. one third
of their market was lost. Dr. Olle
Hansson insisted that the drug in
dustry
knew
only
economic
arguments, and protest by prcscribers
and consumers in boycotting their pro
ducts was a major tool in our hands.
Dr Hansson's
*
efforts helped SMON
victims in Japan obtain compen
sation— a percentage of which
was set aside by the victims
themselves to fight against drug induc
ed suffering elsewhere. Similarly. 38
individuals afflicted with serious side
effects in Sweden sued Ciba Geigy and
were paid 1.8 million Swedish Kroners
in an out of court settlement.
Last year, it was he who informed the
Drug Action groups worldwide about
Tandril and the association of deaths
due to agronulocytosis. Consumer
Alerts were immediately sent off. Ciba
Geigy, realizing that facts from their
own internal documents were now
publicly known, were forced to decide
to withdraw the product by the third
quarter of 1985.
Dr Olle Hansson stood for ‘right to in
formation by the consumers and
preseribers’. He insisted that people
should know about the medicines they
consume. Tandril (sold under any
other name) could ’shut down’ *
t;one
marrow. High dose of estogenprogesterone drugs which are still be
ing used for pregnancy testing can lead
to abnormal babies being born. (It is
ironic that, thanks to a stay order ob
tained by Organon. Nicholas and Unichem from Calcutta and Bombay High
Courts against the Drug Controller of
India’s ban order on the product in
1983. their sales continue, flaunting
rules of ethical marketing practices).
At this time Dr Olle Hansson was not
merely fighting multinationals, but
fighting cancer, which had already
begun to spread. The fight that Dr
Hansson was involved in was against
malpractices and deliberate misinfor
mation. He believed that informed
public could resist their being
manipulated and exploited in the name
of medical science by profii-oricnted
commercial interest in connivance
with vested interests within the
medical
establishment
and
bureaucracy. He fought for effective
drug controls at the national and inter
national levels.
Dr Olle Hansson was one of the
pillars of Health Action International
(HAI) which is an informal cooperating
network of health groups, consumer
groups and public interest groups
worldwide. HAI networkers have been
21
fighting for safe rational and economic
use of pharmaceuticals in their own
countries and also worldwide.
Dr Hansson was a source of informa
tion and inspiration to individuals,
groups and organizations involved
with drug action. His work and life
depicts what a single person with a
purpose, awareness, courage and con
cern for the people can do. He fought
a lonely battle against pharmaceutical
malpractices since 1965: appreciation
by the people came only in the eighties.
His experience in fighting unequal bat
tles has been of special significance in
our country.
Dr Olle Hansson visited India in April
1983 as a guest of VHAI. During this
visit, he addressed a public meeting at
the All India Institute of Medical
Sciences on the role of anti-diarrhoeals.
Dr Olle Hansson died this year on
May 23rd. While all over the world
various intellectuals, scientists, doc
tors. consumer groups, human rights
groups involved in the health and
drugs issues share the sorrow of his
passing away, his death chalienges all
of us to continue this fight between
Davids and Goliaths, between concern
ed individuals and corporate powers
and their supporting bureaucracies
and political patrons. His quiet
tenacious struggles teach us how to
fight for others and for truth and
justice; how to persevere, be consistent
and single-minded. Swimming against
the current has always required great
moral courage. Dr. Olle Hansson stood
as an epitome of moral courage. In
Sweden and world over he is a hero, a
legend. For us, he was a friend-needed
and valued.
DRUG ACTION ALERT
The Hatch bill No. S 2878 introduc
ed by Senator Orrin Hatch last year and
vetoed due to protest from several
countries and organizations would
have allowed the expert of U.S. FDA
unapproved drugs. The existing
American law embodied in section 801
of the 1938. Food. Drugs and
Cosmetics Act prohibits export of
drugs which have not been approved
for use in the US. This bill has been
reintroduced with some modifications,
which, if passed would allow drugs not
yet approved by the FDA to be ex
ported to countries where import is
legally allowed. The problem for the
Third World countries is that re-export
cannot be regulated and controlled
from these courts.
There is a move to get Senator Ed
ward Kennedy to co-sponsor the bill. If
he does this, the chances of the bill
becoming a law are very bright.
Please send your view immediately
by cable or a letter to
Senator Edward Kennedy
U.S. Senate.
113. Russel Senate Office Buildings.
Washington D.C. 20510
U.S.A.
There is also a move to exclude the
brand name and the manufacturing
data and also to exclude drugs that
were recommended for being weeded
out because of their therapeutic
uselessness from the UN Consolidated
List of Hazardous Drugsand Chemicals
which have been banned or restricted.
These changes are being contemplated
due to pressure from certain sources.
Please write immediately to:1.
2.
Mr. Peter Hansen,
Executive Director,
UNITED NATIONS.
Centre on Transnational
Corporations,
DC 2, 12th Floor,
New York 10017. USA.
3.
Ms Inger Brugemann
Director
of
External
Coordination.
WORLD HEALTH
ORGANISATION.
20. Avenue Appia,
1211. Geneva 10.
Switzerland.
with a copy to:
1.
2.
22
Mr. Joe Goffman
Public Citizen
Congress Watch.
215. Pensylvania Ave.
Washington D.C. 20003.
Ms Virginia Beardshaw.
HAL IOCU
2595, EG The Hague.
Netherlands.
Mr. Luis Gomes,
Asstt. Secretary General.
UNITED NATIONS,
DIESA—Program Planning and
Coordination Office.
DC 2. 18th Floor
New York, NY 10017,
4.
Mr. Jan Huismans,
Director.
1RPTC/UNEP
Palais des National.
1211. Geneva 10,
Switzerland.
Please send copies of all your com
munication to:
Dr. Mira Shiva,
Coordinator,
Low Cost Drugs and Rational
Therapeutics &
All India Drug Action Network,
VHAI.
C-14, Community Centre,
S.D.A.,
New Delhi-110 016.
Continued from Page 17
Caution
Infant formula foods usually contain
added vitamins, including vitamin A.
Dried skimmed milk (DSM) has had the
vitamin A removed in processing,
along with other fat soluble vitamins
such as D and K. DSM used in nutri
tion feeding programmes must be for
tified with vitamin A. Always check the
pack label for the vitamin A (and D)
content. Many children have been
blinded through wrong use of non
fortified dried skimmed milk.
Based on material provided by Nicholas
Cohen, Mira Mitra, E. Leemnuis de Regt,
J. Davidson of Helen Keller International,
Bangladesh, in collaboration with the In
stitute of Public Health and Nutrition.
Dhaka Bangladesh.
Reproduced from Dialogue on Diarrhoea,
issue 21, June 1985.
BOOKS
A MANUAL OF NATURAL FAMILY PLANNING
Dr. Anna M. Flynn and Mollssa Brooks
The body of a woman displays various signs and
symptoms of fertility throughout her menstrual cycle
during the reproductive years. This book describes each
of the main indicators of fertility—basal body
temperature changes, the presence/absence plus
amount/consistency of cervical mucus, changes in the
cervix itself—and also minor physical changes common
to many women. This book will serve as an introduc
tion to anyone who is interested or intrigued by Natural
Family Planning methods, while teachers and users can
use it for reference.
Dr. Flynn is an obstetrician .and gynaecologist with
special research and training in fertility awarness. She
has been associated with the WHO and is the co-founder
of the National Association for Natural Family Plann
ing Teachers in England and Wales.
FOOD AND NUTRITION
A resource and action pack from the International
Consumer Unions.
Produced under the direction of the IOCU by a special
ly assembled team of graphic designers and writers.
This Food and Nutrition Pack is:
•
a valuable tool for consumer groups, educators.
public interest groups, teachers and ordinary peo
ple concerned with world hunger:
•
a blend of posters, action leaflets, charts and discus
sion starters.
Those interested may contact:
International Organization of Consumer Unions
P O Box 1045, Penang
Malaysia.
HERBAL MEDICINES AND THEIR USE
Sister Innocent MSMI
PREPARING SIMPLIFIED TRAINING MATERIALS
A.C. Lynn Zelmer
The booklet explains how to prepare written text.
understandable illustrations, posters and wall charts.
It also gives a systematic way of pre-testing materials.
Price : Rs. 3/- For copies, write to VHAI.
It is a booklet that describes in Malayalam, herbaf
remedies for cuts, skin diseases, leucorrhoea. haemorrage wounds, hook worm, bleeding, bums, cough, piles.
toothache, conjuctivitis. eye-infection, diarrhoea, dan
druff. fever, tonsillitis, whitlow, round worm, tape
worm, pin worm, ringworm, asthma, whooping cough.
diabetes, car infection, bacillary dysentry. amoebiasis.
peptic ulcer, eczema, anaemia, jaundice, migraine and
hypertension.
The price is not mentioned.
THE COLD CHASM
Appropriate Health Resources and
Technologies Action Group Ltd.
(AHRTAG) has produced a booklet en
titled How to Choose and Make a Cold
Box.
Keeping vaccines at the right
temperature often presents the greatest
difficulty for managers of immuniza
tion programmes at a distance from ur
ban centers. It is here that the weak
link in the programme’s cold chain is
most likely to be found. But the pro
blems are not insoluble for even a
moderately trained technician and
AHRTAG has provided a very useful
service in publishing a book to help
him construct this essential piece of
equipment.
It does more than this for there is
good advice on deciding the type of
Choosing • Buying Adapting-Making-Testing CoWBox&s
cold box that is most suitable as well
as the features to look for when a cold
box, vaccine carrier or vaccine flask is
to be bought or when a specification
has to be written.
The book is mostly written in good.
plain English (I hope it is to be
translated) although the insulation for
mula at the end of the book will be
found difficult to understand by all but
the real expert and a few technical
phrases such as cold life graph and glue
line will cause many readers to stop and
think—but perhaps no bad thing.
The illustrations are clear, clean line
drawings which are a pleasure to look
al—with one exception. The drawing of
external limber strengthening of a cold
box is a puzzle and a puzzle that I. for
one. have been quite unable to solve.
But one drawing difficult to understand
is a small price to pay for an otherwise
excellent book of instructions. DG
23
NEWS FROM THE STATES
KERALA
For this please contact:
The Co-ordinator. School Health.
Kerala VHS.
Rajagiri College.
Kalamassery-683 104.
For the formal inauguration of the
school health programme is likely to be
field sometime in September.
TEACHERS & STUDENTS HEALTH
A healthy child—is tomorrow's
wealth. Simple health messages given
to the children reach their family more
easily. School teachers are identified as
the best resource to generate health
consciousness in the school children.
These are the basic concepts guiding
the new school health programme be
ing launched by Kerala VHS.
The VHS has planned a comprehen
sive school health programme—which
is teacher centered, and with maximum
involvement of students and teachers.
At the same lime it is affordable and
hopes to be cost effective.
THE COMPONENTS
1. Health Education
In the form of simple health
messages—teacher gives to the
students School Arogya darshini. It is a
newspaper like publication being
prepared and used for this purpose. It
is well illustrated and specific.
2. Identification of Disabilities
in Children
Most of the common ailments in
school children can be identified by the
teacher if he is properly trained to do
so. lie can also suggest remedial
measures or undertake them in the ear
ly stages. Allcast one teacher from each
school in the implementing area will be
given special orientation and training
in this line. Hc/she can pass on the
know-how and messages to other
teachers.
3. Prevention of Communicable
Diseases
Early detection of diseases like
mumps, jaundice, influenza and
24
UTTAR PRADESH
News
scabies etc. in children can help
teachers to prevent them spreading in
the school. Hc/shc can also suggest
vaccinations or even arrange to do it in
the school.
4.
Environmental Education
This particular aspect emphasizes
the need for ecological balance in the
world where we live in and encourage
students to love nature.
5.
Implementation
This programme is to be im
plemented in one educational district
in Kerala for demonstration. Il will take
at least three years to cover the target
group and is being implemented in five
stages. Later the schools can run it
themselves without any external
assistance. If proved successful and
cost effective, other interested agencies
can replicate it. Similar programmes
arc also being launched in most of the
states in India.
A few copies ol School Arogya darshini
will be available for (hose who are in
terested to start this programme.
The governing body of UP VHA met
on July 14. 1985 al Balya Kalyan
Sainili. Hardwar. Dr. Sundaram the
President of UP VHA presided.
Among the programmes and projects
mooted by UP VHA arc organization of
rehabilitation camps. Child care and
formation and training for village
youths and farmers.
SMOKING
Mid-summer Sanity
June was a good month lor the UK
anti-tobacco campaign. The British
Medical Association (BMA) and the
Health Education Council published a
report—Smoke Gels in Your Eyes—
attacking cigarette advertising in
women’s magazines. The BMA also
launched a tobacco-free unit trust
which will offer investors the option ol
giving some of their profits to light
cancer. This follows the withdrawal ol
BMA investment in tobacco companies
and unit trusts containing tobacco
shares. In a separate move, the UK
Department of Health and Social
Security announced that smoking is to
be severely curtailed in hospitals and
all National Health Service premises.
OPPORTUNITIES
WANTED FOR SIR WILLIAM WANLESS CHEST HOSPITAL, P.O. WANLESSWADI, DIST.
SANGLI, MAHARASHTRA—fully qualified, dedicated Christian to take up the respon
sibilities of SECRETARY with the following qualifications:
a)
Graduate or Post-Graduate in Commerce, Science, Arts, Law with additional
qualification as under:
Master of Hospital Administration or Master of Business Administration with 5 years
experience of having worked in a hospital with 300 or more bed capacity on the
administrative side.
OR
University Diploma in Hospital Administration or University Diploma in Business
Administration—5 years experience preferably in a hospital.
Please write to The Medical Superintendent, Sir William Wanless Chest Hospital,
P.O. Wanlcsswadi, Dist. Sangli, with copies of certificates and testimonials, with
two names of persons for confidential reference.
CALENDAR OF EVENTS
Nurse Anaesthesia Course:
Applications arc being taken for the January 1986 Batch No. 21. Course starts on
20th January at Frances Newton Hospital. Ferozepur. Punjab. 152 001. Applica
tions and prospectus on request.
VHAI ANNOUNCES
A Correspondence Course leading to certificate in
Community Health Planning, Organization and Management
Target group:
•Persons in the Voluntary Sector
who have been appointed as area
managers, or advisors for health
education:
•People who wish to learn how to
train others of their own locality, in
community health education, ser
vices and management.
Objectives:
•To develop and improve the skills
ol directors, area managers and
consultants of community health
programmes:
•To improve efficiency and widen
the scope of persons engaged in
planning, organizing and manag
ing of community health
programmes:
Methodology:
The course will, consist of
seminars, regional study meetings
and individual learning material.
Duration of course: Two years to complete all the
assignments including seminars
and personal visits to the student’s
project.
For details, prospectus and application forms, contact:
The Senior Co-ordinator
Community Health Education, Training and
Personnel Development.
VHAI, C-14. Community Centre.
SDA,
New Delhi-110 016.
ANNOUNCES
VHAI'S COMMUNITY HEALTH DIVISION
Regional Training Programme
in
School Health
Looking at School Health as an important alternative
Health Education Strategy.
Seeing School Health as an action oriented Health Pro
gramme involving teachers, children, parents and the
community.
Learning how to plan, implement and evalutc on a
School Health Programme.
Starting a meaningful School Health Programme.
Preparing and Collecting resource materials for child
to child activities.
If you af interested in:
Write to:
The Coordinator.
Community Health Education.
Training & Personnel Development,
VMAI.
C-14 Community Centre.
SDA. New Delhi-110 016.
Last date for Enquiries: 15 December. 1985.
COMMUNITY HEALTH PROGRAMME
A 10-week course is available in Community Health and Development for medical, para-medical and social workers,
involved in community health and interested in training communily/villagc health workers. Registration lec-Rs.
500/- per participant. All other training costs will be met by INSA.
1986 Course
Contact
:
14th April 1986 to 20th June. 1986. application to be sent in by 15th February. 1986.
Programme Director,
INSA/1NDIA
Rural Health and Development
No. 2. Benson Road.
Benson Town,
Bangalore-560 046.
Designed and Produced by Parallel Lines Editorial Agency. E-8 Kalkaji. New Delhi-1 10 019 for Voluntary Health Association of India
C-14 Community Centre. SDA, New Delhi-110 016.
HEALTH FOR THE MILLIONS
VOLUNTARY HEALTH ASSOCIATION OF INDIA
OCTOBER 1985
Volume XI No. 5
CH1LP
-AN AGENT
OFOCW§e
*
THE EDITORIAL EYE
*
Today’s child is tomorrow’s adult; and in the year 2000, this child
will be involved in planning and providing health care.
In fact today’s child is already doing this—older children often
look after younger children in homes where both parents work.
where the children have no mother. We know that play has a vital
role in reinforcing messages, and that children have a tremendous
source of undirected energy just waiting to be tapped.
It then becomes mandatory to direct some of our health messages
towards this child, so that she grows up convinced that good health
is her birthright. Convinced that she herself can do something to
ensure that there is Health For All by the year 2000.
With this in mind, the CHILD-to-child programme was conceiv
ed. In this issue of Health for the Millions, we reproduce excerpts
from David Werner’s book, “Helping Health Workers learn”, giving
his ideas and experiences with this programme.
While reaching children who do not go to school is difficult, it
is possible to impart knowledge of health to school children. This
knowledge awakens health consciousness and encourages action
for improving health. An earlier Meet on School Health Education
determined the methodology for such education. VHAI has con
sistently been motivating schools and health projects to participate
in School Health programmes. Starting from Page 3, we analyze
the need for such health programmes, and how to organize and
conduct them. Reports from successful programmes are also
Included.
R.H.B.
CONTENTS
Children as Health Workers—CHILD-to-child
Teachers and Pupils as Health Workers
Why School Health and How?
Resource Material and Institutions
Teaching Health to Primary School Children
A Pilot Study on the Effectiveness of TB Models
News From the States
Reaching the Unreached
All-India Drug Action Network—AIDAN
1
3
8
15
18
20
22
24
25
This issue of Health for the Millions was compiled and edited by Radha Holla-Bhar with assistance from Dr. Amala
Rama Rao and Ms Christina de Sa, and published by the Voluntary Health Association of India, C-14 SDA Community
Centre, New Delhi 110 016. Designed and produced by Parallel Lines. Editorial Agency, E-8, Kalkaji. New Delhi-110 019.
CHILDREN
AS HEALTH WORKERS
—CHILD-to-child
excerpts from 'Helping Health Workers Learn
*
by David Werner
Tin villages and communities
roughout the world, young
uildrcn are often cared for by their
rder brothers and sisters. These
suing “child-minders” not only
ay with their smaller brothers and
sstcrs, but carry them about and
■•en bathe, change and feed them.
iiis not unusual fora small child to
mend more time under the care of
11 older sister or brother than with
es mother or father.
Iln some areas, children—
specially girls—do not attend
Ihool regularly because they are
seeded at home to watch the smaller
nildren while their mothers work.
Ilf children can learn more about
jow to protect the health of their
Hunger brothers and sisters, they
i n make a big difference in the
cell-being and development of
»ung
children
in
their
^immunities.
SSome of the best ideas for teaching
nd involving children in health
i re have been developed through
-HLD-to-child Programme. The
uildrcn learn simple preventive
nd curative measures, appropriate
it their communities. They pass on
hiat they learn to other children
nd to their families.
■HE SOCIAL AND EDUCAtONAL VISION BEHIND
HILD-to-child
SSome of us involved in CHILD-touild see far more possible value in
than simply teaching children
nout the health needs of younger
♦others and sisters. The educa
tional process that it encourages is
equally important.
These are some of the social and
educational principles behind
CHILD-to-child:
★ Children are not only a first
priority for health work, but also
an enormous resource as en
thusiastic health care providers.
With a little assistance, children
could soon do more to improve
the well-being of their younger
brothers and sisters than all doc
tors and health workers put
together—at a far lower cost.
★ Through learning in an active,
practical way about health care
when young, children will
become better parents. They will
be more likely to meet the needs
of their own children.
★ CHILD-to-child can help in
troduce a liberating learning pro
cess into schools. It can help
bring schooling closer to the
needs of the children, their
families, and their communities.
★ It can also make children more
aware of their own ability to
change and improve their situa
tion, through sharing and helping
each other.
THE ROLE OF THE HEALTH
WORKER IN CHILD-to-child
CHILD-to-child activities can be
led by health workers, school
teachers, parents or anyone who
likes working with children. But
health workers can play an especial
ly important role in promoting and
developing these activities with
children.
INVOLVING
THE
SCHOOL CHILD
NON
Some children often miss school
because they are needed at home to
care for younger brothers and
sisters. Other children have to work
to help their families earn a living.
Health workers also need to look for
ways to reach these children who do
not attend school. After all, they are
the children who can benefit most
from CHILD-to-child.
Encourage these children to come
to the health post with their baby
brothers and sisters, especially on
days of baby weighing, “underfives” clinic, or child nutrition pro
grammes. Or try to set up special
meetings to involve them in CHILD-
to-child activities. Invite parents and
school children to help.
Some health programmes have
helped start “day care” centres for
babies of working mothers. Such
centres free more of the older
children to attend school. Some of
those who still cannot go to school
may help care for their younger
brothers and sisters at the day care
centre.
Sometimes, school children
themselves can become the
“teachers” of those who do not at
tend school. If a health worker can
help this to happen, he will not on
ly be acting to solve immediate
health problems. He will also be
preparing children to help build a
healthier community as they grow
up.
AVOIDING PARENT-CHILD
CONFLICT OVER NEW IDEAS
People, including parents, often
have very fixed ideas about manag
ing common Illnesses. Is it fair to ask
children to take home new ideas
that may conflict with the beliefs
and customs of their parents? Could
this weaken children’s respect for
their parents or for local traditions?
Or will it make parents angry with
the children and perhaps, with the
school?
These are valid questions. In
many areas, for example, parents
believe it harmful to give a child
with diarrhoea anything to eat or
drink. They argue from experience
that giving food or drink to the child
may make him have another watery
stool more quickly. How, then, can
a boy or girl convince parents that.
even though the sick child continues
to have diarrhoea or to vomit, it is
very important to give lots of liquid
and also food?
There are no easy answers to
these questions, but one thing is
clear. It is not enough to work only
with the children in these activities.
Health workers and teachers need to
work with the parents and the com
munity as well. There are ways they
can help families become more open
to the new ideas children bring
home from school. These include
discussion groups, mimeographed
sheets, and evenings of entertain
ment with role plays and skits.
It is best when both children and
adults take part. A good way to win
community acceptance is to involve
parents and opinion leaders from
the first.
It is important that teachers and
health workers show respect for the
ideas and traditions of the child’s
parents. At the same time, try to
prepare the children for some of the
difficulties that may arise when they
introduce their new ideas at home.
PARENTS' RESPONSE TO
CHILD-to-child
In the village of Ajoya, most of the
parents were enthusiastic about the
CHILD-to-child Programme, even
though some of the new ways of do
ing things seemed strange to them.
Among the reasons for the com
munity’s acceptance were the even
ing theatre and puppet shows.
The children also gave demonstra
tions of dehydration and rehydra
tion using the “gourd babies.”
which everyone loved! It was the
first time that most people
understood that the sunken soft spot
is caused by water loss from
diarrhoea.
In Ajoya, the boys and girls found
that most of their parents accepted
the idea of giving Special Drink to
children with diarrhoea.
2
What really shocked people.
however, was the result of the
children’s survey conducted as a
part of the Diarrhoea Activity. This
study showed that 70% of mothers
were bottle feeding their babies, and
that the bottle-fed babies in Ajoya
suffered from diarrhoea five times as
often as the breast-fed babjes!
Some of the mothers were so con
cerned that they staged a short play.
or “skit” entitled “The Importance
of Breast Feeding”. It was a great
success.
It is hard to say how much in
fluence the children's study and the
skit have had on the way the village
mothers feed
their babies.
Throughout Latin America, many
mothers have been changing from
breast feeding to bottle feeding, in
part because of advertising by pro
ducers of artificial milk. However,
we have talked to several mothers
who decided to breast feed their
babies as a result of the children’s
study and the women’s skit.
Apart from measurable results.
however, the cooperation, concern,
and fun that have come out of this
activity have made it enormously
worthwhile. What final effect it may
have on the children themselves,
when they grow up to become
parents and perhaps leaders in their
communities, we may never know.
TEACHERS
AND PUPILS
AS
HEALTH WORKERS
Dr. M.V. Joseph
PERSPECTIVE
It is well-known that schools are
easily accessible to health promo
tion; yet the vast majority of school
children in many countries are
neglected from the health point of
view due to constraints such as lack
of personnel and resources.
School Health Programmes are
often limited to a few favoured
schools in urban areas where
children are medically examined,
but with no follow-up action. A very
grave shortcoming of school health
systems in developing countries is
that they are, for the most part, illadapted Imports from developed
countries. Unfortunately, it is taken
for granted that the present system
takes care of the health problem of
school children. There is the con
ventional thinking that medical in
spection by the formally qualified is
a major requirement for health in
tervention of school children. This
idea, perpetuated by the profes
sionals themselves and others con
cerned, appears to create a bot
tleneck. Over and above this, the
disturbing sense about scarcity of
medical personnel due to the brain
drain, causes, what amounts not on
ly to grave implementational dif
ficulties but also a mental block
which prevents innovative thinking
and alternative course of action.
The task Involved in primary
health care of school children is not
merely examining children and fin
ding out cardiac murmurs and
similar defects or making sporadic
efforts in health education. It should
be an on-going intervention to tackle
the problem of common ailments
which results from infection,
parasitic
infestation
and
malnourishment. The charityoriented “delivery of health” which
is community oppressive, must give
way to an active learning of health
problems in the context of each
community and a striving and en
during effect on the part of teachers
and pupils to solve the problem with
emphasis on self-help. The influence
of such a course of action should be
lasting and should pass from the
child to the family and to the
community.
School teachers constitute a
resource of a high order, particular
ly in the developing world. The
highest concentration of educated
manpower is found in the educa
tional field. Of all the organJsed in
stitutions set up in a society, the
school tends to reach the maximum
number even in the under-privileged
rural communities. Teachers are
held in high esteem and they are
looked up to by the community. The
emerging role of teacher as
community-leader and change
agent makes him eminently suitable
in the role of health worker as well.
BACKGROUND
TO
THE
KANGAZHA PROGRAMME
Alms
This programme, ante-dating the
Alma Ata Declaration on Primary
Health, had aimed to make teachers
and pupils aware of:
o Primary Health Care;
© What it stands for; and
© What role they have to play in
it.
In addition to providing simple
and practical solutions to the healthrelated problems at school level, the
programme attempted to carry to
the community the message of
primary health care in such areas as
nutrition, parasitic and com
municable diseases, sanitation and
water safety.
Objectives
* Enabling teachers to identify and
treat common ailments so as to
reduce the morbidity in school
children.
☆ Enabling teachers to screen for
remedial disabilities and seek fur
ther help whenever required.
* Improving the hygiene standard
to acceptable levels and fostering
good practices.
★ Prevention of communicable
diseases by immunisation of
children and proper application of
quarantine regulations.
Promoting a healthy school en
vironment through participatory
action which lends itself to im
proved basic sanitation at the
family and community level.
Th® Philosophy
☆ Health care is not only everyone’s
right.
but
everyone’s
responsibility.
3
A THREE TIER ORGANIZATION
IN A DYNAMIC RELATIONSHIP
• School—1st tier
• Health Centre—2nd tier
• Base Hospital—3rd tier
The programme was im
plemented in several progressive
phases. The genesis and progress of
the programme is described
chronologically so that the reader
gets to know how it was evolved
over the years; how the community
participated in the exercise; how the
contemporary thinking affected the
strategies and what problems were
faced at each stage and how solu
tions were found.
THE PROGRAMME IN
PROGRESS
Phas« I—Toachera
Workers
(Year 1975-76)
A GROWING PROCESS OF
DE-PROFESSIONALIS ATION REDUCING THE COST OF CARE
★ Informed self-care should be the
main goal of any health pro
gramme or activity.
★ Teachers provided with clear
simple information, can prevent
and treat most common health
problems in their own schools
earlier, cheaper, and often better
than doctors can.
★ Medical knowledge should not be
the guarded secret of a select few,
but should be freely shared.
★ Basic health care should be en
couraged; not delivered.
Location
The programme area is rural,
situated in the hilly hinterlands of
central Kerala, South India. Thirty
schools with a total student strength
of 30,000 were selected for the im
plementation. With a long tradition
of school education and with the
State offering free education up to
secondary school stage, almost
every child tn the area attends
school. The drop-out rate at primary
class level is extremely low. The
adult literacy rate is as high as 95%
4
and teachers are held in high
esteem.
Commencement
The programme was started in
1975 after a preliminary dialogue
which commenced early in the year.
The idea of training teachers as
health-workers was discussed with
school communities. Although in
itially skeptical about its success,
the schools decided to co-operate on
a trial basis. It must be stated that
the idea of self-help was not fully
conceived at this stage.
The health problems in a few
selected schools were reviewed in
the context of training the teachers
and the tasks were defined and
analysed. A simple three-tiered ap
proach was adopted in which the
trained teacher had a Health Unit
established in each school, function
ing as the peripheral tier (i.e. 1st
Tier). The school units were later
linked to Primary Health Centres
where the teacher could refer pro
blem cases (2nd tier). The Base
Hospital (3rd tier) was responsible
for training and for referral services.
as
Health
The programme got off the mark
in mid 1975 with the training of 30
teachers from 10 selected schools.
The training was task-oriented and
the tasks identified at this stage
were:
• identification and treatment of
common ailments such as
scabies, skin sepsis, teniasis.
trachoma and conjunctivitis.
• identification and correction of
common nutritional deficien
cies such as deficiency of
Vitamin A and Iron.
• treatment of minor wounds
and Injuries and first aid for
emergencies.
• identification of children with
growth failure leading to
recognition of chronically ill
children.
• screening for defective vision.
• recognition of Infectious ill
nesses such as mumps,
chickenpox and application of
quarantine practices for
prevention of their spread.
• Fostering health habits in
children.
STEPS TO HEALTH
After the training, the trainees
made a report to the school council
and organised a Health Unit in each
school by acquiring the simple items
of drugs and equipment.
This was followed by a medical in
spection which was Intended as a
revision of the training. The im
munisation services were provided
by the external health team with the
teachers assisting.
The programme was well receiv
ed by the school community,
although it did not have a significant
Influence on the families. Teachers
did seem to enjoy their new role. A
major constraint was that of time in
volved in screening procedures and
maintenance of records.
Phase II—Pupils as Participants and
Beneficiaries
(Year 1976-77)
A new concept that emerged dur
ing this period was that pupils, for
whom the programme was meant,
should not be seen merely as
beneficiaries but should be con
sidered as participants as well.
Seventy-five pupils were initially
trained at the Base Hospital for the
participatory role. The aim of the
training was to ensure their par
ticipation in the following ways:
★ to assist the teacher in record
maintenance;
★ for daily appraisal and reporting
on the health of the pupils;
★ to assist teachers in screening
procedures (Vision. Charting of
Height and Weight);
★ to help the teacher to improve
school hygiene;
★ to create better awareness of
health and hygiene among the
pupils.
The review of the work at the end
of the year showed that the pro
gramme had developed more steam.
The pupils had taken an active role.
Routine screening programmes
could be done more effectively with
pupils’ help. The schools reported
improvement in attendance as an
outcome of the programme. This
was the result of the simple curative
services available at the school
which helped the children to attend
classes even when they had minor
ailments.
It was noted that when the
children had minor ailments, they
were encouraged by the parents to
go to school to avail themselves of
the curative facility at the School
Health Unit. A simple study on mor
bidity of common problems showed
a significant reduction. In course of
time, the parents showed better
understanding and awareness about
the programme.
The teachers had a refresher train
ing at the hospital with new inputs.
Simple laboratory tests such as
estimating haemoglobin, urine
analysis for sugar and albumin were
taught. They were also trained to do
stool-microscopy for identifying
common parasites. Even though
these skills had only limited prac
tical application, the teaching was
continued for subsequent batches as
it seemed to boost the trainees’ con
fidence significantly. A de-wormlng
drug (Piperazin citrate) was added to
the drug stock.
A second batch of teachers from
twelve primary schools was trained
at the request of the Government
and they were encouraged to imple
ment the programme in their
schools.
The number of teachers trained
was decided by the number of pupils
in each school. A ratio of one teacher
to 500 pupils was considered op
timal. With the widening of the field
and the increase in the number of
trainees, institutional training of
pupils at the Base Hospital was
found to be impractical. Hence the
teachers were oriented to developing
and training a batch of students on
their own.
Phase III—Teachers and Pupils Play
a Role in the Village Health
Programme
(Year 1977-78).
The year of the Alma Ata Declara
tion on primary health care gave
new strength and impetus to the
programme. This was because of the
realisation that the approach in
general terms was in tune with the
aspirations of the Conference and its
declarations.
During this period, a comprehen
sive village health and development
scheme was taking shape in the
areas around the schools. The
5
0
10
20
50
40
50
60
70
80 90
100
teachers and an Educational Officer.
The research panel met periodical
ly and discussed the issues in detail.
Necessary field trials were con
ducted by the participants. The pro
posal that trained teachers could
themselves be responsible for train
ing new teachers, was proved by ex
periment. This exercise highlighted
the need for a curriculum design. A
training manual was found to be a
necessity and the same is under
preparation.
Phase V—Teachers and Pupils in In
tegrated Development
CASES OF DISEASE REPORTED PER THOUSAND
STUDENT POPULATION
teachers who were Involved in the
School Health Programme helped to
initiate and animate the village
health movement and they par
ticipated in the village councils. The
school health network was
strengthened by including more
schools in the programme. The
pupils too helped in launching the
village health programme.
A seven-point action scheme for
pupils was formulated with the
following targets:
★ Get 10 under-fives Immunised.
★ Vit. A prophylaxis for 10 underfives.
★ Organise compost and soakage
pits for 5 houses.
★ Chlorinate 5 wells.
* Organise kitchen garden for 5
houses.
★ Give simple nutrition messages
to 10 families.
★ Give a simple lesson in dental
hygiene to 10 families.
The scheme was organised in the
form of a competition and most par
ticipants overshot the targets.
The participation by the pupils in
6
the Under-five Health Promotion
Programme outlined above, sensitis
ed the school children to the health
needs of their own younger brothers
or sisters. The CHILD-to-child con
cept was thus growing and it was
nurtured by the teachers who em
barked on various types of CHILDto-child activities suited to their con
text. Thus through the CHILD-tochild programme, a school-based
health programme was sought to be
extended to the family and the
community.
Phase IV—Towards More Self-Help
(Year 1979-80).
The programme was reviewed at
intervals. The reviews were meant
to identify problems and to find solu
tions. The second half-yearly review
brought up two basic issues:
★ whether the programme could be
extended on a large scale.
★ whether it was possible to
simplify the training and the
tasks.
For this study, a research panel
was formed consisting of eleven
The teachers and the pupils who
were initially the agents of change
in health have in the course of time
become agents for a total change.
While teachers have been the
backbone of the village council for
health and development, pupils
have become promoters of health
and development. This involvement
is expected to have a twofold advan
tage. In the first place, it strengthens
the community participation.
Secondly, it provides a training
ground for pupils’ informal educa
tion. community organisation.
methods of agriculture extension
and animal husbandry in addition to
community health promotion.
EVALUATION AND RESULTS
An evaluation spaced by an inter
val of five years revealed substantial
reduction in common ailments.
A nominee of the Voluntary
Health Association of India who par
ticipated in the evaluation, found
that several thousand school days
had been saved in addition to im
provement of health habits and
hygiene of the school. The overall
reduction in morbidity and correct
application of quarantine regula
tions. (The usual fault is to
overestimate quarantine periods).
The programme was found to be in
expensive, costing less than 1 Indian
rupee per student per year. The
evaluator found the programme
“simple and replicable".
It is strongly felt that an over
emphasised outside evaluation, bas
ed mainly on hard data and in
reference to short-term measurable
objectives, does not provide the
answers which are sought from a
programme like this. What is pro
bably more important than the fulfil
ment of short-term objectives is to
know how the programme has in
fluenced the long-range welfare of
the community; whether it genuine
ly encouraged responsibility and in
itiative. decision-making and selfreliance at the community level and
enhanced human dignity or
whether it actually encouraged
greater dependency and servility; in
other words, whether the pro
gramme has been community sup
portive or community oppressive.
Some Important and key aspects of
the programme are briefly discuss
ed below to highlight how and to
what extent the programme has
been community supportive, in
terms of this new Insight for which
we are thankful to David Werner.
Planning
Priorities
Decision-Making
and
The programme had flexible and
open-ended objectives. The only pre
planned aspect of the programme
was that it should be based on self
help and that the necessary
resources, including personnel.
should come from the community.
The responsibility or prioritisation
and decision-making was left to the
community and not imposed top
down.
Community Participation
The essence of the programme
was the intensive and resourceful
participation of teachers and pupils.
The outside agents only advised and
inspired. The community participa
tion was achieved through close
relationship and mutual trust. The
schools had the option to decide who
should be trained to work for them
and how he/she should work. The
teachers and pupils worked on a
completely voluntary basis without
financial or other incentives.
Training
The training of teachers included
scientific approaches to problem
solving. Initiative and thinking were
encouraged at all stages. The
teachers were provided information
and books to increase knowledge on
their own and were allowed to share
the knowledge and skill freely with
their colleagues. The teachers were
encouraged to train teachers from
other schools aimed at self
propagation of the programme.
Financing and Supplies
The financing and resources were
largely from the community. The
cost of the programme was kept as
low as possible, through effective deprofessionalisation. The decision
regarding income and expenditure
and resource generation was com
pletely decentralised, each school
devising its own method.
A GROWING PROCESS OF DEPROFESSIONALISATION REDUCING
THE COST OF CARE.
Phase V—teachers, pupils
Phase IV—teachers, pupils
Phase III—teachers, pupils, health
workers
Phase II—teachers, pupils, doctors.
specialists
Phase
I —teachers,
nurses.
paramedicals, doctors, specialists.
The programme was open to
growth and improvement. Newer
approaches and improvements were
made at various stages. Provisions
were made for teachers to try out
alternative strategies with prospects
for wider application if the new idea
worked. The teachers continued to
learn about health. They took pride
in what they did and served one of
the felt needs of lhe community.
They stimulated initiative and a
sense of responsibility in others.
CONCLUSION
Evaluation
Involvement
Towards
Greater
“For a long time health experts
have been pushing for more preven
tive medicine at the village level and
with good reasons. But too often this
has been used as a convenient ex
cuse to keep curative medicine com
pletely or almost completely in pro
fessional hands”, David Werner
writes. This is very true in the con
ventional health programmes.
The over-emphasis on safety in
hibits the lesser skilled rendering
curative service. It also jeopardises
their credibility and in turn.
adversely affects the effectiveness of
preventive and promolive health
service. In this programme, the
scope of curative service was deter
mined realistically, and in response
to community needs. Factors such
as distance from health centres, lhe
non-availabilny of immediate
medical aid, were sought to be over
come by proportionally strengthen
ing the school writs. The limits
defining what a teacher should do
were determined by the knowledge
and skill which was being constant
ly fostered and encouraged. An in
teresting
degree
of
deprofcssionalisation
and
de
institutionalisation was achieved.
What is borne out by this ex
perience is that school teachers form
a great resource for primary health
care at the school level which lies
dormant for the most part and ii is
possible to tap this resource.
Whether it is possible to mobilise
this potential by a “top-down” ap
proach is not known; but it certain
ly is possible through a community
supportive approach as was adopted
in this programme.
The process of involving teachers
and especially pupils, at their im
pressionable age, in the health and
welfare of the school, lhe family and
community, promotes community
self-reliance in health.
The School-based Health Pro
gramme with the participation of
teacher and pupil can thus be the
Second Front in the health develop
ment of a community.
We conclude with a quotation
from Dr. Albert Schweitzer and
relating it to our present context:
“Each patient carries his own doc
tor within him... We are at our best
when we give the doctor who resides
within each patient a chance to go
to work”. Each human being, even
a child, has the potential to be a
health worker: we will be at our best
if we give him a chance.
7
WHY
SCHOOL HEALTH
AND HOW?
WHY SCHOOL HEALTH AND
HOW ?
★ School health is not regular
medical check ups of students.
★ School health is not mid-day
meals.
★ School health is not physical
education.
★ School health is not giving vac
cinations in the school campus.
★ School health is not an intellec
tual exercise in health planning
at the central and state levels,
and wishful thinking and a seem
ingly unrealistic dream by those
involved with rural schools.
WHAT IS SCHOOL HEALTH?
It is a part of community health
programme through which com
prehensive care of the health and
well being of children throughout
the school years is taken care of. The
school health service is an
economical and powerful means of
raising the health of the com
munities. It is a personal health ser
vice. It has grown from the narrow
concept of medical examination of
children to the more comprehensive
care of health and well being of
school-going children. Today, school
health programmes stress the role of
the child as a "change-agent” for the
community. A child has greater
capacity to observe, learn, experi
ment and then transfer knowledge
to others. She is more prone to a new
way of life, and changes come to her
more naturally. A physically, social
ly and mentally healthy child can
best learn whatever is taught in the
school. In some countries, like in
England, the school health pro
gramme is taken care of by the
Ministry of Education whereas we
leave it to the health planner who
has to plan school health program
mes. This therefore has been
nothing more than periodic medical
examinations of the' school-going
child, with very little or no follow-up
activities. At times, children have to
waste many school hours waiting in
line for the treatment of a few minor
ailments detected at the school
medical examination. The whole
programme does not involve the
teachers, parents and the child who
should be the focus of the
programme.
The responsibility of the com
munity is to see that the child is ful
ly developed and that health care
becomes a responsibility of school
authorities.
Scientific evidence clearly shows
that the health of a child is a good
indicator for determining school per
formance and achievement. Early
malnutrition or poor nutritional
status among school children has
significant adverse effects on school
progress. Schooling as an instru
ment of Individual and social
change, has been well recognised all
over. A comprehensive school
health programme and an educa
tional programme are both defined
as having the same objectives i.e.
the growth and development of the
child in all its components—social,
physical, mental and economic.
OBJECTIVES OF A SCHOOL
HEALTH PROGRAMME
★ Promotion of positive health:
★ Prevention of disease:
school. Plan and supervise a pro
gramme of safety promotion.
★ Provide means for building up a
better relationship among
students and faculty, and among
all other school personnel.
★ Assume responsibility for a
healthy and educational school
meal programme if one exists.
★ Using all available resources, set
up a complete health education
programme.
★ Obtain instructional material for
teaching staff.
★ Arrange necessary in-service
health preparation of the
teaching staff.
★ Assume responsibility for evalua
tion of health instruction
programme.
Stop 2
★ Health conscientisation among
school children;
★ Providing healthful learnings in a
healthy environment:
★ Recognising the child as a
“change-agent” in the family.
HOW TO START A SCHOOL
HEALTH PROGRAMME
Step I
Organise the principals of the
schools—involve them and make
them realise the importance of
School Health Programmes in their
area. They are the pivot of the pro
gramme and around them the
teachers revolve. If the principal
cannot see the point, the school
health programme cannot progress.
If he also acts as a catalyst between
education authorities and health
authorities, he helps in the progress
of general health and development
of the community.
Role of a Principal
★ Assume the role of co-ordinator
between the school, the home.
and the individuals and agencies
in the community that can con
tribute to the health of the child.
★ Exercise direct supervision over
the school health programme.
★ Demonstrate healthy inter
personal relationships with other
principals, and school staff.
★ Plan with staff the educational se
quences in accordance with prin
ciples of learning and individual's
ability, to ensure that students
take curricular tasks in a
challenging manner.
★ Provide situations to encourage
experimentation by students and
appreciate achievements in front
of others.
★ Supervise food sanitation prac
tices when food is procured,
stored, prepared and distributed
in the school.
* Plan community health educa
tion activities and campaigns
through students to educate the
community about common and
immediate health problems. En
courage them to take remedial
and preventive measures. Co
ordinate with local health person
nel for their support in the
programme.
* Provide for on-going evaluation
and improvement of the School
Health Programme.
* Ensure adequate physical
facilities in schools for satisfying
the health needs of school
children viz. safe water for drink
ing. sewage disposal facility.
waste disposal arrangement, ade
quate toilet facilities, classroom
and playroom lighting and
ventilation.
☆ Assume responsibility for all fac
tors related to safety in the
Role of the Teacher
Teachers are where the schools
are. and they are a rich local
resource. They are available in large
numbers, present even in remotest
areas.
They are best equipped to under
take the task of health education.
their educational background and
skills befit them for this work.
They
have
considerable
acceptability—personal as well as of
what they teach—with pupils and
their parents and through them.
with the community. Most teachers
are natives of the region and know
the beliefs and customs. Convincing
them to change those affecting
health will be an example for the
community.
They have social status in the
community and faith of the people.
good support from voluntary agen
cies. Government and
the
community.
Involvement of teacherb in the
health programme is consistent
with the overall philosophy of
developing nations to maximally
utilise locally available resources.
Teacher knows the customary
behaviour; therefore can pick any
deviations. A good teacher
understands students’ physical.
social and emotional needs more
than outside health personnel.
Teachers can observe:
9
PLANNING PROCESS OF SCHOOL HEALTH PROGRAMME
Again
Gather Health
Tabulate
Redefine the
Datai ----------------- ► Analyse-------- ► Objectives
Compare
1
1
Evaluate the
Results
Operate the
Programme
Implement the
/ Activities Step
by Step
★ pupils’ eating, study, health and
play habits;
★ their attendance;
★ their growth chart;
* their scholastic record and any
discrepancy between capacity
and performance.
Health education helps the
teacher in developing and maintain
ing his own health; objective con
sideration of existing prejudices and
superstitions about health are made.
The Principle Objectives in Teacher
Preparation for Health Education Ac
cording to WHO/ UNESCO Expert
Committee—are to develop:
• a standard of personal health
practices which will help
maintain the health of the in
dividual and serve as an exam
ple to the pupils;
• understanding and developing
skills in maintaining an op
tional emotional environment
through desirable interper
sonal relations;
• an appreciation of the value,
importance and place of
education in health, as a part
of the
total
education
programme;
• a willingness to play an ap
propriate part in the promo
tion of health in school and in
the community:
• an adequate background of
professional knowledge about
child growth, development,
personal and community
health, and programmes and
procedure in school health;
• understanding and apprecia
tion of a healthy physical en10
'
Gather Health Data In Schools
4
Define Programme Objectives
|
Design the activities to meet
these objectives|
1- Organise the principle and
advice to them.
2. Teachers Training
3. Student Health Education
Centre
4. CHILD-to-Child activities
in schools
5. CHILD-to-famlly activities
6. CHILD-to-day care centre activities
vlronment and how it is
maintained;
• skill in promoting health
education and in working co
operatively with others in this
sphere;
• a knowledge of community
health and social agencies and
the ways in which the teacher
may work effectively with
them and with the home.
Preparation in health education
helps the teacher to meet the expec
tations of society. She will help
develop attitudes, habits and
knowledge in the field of health
which are needed by the younger
generation.
Training also makes the teacher
aware of her own health re
quirements and she learns how to
meet them.
★ it helps the teacher understand
the child psychologically;
★ it helps the teacher work more ef
fectively with the other members
of the school staff and contribute
more to the community;
★ the teacher understands the
health problems of children and
can collaborate with the home
more effectively;
★ it helps the teacher realise that
even though knowledge of fun
damental health facts is essential
for any positive change in health
behaviour, mere imparting of
knowledge cannot be expected to
do so.
Behaviour is more important than
either knowledge or elusive attitude
because without action the thought
is unimportant. Hence a trained
teacher’s approach is “behaviour
oriented” rather than “knowledge
oriented”.
No one is better equipped than an
observant trained teacher who can
observe and encourage good health
behaviour and can check unhealthy
behaviour.
Changing Role of Teacher
*
Past Role
★ Teaching facts and techniques.
★ Preparing child
to
pass
examinations.
★ Teaching a curriculum irrelevant
and divorced from life’s needs and
aspirations of the community.
★ Being indifferent to the place of
school in the community.
New Role
★ Transmitting a capacity to han
dle facts, to know where and how
to find them and what to do with
them.
★ Preparing the child for life-long
learning.
★ Stimulating the child to identify
himsclf/herself with the environ
ment and awakening in him/her
a loving concern to take care of it.
★ Implementing a curriculum rele
vant and related to life, needs and
aspirations of the community.
★ Taking loving care to make the
school an integral part of the
community and a centre of
* life,
learning, beauty and harmony.
★ Devising and implementing ac
tion oriented health activities for
children.
Step 3
Training—The training could be
more meaningful and effective if
local health problems are studied.
Community Health Surveys could
be carried out to find out the health
situation involving the children. The
programme must focus on meeting
the health needs of the community.
A short course of eight to ten days
covering the following subjects,
must be organised in each area:
★ Alms and objectives of School
Health Programme—planning
and evaluation;
★ Teacher’s role in School Health
Programme;
★ Growth monitoring;
★ Screening for defective vision,
hearing defects and behavioural
problems;
★ Identification
of common
ailments;
★ Prevention of common com
municable diseases:
★ Oral and dental hygiene:
★ First Aid in schools;
★ Food and nutrition:
★ Role of home remedies;
★ Development and use of health
education media.
This curriculum can be modified
to meet local needs. Reviews and
follow-up training will also be
necessary.
The Health Committee
Form a co-ordinating Health Com
mittee consisting of principal,
teachers, parents and school
children in each school. This com
mittee takes full responsibility for
the school health programme and
the day-to-day activities in relation
to health of the children in school.
Step 4
Materials, Equipment and Sup
plies may be procured from various
Resource Centres (Page 15.) School
Health fund can be built to maintain
Resources.
Step 5
Implement and Evaluate
The effective implementation of
the School Health Programme can
be possible only if the children's
potential is utilised properly.
Learning is better through ac
tivities and as such children should
be involved in health activities. In
this way they act as change agents
in the family and the community.
The child will become the best pro
vider of primary health care to socie
ty in years to come.
Children can be involved in:
★ keeping themselves, their
classroom and school clean;
★ health
exhibitions
and
competitions;
★ making their own midday meal
menu within the resources
provided;
★ forming health clubs for healthful
living and learning, like organis
ing health surveys, clean-up
campaigns.
★ making health educational
materials like posters, songs,
stories, plays, games etc.
Close co-ordination and regular
field visits to School Health Units is
necessary to facilitate programme
functioning.
This
includes
maintenance of records, adequacy of
supplies, keeping in touch with
resource persons and material, to
fulfill local needs.
Progress of the School Health and
health education activities can be
assessed
using
measurable
objectives.
An ongoing yearly evaluation of
the programme can be undertaken
with the participation of teachers
and children. Decrease in the in
cidence of communicable illness will
indicate hygenic level of school
children. Effectiveness of health
education can be evaluated by
assessing through quizes, competi
tions etc. The expected outcome of
health education in terms of
changes in behaviour can be defin
ed and spelled out as objectives e.g.
50 per cent children will be keeping
nails clean at the end of one year. In
an evaluation one can determine
how many have adopted this
behaviour in actual practice.
VHAi'S ROLE
HEALTH
IN
SCHOOL
The school health vision at VHAI
calls for the:
★ initiation of innovative, need
based. relevant school health pro
grammes as an integral part of
community health;
★ promotion of appropriate plann
ing. implementation and evalua
tion of programmes through
training programmes at regional
levels:
★ propagation of action-oriented
health programmes involving
children and thereby members of
the community:
★ dissemination and preparation of
relevant resource materials that
envisage school health as an im
portant alternative education
strategy.
Our training programmes are
geared towards creating in educa
tional and community development
personnel, a commitment to under
take activities and projects in rele
vant need-based areas and to bring
about a greater collaboration and
cooperation among them. Our train
ing workshops cover a wide range of
objectives in response to communi
ty needs.
For the school going child.
creating a deeper health con
sciousness has been encouraged by
VHAI through School Health
Essay/Poster competitions.
The school health programme can
reach out to the minds of young
11
children with a message about how
their lives can be healthy, more
meaningful and happier. If the
lesson is clear, specific and convin
cing, the children will take off from
there.
HOW DID THEY RESPOND?
Learning experiences on health
can be easily personalised for
children and linked up with real life
situations and events. This leads to
explorations
outside
the
classroom—through information
media, or even action In their own
communities.
The use of available media, when
encouraged and allowed to progress
to self-expressional activities, are
truly unique. Above all, it is essen
tial not to under-estimate confidence
in the child’s ability to understand
and assimilate the most difficult
subject matter. This is achieved not
through the cold provision of pour
ing down of information or struc
tured instructions, but helping the
child step up the path through
discovery and creation, to learn in
an unthreatening way about disease
and how health care facilities exist
and can be harnessed to serve the
community.
Vasudevan
3rd
Class IX
prize
Govt. Kallupatti High
School, Tamil Nadu
Bhavsar Pragnesh A.
Special
Class IX
prize
Municipal High School.
Dehgam Dt.
Gujarat
M. Murugam
Special
Class VII
prize
Ganguvarpatti Middle
School
Periakulam,
Tamil Nadu
Some comments from the projects
who did the initial screening:
★ children from the middle and
high schools responded more en
thusiastically and meaningfully;
★ although many schools could
understand the message, not too
many children could suggest con
crete ways for improving their
health;
★ some paintings were found total
ly Irrelevant. The reason could be
the inadequate time and Inputs in
the children, and a lack of
understanding of the Importance
of dynamic and effective teacher
child relationship:
★ there is a strong feeling that such
programmes should be arranged
regularly to make school children
aware about the Important
aspects of health.
VHAI'S ESSAY COMPETITION
ON HEALTH
The prize-winning entry by Manjari
Kashyap, Class VIII, Mount Carmel
High School. Narrangpuram.
Ahmedabad, appears on p. 13.
SOME POEMS ON HEALTH
The insights of two 13-year olds
from a group of young enthusiasts
who were allowed to discuss, ques
tion and express their newly found
learning experiences on T.B.
VHAI'S SCHOOL HEALTH
PAINTING COMPETITION
The competition was conducted
regionally. We received 126 entries
from different parts of the country.
The theme was ‘‘What School
children can do to Improve their
own health and that of their village
people”.
Selections were made on the
understanding of the theme, presen
tation of the idea, which should in
corporate practical ways of improv
ing the health of the village
community.
*
Prix
Winners:
Shamshah Ibrahim
Class V
Hiralal Shah Kanya
Vidyalaya
Benani Kruti Vinod Bhal
Class X
Best High School
Ahmedabad
12
1st
prize
2nd
prize
Shamshah Ibrahim, Class V, 1st Prize.
"TUBERCULOSIS
Oft in the silly night
Ere slumber's chain has bound me
Fond memory brings the light
Of other days around me.
The smiles, the tears, of boyhood years
The word of love that was spoken
The eyes that shone
Now dimmed and gone
The cheerful hearts now broken.
—Mohina Duggal,
VIII ‘B’
"AWFUL TUBERCULOSIS"
“You are old, tuberculosis”, the young man said,
And you have a fearful spite which has become wide;
And yet you incessantly stand on our heads;
Do you think this is right?
“You are old”, the poor man said, “as I mentioned before,
And have made many people suffer from that.
I feared it might kill the patients, if vaccinations wouldn't have been,
But now I am perfectly sure that none could die.
“Why do you do it again and again?
Causing pain at the back and in the front;
Which the sufferers can hardly stand;
Yet you finshed the people, those awful cries.
“Tell me, how did you manage to do that:?
Don't you have love for mankind? Don't you take rest?
Tell me what makes you so awfully bad?
“Your are old, tuberculosis”, the young man said.
—Anita Khokhar
VIII ,B'
MODELS DEVELOPED
CHILDREN
BY
Internalisation of health education
messages resulted in the children
making these models. The enthusiam and conviction, which is at
the heart of making these models,
makes them one of the best methods
of communicating convincingly
about health. It encourages mean
ingful parent-teacher relationships
with the child as the focus.
Produced by rhe children of St. Paul's High School, New Delhi.
OUR HEALTH AND THAT OF OUR VILLAGERS:
KOLE OF CHILDREN
An essoy by Manjari Kashyap
In anyone’s life, good health is
considered an attribute of prime im
portance. A life without good health
can be a life without fun, and a
burden. Good health is not merely
a God-given gift but is also due to
self-discipline. The foundations of
good health are laid in the childhood
itself.
What can we do to Improve our
health? It is common knowledge
that regular exercise, nourishing
food and clean environment are
essential. For maintaining good
health we do not have to depend on
others. It is a matter of self discipline.
Regular exercises help in the
maintenance of body. We can
choose different exercises depen
ding on our aptitude. Different stret
ching exercises or participating in
games or cycling or Jogging or tak
ing long walks or a combination of
various exercises can be done.
Above all, it is very important that
we are regular in whatever we do.
Children mainly depend on their
parents for their food. It is true that
the type of food is governed accor
ding to the family Income. However,
it is not essential that nourishing
food is food that costs more than any
other food. Seasonal fruits and
vegetables do not cost much and are
good for health. Groundnuts are as
nutritious as almonds and bananas
are as good as apples. Eggs are a
cheaper source of protein than milk.
It is essential that the food which we
eat should be recognised. We should
learn which elements are present in
them. Eatables should be cooked in
a way that the essential elements
are not destroyed. Children can help
by educating the people and bring
13
ing all this to the notice of the Ig
norant people.
Clean environment depends on
the consciousness of the people. We
live in filthy areas. Merely keeping
our houses clean won’t d,o. In big
cities, due to the factories and
crowding of too many people in a
small space, there is pollution. The
reason for this is that people from
the villages come to the big cities in
search of Jobs. When they do so,
they are not provided by proper
dwellings. Moreover, the rural way
of waste disposal is ill-suited for the
urban areas.
Thus, we can see that the health
of the urban areas is linked with that
of the rural areas. Further, we can
see that many infants die due to the
ignorance of the illiterate children
and the educated should persuade
the people to get Inoculated against
T.B., tetanus, and whooping cough
at the right age.
To decrease the source of pollu
tion such conditions must be
created in the villages that not only
Jobs but even extension of educa
tional and health facilities are pro
vided. This would help the villagers.
and less of them would flock to big
cities. Mere advice is not enough!
Children should contribute labour in
the building of health and educa
tional institutions.
We have seen that most of our
diseases occur due to the lack of
clean drinking water. For this.
Alteration can be done so that the
water may be free from dirt and
germs which cause disease. Simple
chemicals may also be used for puri
fying the water. Above all we must
make use of modem procedures for
recycling wastes such as the gobar
gas plant. This type of project in the
villages can help the villages to be
kept clean. Manure is also produc
ed. Above all. we can produce
much-needed electricity. Children
can help a great deal In the upllftment of the rural areas. They can
send messages of cleanliness.
With our efforts we shall make the
villages healthy and as a result we
may find urban dwellers being at
tracted towards the clean villages for
fresh air and clean food! Also with
the children contributing substan
tially we shall have a new environ
ment and a healthy society.
EDUCATIONAL GAMES
EDUCATIONAL GAMES can be fun to play, and al the same time teach about important health
messages and practices. With creativity and imagination, commonly-played games can be adapted
to teach about health. New games can be invented in the form of board games, card games, puzzles,
action games and many, many more.
GUIDELINES
*
★
★
14
Create games which emphasise gaining knowledge, practices and skills for better health, rather than win
ning or losing. Educational games should be more than a game of luck or chance. The most
realistic and effective games will help students to practice working together to overcome nutri
tion and health problems. Games which provide opportunities for students to think, decide and
act will have greater impact than those which merely present information.
Adapt educational games to specific teaching-learning situations. Be sure that the messages and infor
mation used in games are suitable to local conditions, and are in keeping with the cultural
background of the students.
Involve students in the creation of educational games. By taking part in making up the games they
play, students will have a more thorough knowledge of the messages presented in the games,
and be more likely to continue to discuss these messages.
RESOURCE MATERIAL
AND
INSTITUTIONS
AHRTAG
AROGYA DAKSHATA MANDAL
—
—
Newsletter
(diarrhoea),
Teaching Aids. Contact at:
AHRTAG
18th Marylbourne High Street
W1M 3DE,
England (U.K.)
AKAP
—
Booklets, materials on T.B. and
other common
diseases,
medicinal plants, acupressure,
sociopolitical analysis. Contact
at:
AKAP
66, J.P. Rizal Street
Project 4. Quezon City
PHILIPPINES
for science experiments, model
lessons,
stories,
‘Silver
Oak'newletter and curriculum
changes and activities. For
details, contact:
Dr. A.R. Patwardhan,
1913, Sadashlv Peth
Pune 411 030.
DEENA SEVA SANGHA
—
ENI COMMUNICATION CENTRE
CHEB
—
—
posters and health education
material. For details contact:
Dr. H.C. Aggarwal,
Central Health Education
Bureau.
2 Kotla Road,
Temple Lane,
New Delhi-110 002
‘Defender Newsletter’ with ideas
for health education methods,
books, Rural health series. Con
tact at:
AMREF
Box 30125, Nairobi,
KENYA
—
CHETNA
—
ANKUR
—
Non-formal education. Details
from:
B-41, Nizamuddln East,
New Delhi-110 013
AP VHA
—
School Health Mirror. For
details contact:
Mr. D. Rayanna,
10-3-311/7/2
Vijayanagar
Colony.
Hyderabad-500 457
for activity sheets on CHILD-tochild. For further details
contact:
Ms. Minakshi Shukla/Indu
Kapoor
Drive-in-Cinema Building,
2nd floor, ThaltcJ Road.
Ahmedabad 380 054.
CHRISTIAN
VELLORE
—
MEDICAL
COLLEGE,
for
health
educational
materials, and Information
about RUHSA school health
programmes and school cur
ricula. For details contact:
AV dept
Christian Medical College
Hospital
Vellore.
Education packages and visual
aids about child health and
nutrition. Contact:
ENI Communication Centre
Box 2361, Addis Ababa
ETHIOPIA.
INSTITUTE OF CHILD HEALTH
AMREF
—
ongoing school health pro
gramme. Contact:
Director
Deena Sewa Sangha
Sewa Ashram, 5th Main Road,
Sriramapuram
Bangalore-560 021
CHILD-to-child readers, hand
books, activity sheets, newslet
ters. health education material
including TALC slides. Contact:
Dr. David Morley
30 Guilford Street,
London WC1N 1EH,
U.K.
KSSP
—
for information on non-formal
methods of communication. For
details contact:
Dr. Ekbal,
Kerala
Shastra
Sahitya
Parishad,
Parishad Bhavan,
Trivandrum 685 037
MGDM
— school health programmes.
teachers’ training programmes,
dental health. For details
15
contact:
Dr. T. Abraham,
MGDM Hospital, Kangazha.
PO Devaglri,
Kerala 686 555.
—
M.S. UNIVERSITY, BARODA
—
health education materials and
CHILD-to-chlld activities. For
details contact:
Dr. A. Chandra,
Reader, Dept of Education
Extension.
Faculty of Home Science,
M.S.U. Baroda.
ongoing school health program
mes. For details contact:
Coordinator, School Health
Programme,
Fr. Muller’s Hospital.
Kakanady,
Mangalore 575 002.
—
for board and card games,
books, booklets, pamphlets,
stories, songs: contact;
Dr. R. Murlidharan,
Ms. Glrija Mohammed Miyan,
Dept, of Preschool and Elemen
tary Education,
New Delhi-110 016.
—
16
for school health programmes,
nutrition education, games,
readers, posters, and other
health education materials,
training programmes for
teachers, teachers’ guides. For
details contact:
1. Dr. Rajammal P. Devadas,
Sri Avlnashalingam Home
Science College,
Coimbatore 641 043
2. School Health Cell,
Institute of Child Health,
Madras.
3. Mrs. Jayaprabha Patel,
Director, Head, Dept of
Food & Nutrition,
Faculty of Home Science,
M.S.U. Baroda.
4. Dr. S. BajaJ,
Director, NHEES Centre
College of Home Science,
PAV, Ludhiana. Punjab.
OF
THE
for activities and lesson plans
based on nutrition for children.
Contact:
Nutrition Centre of the
Phillipplnes
Nichols Interchange,
Makati, Metro Manila.
Phillipplnes
INSTITUTE
OF
for health education materials.
Contact:
NIN, Indian Council of Medical
Research,
Hyderabad.
—
—
“A handbook for Nutrition
Trainers
of
Anganwadi
Workers” and other books on
health education. Contact:
Department of Nutrition
Education.
National Institute for Public
Cooperation
&
Child
Development,
5, Slrl Institutional Area, Hauz
Khas.
New Delhl-110 016.
UNREACHED OF
ongoing school health pro
gramme; Contact:
Fr. James Kimpton.
Boys’ Village,
Ganguvarpatti,
Tk. Periyakulam-624 203
(T.N.).
RUTH HARNAR, LYNN AND AMY
ZELMER
—
Manual of Learning Exercises
for use in health training pro
grammes in India. Available
with VHAI.
SEARCH
NIPCCD
—
ongoing school health pro
gramme. Contact:
Health Coordinator,
Raigarh Ambikapur Health
Association
Bishops House,
Kunkuri,
Dist. Raigarh-496 225 (M.P.)
REACHING THE
VILLAGE INDIA
—
NHEES
—
CENTRE
NATIONAL
NUTRITION
NCERT
—
consultation for planning school
health programmes. Contact:
Dr. A.S. Narayanan
School Health Services.
Institute of Child Health,
Nlloufer Hospital,
Hyderabad.
NUTRITION
PHILIPPINES
FR. MULLER S HOSPITAL
—
RAHA
NILOUFER HOSPITAL
games, kits on health, environ
ment. social awareness, comics.
Contact:
Director,
SEARCH
256, First Block
Jayanagar,
Bangalore 560 Oil.
ST. JOHN’S MEDICAL COLLEGE
—
tranlng
programmes
for
teachers. Contact:
Mr. Subramanaya Shetty.
St. John’s Medical College,
Bangalore-560 034.
PARISAR ASHA
—
teacher training courses, media
aids bank, consultancy services,
research and development,
teacher’s guidelines, children’s
reference books, and other infor
mation on environmental
education. Contact:
Gloria de’ Souza
Environmental
Education
Centre
C/o St. Xavier’s Institute of
Education,
40 A, New Marine Lines.
Bombay-400 020
DR. UMA
—
for health education games and
other materials. Contact:
51/2 Lavelle Raod,
Bangalore-560 001.
UNESCO
—
“Mobilizing Education for
Primary Health Care’’—this
book emphasises the Important
role of the teacher and the child
In health care, and covers the
work done In this by some of the
most effective programmes in
the world. "Nutrition Education
Series"—this series explores
various methods of education in
nutrition: Issues 9 and 10 cover
teaching aids—how to make
them and how to use them effec
tively. Contact:
UNESCO Nutrition Education
Programme,
Division of Science, Technical &
Vocational Education,
UNESCO,
Paris
FRANCE.
UNICEF
—
materials on various aspects of
health, nutrition and environ
ment. Contact:
Information Section
UNICEF
73 Lodi Estate,
New Delhi-110 023 or
their regional offices.
VHAI
—
card and board games, teacher
training programmes, planning
and evaluation of school health
programmes, and other health
education material. Contact:
Ms. Christina de Sa
C-14, Community Centre.
Safdarjung Development Area,
New Delhi-110 016.
VIKRAM A. SARABHAI COMMUNI
TY SCIENCE CENTRE
—
games and other material on
health for children. Contact:
Prof. L.S.P. Rao,
ENACE,
Vikram Sarabhai Community
Science Center,
Navarangapura,
Ahmedabad-380 009.
KERALA VOLUNTARY
SERVICES
HEALTH
'School Arogyadarshini’ —
School Health Bulletin, training
programmes. Contact:
Mr. Jose Varghese,
Kerala Voluntary Health
Services
Rajagiri College of Social
Sciences
Rajagiri P.O.
Kalamassery
Kerala 683 104
WERNER DAVID
—
‘Where There Is No Doctor' and
"Helping Health Workers
Learn"—two manuals that com
plement each other on various
aspects and methods of health
communication, with special
emphasis on the child as a
health worker; slides on CH1LDto-chlld activities in Ajoya,
"Where There Is No Dentist"—a
manual on village dented care;
(All materials available with
VHAI,) Contact:
David Werner
HESPERIAN FOUNDATION
Box 1692, PALO ALTO
CA 94302 U.S.A
WHO
—
health education materials.
Contact:
Information Section.
World Health Organization.
Indraprastha Estate
New Delhi.
WORLD NEIGHBOURS
—
‘Soundings' a newsletter on
rural development communica
tion. filmstrips, teaching aids.
Contact:
5116 North Portland
Okhlahoma City
OK 73112 U.S.A.
YAYASAN INDONESIA GEJAHTERA
—
VIBRO newsletter, training
material. Contact:
The Director
Yayasan Indonesia Sejahtera
Central Java Republic
Jalon Kenanga 163,
Solo,
INDONESIA.
17
TEACHING
HEALTH
TO PRIMARY SCHOOL
CHILDREN
Dr. P.S. Swaminathan
Dr. MJ. Ravindranathan
Dr. R. Abel
INTRODUCTION
In the last few years, it has been
increasingly realised that teaching
school children about the relevance
of maintaining good health and
sanitation is an important objective
of school education. Several con
certed efforts in health education
have been made by a few national
institutes and individual voluntary
organisations to design and experi
ment with programmes which will
ensure basic knowledge, attitudes,
values and skills in children to lead
a healthy life and solve health pro
blems of the family and the com
munity at large. Many of them have
been successful in their attempts.
Rural Unit for Health and Social Af
fairs (RUHSA)
*
is attempting to in
stitutionalise health education at
school level in the K.V. Kuppam
block of North Arcot District, Tamil
Nadu. India.
PROGRAMME
IMPLEMENTATION:
The main objective of the pro
gramme was to develop health con
sciousness in the school going
children of K.V. Kuppam block and.
through them, to disseminate health
• Rural Unit for Health and Social Affairs
is a Department of the Christian Medical
College and Hospital, Vellore, South In
dia, and works with a population of one
lakh in K.V. Kuppam block, North Arcot
District, Tamil Nadu.
18
messages to the community. This
was to be done through teaching
health as a regular subject in the
schools and training teachers for the
same. RUHSA, a voluntary
organisation involved in health and
development activities, initiated this
programme as a pilot study in the
year 1979 during the International
Year of the Child. With the ex
perience gained from the pilot study.
instructional materials such as core
syllabus, guide books for teachers
and A.V. aids in health were
developed for students of classes VI.
VII and VIII of primary education.
Co-operation was sought from the
Government departments to imple
ment the programme in a few
selected schools of the block on an
experimental basis during moral in
struction periods. To equip teachers
in these schools with knowledge and
skills needed for the effective im
plementation of the programme, an
orientation course was organised in
the year 1980-81. This orientation
course was organised in batches.
and teachers from other schools in
the block were also invited to
participate.
The programme is being
systematically implemented in
eleven selected schools of the block
from the academic year 1982-83.
RUHSA has completed two years
with this programme after fully
systematising the curriculum and
teaching methodology, and the third
year is in progress.
So far, a total of nearly 10.000
pupils have been exposed to con
cepts and practices in health and
120 teachers have been trained.
Besides providing instructional
materials and latest knowledge on
health to teacher^ and ad
ministrators in these schools,
RUHSA also carries out the follow
ing activities in collaboration with
them to regularise the programme:
★ Visiting schools regularly, to
know the progress of the pro
gramme, to understand and solve
problems faced by teachers in the
effective implementation of the
programme;
★ Bringing out Health Newsletter
(Tamil monthly) for teachers,
children and government officials
to apprise them about latest con
cepts in health and health
practices;
★ Organising refresher courses for
teachers on teaching of health;
★ Helping teachers to organise
health councils in the schools;
★ Supplying first aid kits;
★ Carrying out vitamin A deficien
cy campaigns to identify Bitotspot cases and following them up,
etc.
PROGRAMME EVALUATION
As part of RUHSA's regular inter
nal evaluation, this programme was
assessed for its effectiveness in the
year 1984. The following criteria
were considered for evaluation.
a) Students' performance on
achievement tests
o knowledge
o comprehension
o application
b) Students' behavioural changes
as perceived by
o students themselves
o teachers
o parents/siblings
c) Students’ and teachers' reac
tions towards the course and the
teaching methodology.
d) Teachers’ impressions about
the orientation programme and
refresher courses organised.
The overall research design
followed for studying the effec
tiveness of the programme was of
the type ex-postfacto analysis in
terspersed with multistage sampling
techinque. The Instruments used for
collecting evidences included
achievement tests, school records
and Interview schedules. Statistical
techniques such as percentages,
percentiles, mean and S.D.'s were
used to treat the data.
PROGRAMME EFFECTIVENESS
The programme has been found
effective in terms of
* imparting basic understanding
about health and its related prac
tices in school children.
* inculcating healthy habits in
children like regularly taking
bath and combing hair, brushing
teeth with tooth powder and not
with brick powder, charcoal
powder, ash etc, covering food
stuffs whenever they are kept ex
posed, wearing clean and tidy
clothes etc.
* in developing certain attributes
such as attitudes, interests and
readiness in children for receiving
information related to health
even In higher classes.
The reactions of the teachers too
have been favourable. All the
teachers interviewed have express
ed about the worth of introducing
health education at school level,
specially at the primary level, and
are satisfied with the adequacy and
appropriateness of the content and
the teaching methodology sug
gested in the guide books.
One significant revelation of the
evaluation has been about the
dissemination of health information
from children to their parents/sibl
ings. Many parents when interview
ed expressed that their wards
generally shared health messages
with them and they could notice
significant behavioural changes in
their wards specially in maintaining
personal hygiene and environmen
tal sanitation. A general reaction
from parents have been that they
could come to know more about the
advantages of ORS, immunisation,
breast-feeding, weaning, and dental
care, etc, from their children.
CONCLUSION
From the impact the course has
made on children and the way it has
been received by children, teachers
and parents, it can be concluded
that RUHSA has been successful in
not only teaching health to children
but also in demonstrating that
children can act as potential sources
for disseminating health messages
to the community.
RUHSA’s experience with school
health education adds to the truth
of the statement, viz.. "The best way
of arousing interest in health among
adults is to convey the message
through their children”.
19
A PILOT STUDY
ON THE EFFECTIVENESS
OF T.B. MODELS
A report by Mr. Daniel Kwamange
This study was aimed at testing
the effectiveness of models on T.B.
among the people with the highest
incidence of disease in the district.
Marlgat Division was chosen as the
study area.
Children in a day school meet
their parents every evening and
were thought capable of passing any
information to them easily. For the
pilot study, we therefore decided to
concentrate on day schools which
afforded us the opportunity to assess
the outcome of the demonstration
within two days.
The T.B. models were shown to
the groups and like the schools they
were given a chance to observe the
models and explain to the team
what they were all about. The
response to the models was very
promising as most of them seemed
to be very impressed by the models
and their message.
Made available by Jean V. Gimpel, U.K., involved in Creating Modelsfor Rural Development.
The group promised to make a
song for the models’ message and
pass the Information to the villages.
Made available by Jean V. Gimpel, U.K., involved in Creating Models for Rural Development.
20
The community health workers
here seemed to be very effective in
spite of the fact that most of them
are not able to read or write. The
models were very easy to recognise
and understand. They seemed to
take the models’ message very
seriously indeed.
The first school to be visited was
Ngambo Day Primary School in
Marigat division. Children aged 12
years and above were shown the
models and asked to study them and
then give their comments.
With the help of the team the
children recognised the figures in
the models as a person coughing out
TB germs over her children. They
also recognised the small health unit
in which the person is first treated.
They were asked questions that
led to their recognition of further
treatment in a bigger health institu
tion (hospital). Here the patients
sputum is examined under a
microscope before treatment is
given. The children were informed
that the sick person was found to be
having TB disease.
At this juncture they were asked
questions as to the symptoms and
signs of TB. They enumerated this
easily, getting help from the team
only occasionally.
The team then Informed the
children about the treatment at the
hospital. They were also told that
after a patient is discharged from the
hospital, he has to continue treat
ment at home for at least 18
months. Fresh supply of drugs is
taken monthly from the health unit
nearest to the patients home.
The importance of regular
medication was emphasised. Failure
to take regular medicines may cause
irreversable resistance to effective,
cheap and readily available drugs.
The children were asked if they
had seen anybody in their com
munities with these drugs (samples
of which were shown to them).
Some of the children replied in the
affirmative.
They were asked to suggest what
they would normally do If they
suspect anybody in their com
munities of having TB. Most of them
were able to give the correct reply
based on the Information contained
in the models. The children were
also questioned on the means of
After a few days, the team visited
the parents and interviewed them.
Six parents from six different homes
related what their school children
told them about the models and its
TB message. Four of the parents
were not told anything. Some
parents claimed they had not had
time for the children to talk to them
about the models but others thought
the children forgot.
prevention of the disease. To this
they gave a number of correct
suggestions.
The children were also given time
to ask any questions related to TB
in general and the model in
particular.
The children were then asked to
pass the information to their parents
and siblings at home. The team left
some cards with their headmaster.
If anybody had a cough for 3 weeks
or more, he would take a card to the
Health Centre. The officers in the
health units were informed about
the cards and what to do with them
and the people who brought them to
the unit.
At the time the team was leaving
the district at least three people had
reported to Marigat health centre
with the individual cards.
Made available by Prof. Christian de Laet, University of Regina, Saskatchewan, Canada.
In another area, of the nine
parents from nine different homes
questioned, six admitted having
been Informed about the models by
their school children but three of
them were not aware. One of the TB
cases identified by the children dur
ing school’s demonstration turned
up at the market place and confirm
ed that he had been admitted in the
hospital with TB but had taken his
medicine for only one month and
then stopped as the nearest health
unit was too far and he was feeling
better by then.
At Kampl ya Samakl. six parents
from different homes admitted that
at least their school children talked
to them about the models and TB.
Most of them were able to remember
some important information related
to the TB models.
As a result of such information,
one old man was identified to be as
possibly having TB symptoms. The
team later took the old man to
Marigat health centre where the of
ficer in charge said that the old man
was very likely to be having active
TB.
Generally the response among
school children, their teachers and
parents was very encouraging. As
stated elsewhere in the report,at
least 2 suspected TB infected people
were identified by the children dur
ing the models demonstrations. This
shows that the message was clearly
taken by the children. Again, the
message received by the parents
from the children was clear and
quite effective among the receivers.
Communicating by use of visual
aid such as models through school
children (who tire easier to reach), to
their communities is simple, fast, ef
fective and cheaper.
21
NEWS
FROM THE STATES
ONE MONTH RESIDENTIAL COURSE ON
COMMUNITY HEALTH MANAGEMENT.
A report by Dorlena David
The one-month residential course
on Community Health Manage
ment. was held at the Catholic
Ashram, Mandla, about 100 km
from Jabalpur in Madhya Pradesh
from October 15th to November
10th, 1985. This course was Jointly
organised by VHAI and the Catholic
Hospital Association of India (CHAI).
It was a new experience to work as
a team to facilitate a questioning
process leading to shift in attitudes.
The twenty four participants from
15 states included nurses, social
workers and project co-ordinators.
The highlight of the opening and
closing ceremonies was a lighted
lamp. At the valedictory function,
each participant placed a lighted
lamp on a large map of India drawn
on the floor. Between the symbolic
opening and closing ceremonies
were packed four busy weeks of
community living and learning.
Sessions often stretched late into
the night. Rapporteurs of the day
worked in groups to make the
documentation ready for the next
day. The facilitating team met to
reflect on each day’s sessions.
"What was done? Why did that
unexpected thing happen? And in
future?" These questions were
thrashed out before planning began
for the next day.
During the four weeks, the follow
ing broad areas were the focus of the
group:
★ health care delivery systems in
India
★ community
health
and
development
★ analysis of Indian society
★ critical analysis of the health care
system
★ communications
★ low-cost audio-visual aids
★ planning and management of a
community health project.
Participants told stories, enacted
dramas and role plays, developed
posters, debated and above all, liv
ed as a learning community—each
sensitive to the other’s needs. Shar
ing of ideas and experiences was the
basis of all interaction. At the end of
the course, each participant shared
his/her plan of action based on the
learning of Mandla.
Some phrases spontaneously
developed into oft-repeated slogans.
"Option for the poor" was one such
phrase. Songs of liberation were
heard in the mornings and periods
of quiet reflection were interspersed
with feverish activity.
From this introductory course it is
clear that there is a need for similar
workshops, where participants can
build on each other’s experiences
and hopes.
"We have the audacity to believe
that people everywhere can have
dignity, equality and freedom—let’s
make it happen!"
NATIONAL
SEMINAR
ON
DEVELOPMENTAL COMMUNICATION’,
VARANASI
The need of an effective com
munication structure for RuralHealth-Environmen tai-CulturalScientific Communications was
discussed and recommendations
made during the first half of the
seminar.
The second half of the seminar
was on the communication
technology used in various media
like traditional print, sound slide,
television and video. Eminent prac
titioners from all over India shared
their experiences and suggested
ways and means of utilising them
for developmental activities.
The seminar was a time to build
new relationships and make new
contacts with various communica
tion experts. Alongwith the formal
sessions, informal sessions over a
cup of tea were very enriching and
thought provoking.
Every speaker led the participants
towards the new horizon of develop
ment communication and the par
ticipants responded well with their
ideas and suggestions during the
discussions that followed every talk.
Organisers have taken the respon
sibility to collect, edit and publish
the report soon, which every partici
pant is looking forward to.
A. Jebamalaidass
ANTI SMOKING CAMPAIGN?
The National Seminar on
Developmental Communication was
organised by Department of Exten
sion Education, Banaras Hindu
University and National Council for
Development Communication,
Varanasi from 7th to 9th November,
1985. Dr. D.K. Dube, Organising
Secretary and his colleagues, while
looking after the delegates very well,
Imparted a deep consciousness
about the important task of com
municators in the process of ac
celerating change for a belter world.
UICC-IOCU Jointly organised a
3-day workshop on "Smoking Con
trol" in Penang, Malaysia from
24-26 October, 1985.
Fifty participants from ten coun
tries participated in this workshop.
Most of the delegates were from the
consumer organisation.
The objective of this workshop
was to prepare the delegates to init
iate an antl-smoking campaign in
their own countries in a small but
realistic way.
Through the role-play and group
discussions the delegates exercised
the art of writing to the press editors,
etc..
This workshop’s effort was to
enlarge skills and the power to deal
with the smoking issue and to
develop a practical programme of
action.
During the workshop, important
Issues were highlighted and discuss
ed e.g. sponsorship programmes.
At the end of the workshop a press
release was prepared and sized by
all the delegates.
Smoking is being increasingly
recognised as tomorrow’s epidemic.
VHAI organised a public meeting
and screened a short video film on
smoking and health.
SM THE NEWS
CHAI CONVENTION
Dr. J.S. Tong
Lucknow has been honoured by
the Catholic Hospital Association. In
mid-November their convention
there attracted speakers of national
stature.
For five days their members
pondered the theme: “The Silent
Emergencies of our Times-Our
Response’’. The silent emergencies
are contrasted with the publicised
ones like the Mexico earthquake and
the Columbia volcano eruption. Dai
ly 3000 babies die of diarrhoea due
to lack of the simple knowledge that
water with a spoon of sugar and a
pinch of salt could save them. These
deaths are of little concern to
newspapers or the general public.
Millions arc sick from hunger with
scarcely any excitement among the
medical professions. The hungry
body becomes an easy prey for TB.
Red blood thins for lack of green
leaves in the diet. The body needs a
trace of iodine in the diet. It is
available in raw onions or in iodis
ed salt. For lack of it, goitre enlarges.
This can lead to an operation and to
children being born cretins. Lakhs
of children have night blindness due
to lack of vitamin A. It is found in
yellow pumpkin and in many other
foods.
WHEN THE CHILDREN WAIT
FOR FOOD
★ For many of the world’s people,
there are more meaningful ways
“Rothman’s king size”, “the
smooth American Experience",
Charms, the “Marlboro Man”, all
promote cancer. We hear no public
protest. These and many others are
the silent emergencies of our time.
The pharmacy companies like to
conceal this knowledge and make us
believe that health is the reward for
buying their medicines.
As a response, the convention
cried out for the church and all
humanity to focus effort on health
promotion and massive health
education. Every parish and school
should take this up. Health is a ra
diant quality of the divine life in
every person.
This message was hammered
home by every speaker. Doctors like
M.M. Dhar, Director. Central Drug
Research Institute: Mira Shiva of
VHAI; Augustine Veliath: Dr. K.B.
Mathur: Krishna Kumar, Deputy
Minister. Health and Family
Welfare: C.M. Francis: George
Joseph; David Haxton. Regional
Director. UNICEF and several
others. Dr. Harcharan Singh.
himself a prominent professor and
member of the Planning Commis
sion. emphasising the new shift of
emphasis , in genial humour, cau
tioned the convention to beware of
the three D’s—Doctors, Drugs and
Dispensaries!
Due largely to sisters living in
small communities in hundreds of
villages, CHAI has emerged as a
powerful promotor of community
health. Their resolve is to share
health knowledge with every fami
ly and every community. Of paying
members, mostly institutional, they
have now 1926. This is a resource
of high church and national value.
of describing time than the com
monly used calendars. “In the
language of the Iteso of eastern
Uganda, as in many African
languages, each month of the
year is given a descriptive name.
August—the month after the
millet harvest is the month of the
big stomachs, but, in poignant
contrast, the pre-harvest month
of May, when the granaries are
empty, is “the month when the
children wait for food."—From
the recently published book.ZTrtding Hunger: An Idea Whose
Time Has Come.
★ Lessons Third World Officials
Can Learn from the World Bank's
35 years' experience with project
financing is the subject of a
610-page in-house book by two
senior World Bank officers.
Among the lessons, reports
World Bank News:
o “Let the marketplace do its Job
whenever possible." since the
capacity for government
management is “among the
scarcest of development
resources."
o “Create a positive policy en
vironment." notably through
pricing policies designed to
allocate resources in support of
social objectives. (The book of
fers some suggestions for
moderating the political pain
this may entail.)
o Project managers charac
teristically underestimate the
cost and time for completing a
project. Careful planning and
consideration of alternatives
“will
pay
handsome
dividends".
° The most pervasive source of
difficulties in project im
plementation is people—weak
government or project ad
ministration and inadequately
trained staff. “Pay attention to
the human dimension."
° Women in many respects “are
the largest underused resource
for development."
23
REACHING THE UNREACHED
Maya Menon
“REACHING THE UNREACHED”
is basically a village outreach pro
gramme covering the villages im
mediately around it, i.e. Ganguvarpatti and Kallupatti and also several
other villages around a radius of 25
kms. The programme gives substan
tial care to leprosy patients. TB pa
tients. old people, malnourished
babies and mothers, the homeless
abandoned children, the sick and
handicapped and uneducated
children of the villages of India.
We have general health education
programmes in at least eight villages
and school health programmes in
two villages—Ganguvarpatti and
Kallupatti. The project Itself has a
clinic and trained community health
workers.
Before we start a school health
education programme, the staff of
our health department and educa
tion department at RTU get together
and work out the specific
theme/subject that is to be conveyed
to the school children. The topic
may be on any communicable
disease like scabies, conjunctivitis.
worm infestations and tuberculosis.
Themes like hygiene and sanitation,
diarrhoea and even leprosy (of
which there is a high incidence) are
often prepared. We usually work in
co-ordination with the school head
master and teachers. The head
master fixes the time—i.e. a leisure
period in which our staff may
organise a health education lecture/programme.
Unfortunately, it is often our ex
perience that the time alloted to us
is barely sufficient for us to repeat
our message several times over as is
desired to get it home to the
children. At present there are no
specific school hours devoted to
health education—we think this
should be a regular part of any
school curriculum. The main media
we use are flash cards and slide
shows—which
we
prepare
ourselves. We also give talks to
24
groups of children. We have trained
puppeteers and we organise puppet
shows which are very popular with
the children. Sometimes we
organise essay and art competitions
for e.g. on World Leprosy Day, Jan.
30th, 1985, when all the children
enthusiastically participated in an
essay competition.
Our object usually is to teach the
children to identify the symptoms of
the various diseases, their effects,
their prevention and cure. This is
done as simply as possible so that
the children can understand our
message. Often they are, as a result,
able to identify a particular disease
(especially leprosy) and even refer
cases to our clinic for treatment. We
teach them simple remedies eg. for
scabies and ORT for diarrhoea.
HEALTH CAMP
We have so far conducted one
health camp which lasted two days
in one of the village schools. The
novelty of the programme was that
it was entirely run by the children.
Further alongside we had sports and
games, so that the camp was like a
children’s festival.
We selected children (about 50)
from the 7th and 8th standards as
the control group and organised a
one day seminar with our medical
team. These children formed a Stu
dent Health Committee. The
children were further sub-divided in
to groups and each group was
separately taught about various
topics: Leprosy. TB. Scabies, Mother
and Child, Worms and First Aid.
The posters for each of these themes
were prepared by us with the
children’s help. One stall however,
was entirely planned and organised
by the children themselves without
any help from our side.
The children manned the stalls in
shifts of 2-3 hours each. Each child
got an opportunity to participate in
the sports and games. A puppet
show was organised and also a slide
show about TB and Mother and
Child Care with a commentary by
our health workers. On the second
day of the programme, children put
up a cultural show with song and
dance with health as the underlying
theme.
We made use of folk media, i.e.
Katha Kalakshepam, to talk about
health. Besides we converted the
latest Tamil cinema hits which in
stantly attracted the children and
public.
During the camp, a medical
checkup was organised with free
treatment and checkup for anyone
who attended.
After the camp, a one-day seminar
was held for the teachers. This was
very successful as they asked us a
number of questions. The Govern
ment Primary Health Centre staff
worked along with RTU staff, and
talks were given on a wide range of
subjects including such topics as
parent-child relationships etc.. A
debate was arranged among the
teachers at the end of the seminar
as also for the children.
The camp was an exploration in
the CHILD-to-chlld, as well as
CHILD-to-parent approach in health
education.
Our staff attend communication
courses, community health workers
courses and workshops. They have
also formed youth clubs in the
village to Inculcate civic sense and
responsibility i.e. street cleaning
drive, toilet maintenance etc. We en
courage them to prepare their own
posters for the school notice board.
We find these media very effective
when used in combination. We have
found music and folk drama and
puppet shows most effective. We are
at present having a demonstration
by a Street Theatre group sent in by
the INDIAN PEOPLES THEATRE
ASSOCIATION.
Maya Menon is a volunteer with
Reaching the Unreached Programme, at
Boy s Village. Ganguvarpattl.
All India
Drug Action Network
-AIDAN
CALENDAR OF EVENTS
BLAT/WHO COURSE ON MANAGING A COLLECTION OF HEALTH AUDIO - VISUALS,
5-21 AUGUST, 1986
Established at the request of the World Health Organisation, the course explores the techniques
of managing a collection ofaudio-visuals-selection, evaluation, cataloguing, classification, storage,
retrieval, maintenance of materials and equipment and the role that the audio-visual resources per
son can play within educational or medi'cal institutions.
It is intended for:
(i)
People without formal library training who are responsible for running libraries or resource
centres, particularly in the developing countries (this may include lecturers, teachers and
health personnel as well as unqualified library staff).
(ii)
Librarians wishing to extend their professional skills to help them cope with audio-visual
materials.
Tuition will be based at BLAT’s London headquarters: visits to other institutions will be arrang
ed. There will be a strong emphasis on practical work.
Further details about the audio-visual course or the works of BLAT in general can be obtained
from Ms B.S. Carney, Information Officer/Librarian, BLAT Centre for Health and Medical Educa
tion, BMA House, Tavistock Square. London WC1H 9 JP, U.K. Telephone: 01 388 7976.
DIPLOMA IN COMMUNITY HEALTH MANAGEMENT BY VHAI
AND
RUHSA DEPARTMENT OF CHRISTIAN MEDICAL COLLEGE, VELLORE
A Course of 15 Months
Starts in July 1986, for People Interested in Community Health Work
The Rural Unit for Health and
Social Affairs (RUHSA).
RUHSA Campus P.O.
North Arcot District
Tamil Nadu 632 209
For Details and Application Form.
Write to:
Position: 270 (11 views)