PRIMARY HEALTH CARE-1985 SEVEN YEARS AFTER ALMA-ATA AND THE RIGHT TO HEALTH
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swasth
hind
Primary Health Care—l'98x5 .
Seven Years after Alma-Ata '
Hospitals' and Primary Health
Care
Nurses lead the way.
' •
Breastfeeding—Recommended
Practices in Indian contextIs Sodium and Hypertension
Related?
■■Biology-of. Ageing"
Tropical Diseases Research ”
swasth
hind
In this Issue
Page No,
Bhadra-Asvina
September 1985
Saka 1907.
Vol. XXIX No. 9
Primary Health Care—1985 Seven years
after Alma-Ata and the right to health
Dr D. Tejada-de-Rivero
209
Hospitals and primary health care
Dr C. R. Trivedi
211
READERS WRITE
Nurses Lead the way
I am a regular reader of Swasth 'Hind. Swasth
Hind helps me in different aspects, pertaining to
Health and Family Welfare Programmes. Swasth
Hind also carries various hbws5 items, articles, casestudits, concerning National Health Programmes.
If any problem arises, I refer to Swasth Hind to
find solutions in connection with educational
approaches on Community Health Education. I
owe very much to Swasth Hind.
V. S. R. Murthy,
Health Educator,
Subsidiary Health Centre,
Gowripatnam, Kowur Taluk,
West Godavari, Andhra Pradesh.
Dr Halfdan Mahler
215
Breast feeding—Recommended practices in
Indian Context
Dr Sanjiv Kumar & Dr V. P. Reddaiah
Food hygiene
Smt. K. Sheela
223
Respond to challenge of development
without degrading environment
Central Health Education Bureau.
(Directorate General of Health Services)
Kotla Marg, New Delhi-110 002
ASST. EDITOR
225
Is sodium and hypertension related?
Smt. Kamal G. Nath
226
Biology of ageing
Dr Hemani Kumar ‘ \ i: ■
Editorial and Business Offices
219
229
’
A historic first id antibiotic development
team
John Newell
232
Tropical Diseases Research—a very special
programme
Dr Adetokunbo O. Lucas
234 .
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PRIMARY HEALTH CARE—1985
SEVEN YEARS AFTER ALMA-ATA
AND THE RIGHT TO HEALTH
Dr D. Tejada-de-Rivero
The health of an individual, a family, a nation,
depends for the most part on factors
outside
the purview .of the medical profession. This
reality is accepted by intellectuals and acade
mics. but! is not generally put into practice, even
today.
he artificial limitations surrounding the
notion
of what the health field is, arc due to a confu
sion of terms that are now obsolete. Health has been
loosely equated with medicine, with hospitals and
with doctors; medicine with the care of the sick; hos
pitals with sophisticated and expensive technology;
doctors with highly specialized care that is provided
without consulting the patient. The human being has
been perceived as a passive object, subordinate to
medicine, to the hospital and to the doctor. How
ever, medicine, the hospital and the doctor are fac
tors that have much less real impact than is general
ly realized on the health situation of a local com
munity or nation.
Let me make it quite clear that I am not opposing
medicine, hospitals or doctors, which are all very
necessary—indeed indispensable—for health
care.
The point I want to make is that they are badly dis
tributed and used, and that the health field is much
wider than these.
TWO CONCEPTS CRYSTALLIZING THE
RIGHT TO HEALTH
There are two very important concepts relating to
the human right to health: (1) the social target of
health for all by the year 2000; and (2) the primary
health care strategy, which is essential for attaining
this social target.
THE SOCIAL TARGET OF HEALTH
FOR ALL
“HEALTH FOR ALL” does not refer to a utopian
situation in which every person in the world enjoys a
permanent state of health—which would be an ab
surd arrogation of immortality—nor does it mean
that disease will disappear from the face of the earth.
Among other things, “health for all” embraces the
following ideas:
SEPTEMBER 1985
1. Everyone, without exception, has the right to
health care. In other words to the promotion of his
or her physical, mental, emotional, social and spiri
tual capabilities; and to access to a permanent health
care system (prevention of preventable disease, early
diagnosis and immediate treatment of diseases that
are not yet preventable, rehabilitation, etc.).
2. Everyone, without exception, has the right of ac
cess to the different levels of complexity of the health
system (from the simplest care within the home or
the community where there are no trained professio
nals, right up to the most sophisticated hospital care),
depending on the nature of the health problem and
on the resources and capacity of the country.
3. Everyone, without exception, has the right to
live in a cultural, social, economic and physical en
vironment inherently conducive to health and affor
ding protection against hazards that could impair
health.
4. Everyone, without exception, has the right and
duty to be an active and decisive partner in looking
after bis or her own health and that of the commu
nity, and to cea^e being a passive object in a system
that imposes priorities, approaches, actions, opera
tions, etc. Everyone should take part not only as a
resource person providing care but in the planning
management, supervision and control of health care.
both individually and collectively.
5. There must be a significant reduction in the
enormous and disgraceful differences in the health
levels of different population groups, both between
countries and within countries. This means giving
genuine priority to those areas and groups that are
at present disadvantaged, starting with those that now
have no access to any kind of permanent health
care.
6. There must be a significant reduction in the
enormous and disgraceful differences in the way
national societies allocate resources—physical, tech
nological, human, financial,, etc.—for the health care
of their peoples.
209
7. To sum up, ‘‘health for all” is a concept that in
corporates a way of implementing a human right—
the right of health—within principles of universality,
equity and social justice.
the concept of primary health
CARE1 The concept is based on the follow
ing essential components:
1. It is an approach that should embrace the en
tire health system of a country (reaching into the
home, the workplace, the local community, right up
to the most advanced hospital or research institute).
2. It is based on the active and responsible parti
cipation of the people—individually and collectively
—at all levels of complexity of the health system
and in all the processes that make the system work.
From planning, which decides the priority problems
to be tackled, up to the management, supervision
and control needed to assess whether these priority
problems really are tackled and how efficiently and
effectively. Participation of the people is much more
than the use of f^ee labour to carry out certain acti
vities. It is the permanent presence of the people
as decision-makers, as active subjects responsible for
their own individual and collective health.
3. People’s participation, real health needs, and the
actual resource of the countries and their local
communities should govern the type of technology to
be used by the health system at its different levels.
That is why within the concept of “primary care”
we talk of “appropriate technology”, which besides
being scientifically sound and effective must be adap
ted to the possibilities of the country concerned and
acceptable both to those who* will use it and to
those who will benefit from it.
4. The above elements indicate the absolute neces
sity of multisectoral action, for many of the factors
influencing the presence of diseases are outside the
so-called health sector.
There are many instances
of countries where better education, proper nutrition,
the provision of drinking water and sanitation, good
housing, suitable working environments, etc. have
made a more significant contribution to improving
the level of health than any conventional system of
curative medical care could have done. Thus, pri
mary health care is unavoidably multisectoral?
5. The above components also, govern the absolute
necessity of gradually delegating responsibilities for
health activities.
6. Finally, “primary health care” must be a com
ponent of land never isolated from a national socio
economic development strategy. Its implementation
requires the political will and decision of govern
ments, not just the goodwill of institutions and
authorities in the health sector. It also requires con
stant political pressure from the people, “as active
participants” in such implementation, for it is only
this constant political pressure that can guarantee the
continuity and permanence of the initial political
decisions taken by governments.
Thus ‘TRIMARY HEALTH CARE” is clearly
not a level of medical care that is elementary, rudi
mentary. primitive even, with no scientific basis,
using crude'technology, and provided by non-professionals with a little training. Nor is it a second or
third class vertical programme operating parallel with
and independant of the conventional health care
system. It is not a campaign separate or isolated
from the health sector, which by means of a set of
simplified activities decided upon by some organi
zation or other, is directed patemalistically at the
rural inhabitants or the urban poor as some form of
charity to relieve some of their misery. Far from it.
The countries belonging to the World Health Or
ganization (164 of them at present) by acting jointly
•and collectively through their Organization (i.e.
W.H.O.), acknowledge in practice what is stated in
the Preamble to the Constitution of this “coopera
tive of countries”, drafted 37 years ago: “The enjoy
ment of the highest attainable standard of health is
one of the fundamental rights of every human being
without distinction of race, religion, political belief.
economic or social condition.” They explicity re
affirm that:
HEALTH IS A BASIC AND FUNDAMENTAL
RIGHT
(Extracts from an address by Dr David A. Tejada-de-Rivero,
Assistant Director-General, World Health’Organization, during a
Seminar on “International Protection of Economic, Social and
Cultural Rights”, Mexico City, August 1984. Reproduced from
the ‘Appropriate Technology for health’ Newsletter, No. 16,WHO.
Mima-Ata, 1978: Primary health care, “Health for all” Scries No. 1 WHO Geneva, 1978.
•Nutritim is perphaps the clearest example of the multisectoral nature of a problem and the multisectoral nature of the possible ways
of tackling it.
210
SWASTH HIND
Primary health care can prove to be an effective strategy to achieve the goal of Health
for All by the Year 2000 only when hospitals become community oriented, think
of patients as a part of community, feedback their observations for the benefit of
community at large and synchronously pulsate with every pulsation of primary
health care.
HOSPITALS AND PRIMARY HEALTH
CARE
Dr C. R. Trivedi
D RIMary Health Care (PHC) has been a talk of
the world, ever since its concept was accepted
at Alma-Ata in 1978, as an effective strategy to bring
home health to all, particularly those who have so
far remained unserved and unreached.
including family planning;
immunization against
major infectious diseases; prevention and control
of locally endemic diseases; appropriate treatment of
common diseases and injuries and provision of essen
tial drugs.
In the Declaration of Alma-Ata, PHC has been
defined as an essential health care, based on prac
tical, scientifically sound and socially
acceptable
methods and technology, made universally available
to families and individuals in the community, through
their full participation and at a cost that the com
munity and country can afford to maintain at every
stage of their development, in the spirit of selfreliance and self-determination. It forms an integral
part both of the country’s health system, of which it
is the central function and main focus, and of the
overall social and economic development of the
communiy. It is the first level of contact of indivi
duals, the family, and the community with national
health system bringing health care as close as possi
ble to where people live and work, and constitutes
the first element of a continuing health care pro
cess.
Thus, the important operational components
Primary Health Care could be formulated
follows:
The primary health care includes at least these
eight elements: Promotion of food supply and pro
per nutrition; an adequate supply of safe drinking
water and basic sanitation; education concerning pre
vailing health problems and the methods of preven
ting and controlling them; maternal and child care
SEPTEMBER
1985
of
as
1. It should be need based.
2. It should be accessible to all.
3. It should conform to cultural and
set up of the community.
economic
4. It should involve people actively and ultima
tely make them self-reliant in health.
5. It-should have appropriate linkage with other
health services.
6. It should be accompanied by necessary socio
economic development of the community.
Role of hospitals
Hospitals today are the apex bodies for provision
of medicali services. Hospital (from Hospitalis
ation) means a place where guests—of course the
patients, when they come get all hospitality and
care. There is no element of hospitals going to door
steps of people, nor is there any feasibility of ren
dering first contact care.
211
in some countries, 80% of total health budget is
consumed by hospitals. Hence, Primary health care
is less likely <to succeed, if hospitals are allowed - to
keep aloof and work in ivory towers, as they are
often .described. Hospitals could no more be allo
wed to enjoy complacency by “curing as far as pos
sible, relieving often, and atleast comforting always”
—the time old ideals of hospitals. Hospitals could
no more feel contented by saying goodbye to cured
patients at 'the gates of hospital or saying sorry in
case of death or disability of patient. Hospitals will
have to develop epidemiologic, preventive, commu
nity and comprehensive approach.
Hospitals in India today, are not needbased at
large. There are more and more services for few at
least in terms of money, and even duplication of ser
vices exist. They are not effectively accessible to our
rural masses, nor culturally acceptable to them and
are not in tune with eonomic limits of community.
They have hardly any active liaison with other
health and socio-economic services, unless specifical
ly demanded. People have no say in hospitals, and
they get lost there.
Patients coming to hospitals form a reasonably
reliable index of the situation in the community. With
an epidemiological approach hospitals could find out
what are the causes operating, at large, behind pre
valent mortality and morbidity. These inferences
could be passed on to the concerned authorities for
corrective action to bring about long term effects.
Patients and family members coming to hospitals
should be sent back home after fully educating them
on the disease, it’s prevention, their personal role,
etc. Protective rehabilitative services should form
an integral part of hospital services.
Keeping in mind the imbalance between scarcity of
resources and magnitude of problems at most places,
we can think of three categories of hospitals, i.e.,
taluka, district and State/teaching hospitals, which
should be roughly located at maximum distance of
25, 50 and 100 kilometres respectively from popu
lation served by them. Taluka hospitals should be
equipped to deal with most common and easily
tackled problems’ of the area served, i.e., it should
be absolutely need based in right proportion. Dis
trict and State hospitals should be equipped for pro
blems which can wait for transport, which are rela
tively less common, and which require sophistica
ted care and even superspecialities.
Involvement in primary health care
Thus, the strategy to involve and link hospitals
with Primary health care could be formulated as
follows:
212
Provision of promotive and protective services
— Every hospital must have fullfl edged facility to
:eguiarly educate patients and their relatives re
garding their disease and the dieases prevalent
in their comunity. People arc most receptive
when they are in hospitals. This activity could
be carried out while patients are waiting in out
patient department (O.P.D.) and during the
evening hours. The ideal should be to see that
the patients do not come back to hospital with
the same illness. Health education should also
include sex education and population education
for relevant groups. Hospital based programmes
on television could help people <to understand
the health situation in the community to become
health conscious and to participate in preven
tion of diseases.
— Counselling services for various health problems
and purposes should form a regular feature of
hospital services.
— Specific protection in the form of immunopro
phylaxis for diseases common in the community
should be made available freely.
— Screening facilities for certain common and
chronic conditions like heart diseases, hyperten
sion, diabetes, cancer, etc, should also form a
regular feature of every hospital.
Registries
should be established for chronic conditions, so
-that followup services could be planned.
2. Epidemiologic Services
Each hospital must have an up-to-date record
system and a statistical unit. District hosptials and
beyond should have a full time qualified epidemiolo
gist in charge of this section. Periodic review of re
cords and mortality and morbidity statistics could be
utilised to monitor the situation prevailing in the
community.
This can be strengthened and substan
tiated by periodic epidemiological investigations in
the community. Maternal and infant deaths should
be vigilantly audited for corrective purposes.
3. Liaison with other organisations I authorities
Inferences drawn from epidemiological ireviews
should be routinely communicated to concerned
authorities and organisations for necessary action to
the advantage of the community, e.g., ensuring puri
fied water supply, laying drainage system, vector
control, etc.
4. Mini-hospitals
Mini-hospitals should periodically move on wheels
to community to render simple diagnostic, screening,
curative, surgical and health educational
services
which will save a lot of time and money of commu
nity.
It will strengthen the rapport between the
community and the hospitals. It will also boost pri
mary health care.
SWASTH HIND
Hospitals today are the apex bodies for providing curative services. To become an active partner in primary
health care the hospitals should render preventive, promotive and rehabilitative services in an integrated form.
5. Communication system
Communication system among hospitals and bet
ween hospital and the community in the form of
messages, information and transport should be per
fected. Round the clock experts services through
telephones could help save many lives.
Similarly,
ambulance services with experts, under the control of
hospitals could help avoid preventable loss of many
lives.
6. Involvement in health programmes
Hosptials should get actively involved in the im
plementation of National Health Programmes.
7. Rehabilitation Services
Rehabilitation services should either be available
SEPTEMBER 1985
in hospitals or at least dependable references and de
tails should be made available from the hospitals.
8. Training, Research and publications
Every hosptial should participate in training of
various health workers, and reasearch to solve com
munity problems. Periodic publications by hospitials
might help people understand the problems of the
community.
Primary health care can prove to be an effective
strategy to achieve the goal of Health for All by the
Year 2000, only when hospitals become communitty
oriented, think of patients as a part of community,
feedback their observations for the benefit of com
munity at large, and synchronously pulsate with every
pulsation of primary health care.
O
213
s WHO's Member States began to implement
their policies and strategies to achieve the goal
of Health for All through primary health care, it
became more evident that successful implementation
would depend strongly on dedicated people,, for what
is sorely needed to practice primary care is love for
one’s fellow man. I consider that nurses, by their
very vocation, must have just this kind of love.
A
PRIMARY
EYE CARE
rimary eye care comprises a simple but compre
P
hensive set of preventive and curative actions,
which can be carried out by primary health workers,
by specialized auxiliary personnel or by other inte
rested persons.
The clinical activities involved in primary eye care
consist of basic ways of dealing: with the three major
eye symptoms presented by patients:
inflamed
(“red”) eyes, loss of vision, and pain in the eye. At
the primary level, the health worker can manage
these problems either »by definitive treatment, by
referral after immediate treatment or by referral
alone. General guidelines for this action have been
developed, but they must be adapted to conditions in
the communities served.
In addition, the primary health care worker should
carry out promotive and preventive activities, focus
ing on essential education and community participa
tion with regard to the prevention of visual loss.
Only a few medicaments and other materials are
necessary for primary eye care. At the very least, an
antibiotic eye ointment (usually a tetracycline) is
needed, but other drugs that may be useful are vita
min A capsules, a second antibiotic ointment and zinc
sulfate drops (for mild irritations). Bandages, stick
ing plaster (tape) and eye shields are very useful for
primary workers, and' optional equipment may include
a simple chart to measure visual acuity and a hand
torch.
The fundamental shift towards health systems
based on primary health care means that the accent
is now on the promotion of health and the care of
people wherever they work, live' and play. Millions
of nurses throughout the world hold the key to an
acceptance and expansion of primary health care
because they work closely with people, whether they
are community health nurses in the Amazon rain
forests or intensive care nurses in a heart transplant
unit.
During the meeting of WHO’s Executive Board in
January 1985. there was a lively discussion concern
ing the report of an expert committee on the educa
tion and training of nurse teachers and managers.
In
Finland, nurses participated in the “heart
health” project, monitoring and offering advice on
diet and exercise to susceptible target groups.
Result :
Reduction in heart attacks.
If the millions of nurses in a thousand different
places articulate the same ideas and convictions
about primary health care, and come together as one
force, then they could act as a powerhouse for
change. I believe that such a change is coming, and
that nurses around the globe, whose work touches
each of us intimately, will greatly help to bring it
about. WHO will certainly support nurses in their
efforts to become agents of change in the move to
wards Health for All.
In order to realise the full potential of this power
house, nurses will need to be organized and equip
ped to break down resistance to change, to sustain
the initial effort, and then to develop strategies and
action plans. What is very clear is that the nursing
profession is more than ready to respond to this
challenge.
The most important factor necessary to initiate
primary eye care is the training of primary health
workers to recognize eye conditions and to take ap
propriate action to deal with the problem. Train
ing manuals for primary health workers should there
fore include material on primary eye care. Primary
eye care must be supported by reinforcing training
and by adequate referral services at the secondary
level.
After some years of doubt, WHO has now grasped
the significance of this potential. Indeed, the Orga
nisation is well aware that nurses have already begun
to lead lhe wav. and have many good successes to
show. Given the potential of nurses, .to take their
place in the forefront of the Health for All move
ment. the members of the Executive Board and my
self forsee the following things taking place:
From : Strategics for the prevention of Blindness, A primary
hei’th care approach, Geneva, WorlcTHcalth Organisation, 1984
pp. 11,-15.
— The role of nurses will change: more of them
will move from the hospital to the everyday life
of the community, where they are badly needed.
214
SWASTH HIND
KEY ROLE OF NURSES IN PRIMARY HEALTH CARE
NURSES LEAD THE WAY
Dr Halfdan Mahler
If the millions of nurses in a thousand different places articulate the same ideas
and convictions about primary health care, and come together as one force, then they
could act as a powerhouse for change. Such a change is coming, and that nurses
around the globe, whose work touches each of us intimately, will greatly help to
bring it about.
— Nurses will become resources to people rather
than resources to physicians; they will become
more active in educating people on health mat
ters.
— Nurse leaders will increasingly innovate and
participate in programme planning and evalua
tion.
—
Nurses will participate more actively in inter
professional and intersectoral teams for health
development.
—
More and more nurses will become leaders and
managers of primary health care teams; this will
include guiding and supervising non-professional
community health workers.
—
Nurses will thus assume greater responsibility
for taking decisions within health care teams.
All this will not be an easy process. The Expert
Committee, whose report we discussed, recognized
the importance of four factors to support the chang
ing roles and functions of the nurse: new attitudes
and values; reorientation of education programmes;
better resource allocation; and well-defined policies
and plans for the development of nursing personnel.
In the light of this, the Executive Board was convin
ced of the need for urgent action by the Member
In several countries of Africa and Asia, nurse
midwives trained and supervised traditional birth
attendants.
Result :
Decreased incidence of neonatal tetanus.
SEPTEMBER 1985
States to implement the Expert Committee’s recom
mendations, and for WHO to disseminate widely the
report and to respond favourably to the requests of
countries in their efforts to reorient the post-basic
education of nurses to primary health care.
Let me draw together the threads of my argument,
and state them as a positive commitment by WHO to
support the nursing profession in its move to orga
nize and facilitate the changes needed.
In one community in Kenya, nurses gave a series
of lectures aud workshops on sex education.
Result :
Reduction of the pregnancy rate among
adolescents.
We need to acknowledge the crucial role of nur
ses in arousing interest in the benefits of positive
health and in identifying what needs to be done to
achieve it.
Since the majority of training programmes for nur
ses are not fully relevant to the main social and
health needs of society, we shall have to increase
support to schools which reorient their
curricula
and monitor their experiences for wider dissemina
tion.
As for educational administrators and teachers
themselves, we would support crash training pro
grammes to make them aware of the goal of Health
for All through primary health care, and to en
courage them to plan their educational programmes
with this goal as the basis.
215
Cursing students must be made sensitive to pri
mary health care, the importance of involving the
community in health care andi the need <to strengthen
the bond between nursing schools and health ser
vices. Teachers must always be aware that the stu
dents of today will become the instigators of change
tomorrow.
motivating people, bringing about change, and main
taining morale. Nurses can voice the feelings of the
people whom they serve, and can give them credibi
lity and reasoned support.
It is imperative that an adequate number of nurses
be trained to assume a greater managerial role and
to participate in developing policy with assurance
and confidence. We should lend more support to
the acquisition by them of managerial skills.
In Thailand, nurses supported and participated in
imaginative community—sponsored campaigns on
family planning.
However no change can be effected in real terms
without an accompanying reappraisal of the poli<
cies on health manpower. We have, for so long, been
locked away into our separate areas of activity—
nurses having been excluded from decision-making;
now is the time for manpower planners and adminis
trators to involve them in this process.
Behind every successful movement there are
effective leaders. Effective leadership should be en
couraged amongst nurses since it is a key factor in
Result :
A wider acceptance of family planning.
Primary health care is one of the social pheno
mena of our times. It is a powerful potential for im
proving the quality of human life. This objective
has always been a fundamental driving force for
nurses and nursing. The harnessing of nursing ex
perience, energy, capabilities, and commitment would
add greatly to the momentum of primary health care
development and would accelerate the achievement
of the goal Health for All.
—>
ROLE OF NURSES
Seventy-fifth Session of WHO’s Executive
Board, which met in Geneva recently, decided on
the issue of a special publication emphasizing the im
portant role which the nursing profession can and
must play in the Health for All movement.
he
T
This decision was taken following a lively debate on
“Education and Training of nurse teachers and mana
gers with special regard to primary health care”, pu
blished in the WHO Technical Report Series, (No.
708). The report was considered most useful and all
its recommendations were supported.
The issue is that of nursing education generally, and
the reorientation of nurse teachers and managers or
leaders specifically. Harnessing nursing to the Health
for All strategy requires a deepened commitment to
change on the part of the nursing profession, and this
can be hastened through supportive development of
nurse leaders who could serve as activists, stimulating
change, and pushing for action. Nursing leadership
must be able to innovate and participate in both pro
gramme planning and evaluation.
216
The changing role of nurses in the Health for All
strategy demands a radical change, not only in a sound
grasp of nursing know-how, but in their relationship
with other health personnel and the community in need
of health care.
It was noted in the Board that a previous WHO
Expert Committee dealing with nursing had met in
1974 and had, even then, identified changes required
in nursing education. The present report points out,
however, that, if the findings of the 1974 Expert Com
mittee had been implemented more widely, nursing
personnel could now have been in the forefront of the
primary health care movement.
The Board clearly felt that the findings and recom
mendations of WHO Expert Committees were either
not disseminated widely enough or to the right people
in the right languages, or were not implemented due to
lack of awareness.
SWASTH HIND
Training of nurses need to be made more relevant to the changing social and health needs of the
Society. This requires additional emphasis on the delivery of primary health care services.
The Director-General of WHO, Dr Halfdan T.
Mahler, said it was now evident that the nursing pro
fession was infinitely more ready for change than
In Hungary, a nursing team won a prize for their
other professional groups. He pointed out that to prac
study on the attitudes and needs of the elderly in a
tise primary health care one needed love for one’s
local community.
fellow travellers and he considered that nurses had
Result : A better appreciation of the health pro
great potential for that kind of love. The Directorblems of elderly people and how the health
General stated that it was now time that nurses were
care
facilities can solve them.
brought in much more than hitherto “fairly and
squarely as leaders and managers of the primary health
care Health for All team, together with others.”
------------------------HFA 2000 January—February 1985
SEPTEMBER 1985
217
CREATION OF A CRITICAL MASS OF HEALTH LEADERS
A good strategy is of no value without good gene** rals to direct it. There can be no exceptions to
this rule, even when the strategy is as far removed
from the battlefield as that of Health for All by the
Year 2000—the over-riding priority of the
World
Health Organization.
Dr Halfdan Mahler, Director-General of WHO, is
well aware of this “rule”, and one of the novelties of
the programme budget presented before the Seventy
fifth session of the WHO Executive Board is that, on
a global scale, it calls for the creation of “a critical
mass of active leaders in the struggle for Health for
All.” In member states, in WHO itself, in bilateral
and multilateral institutions or even in the nongovern
mental and charitable organizations, these leaders will
be the generals who will ensure the success of the
common strategy.
At their January 1985 meeting in Geneva, members
of the WHO Executive Board gave a warm welcome
to this initiative, which they felt would mark a positive
step forward to the agreed targets.
Tn effect, what is envisaged is to ensure that this
cadre of leaders disseminate the idea of Health for
All through all levels of society, so that theory will
be converted into reality.
Such leaders will have to be sufficient in numbers—
hence the notion of “a critical mass” which must be
reached. As the Board has observed, the training of
health professionals according to the needs of the
Health for All strategy is making only slow progress
in many member states. The Board also noted that,
although the existence of a critical mass of people
capable of conceiving and carrying out the national
strategies of Health for All is of immense importance,
in the whole world there is not a single establishment—
whether university, school of public health or other
teaching centre—which has a training course in this
field.
In an effort to fill this gap, Dr Mahler has called
for training courses specifically aimed at fostering
Health for All activities.
This training will be as
valid for senior officials of health ministries as for
clinicians, nursing staff, hospital administrators, uni
versity senior staff, research workers, teachers, specia
lists in the human sciences and politicians.
Moreover this training will be obligatory for senior
officials of WHO. and strongly recommended for
officials of other concerned agencies of the United
Nations system. It will be carried out at national
institutes, preferably those linked with universities,
and as early as possible each of WHO’s six regions
should have at least one establishment offering training
possibilities in the requisite languages.
—Philippe Stroot
CAMPAIGN TO PREVENT CANCER
From the National Cancer Institute (USA) comes: (1) the “Good news” that every
one does not get cancer—two out of three Americans will never get it; (2) the “better
News” that more and more people with cancer are cured; and (3) the “best news”—
that individuals can do a number of things to help protect themselves from cancer.
These are the messages in a new brochure issued by the NCI as part of a
national cancer prevention awareness campaign.
Individuals are given the following advice:
(1) Don’t smoke or use tobacco in any form.
(2) Eat foods high in fibre and low in fat.
(3) Include fresh fruits, vegetables, and whole grain
cereal in your daily diet
(4) Keep yourself safe on the job by using protec
tive devices, such as respirators and protective
clothing.
(5) If you drink alcoholic beverages, do so only in
moderation.
(6) Avoid unnecessary X-rays.
(7) Avoid too much sunlight;
clothing and use sunscreens.
wear
protective
(8) Take estrogens only as long as necessary.
Courtesy: Health Messenger
State of Hawai
Summer 1984
218
SWASTH HIND
BREASTFEEDING
Recommended Practices In Indian Context
Dr Sanjiv Kumar & Dr V. P. Reddaiah
Breastfeeding still holds its rightful place in India. This article is based on
two studies carried out at the centre for Community Medicine, All India Institute of
Medical Sciences, New Delhi, and some other Indian studies. According to the
authors the recommendations suggested by them are applicable in the Indian
situation.
been rightly called as the
life line of the baby. Luckily for the children in
India, breastfeeding still holds its rightful place. Yet
there are certain wrong practices prevalent in infant
feeding. In view of these following recommendations
are made.
reastfeeding has
B
1. Breastfeeding should be initiated as soon as
sible after birth (within a half to one hour):
pos
A normal full term baby at birth has rooting and
sucking reflexes which make the baby suck. These
are the strongest soon after birth. Hence, baby can
suck on the breast more effectively. This will assist
in starting milk flow in the breast. Early nursing after
birth avoids mammary congestion
and breast
abscess1,2,3,4,5. This also ensures that the baby receives
colostrum and also causes release of oxytoxcin which
helps the womb to contract and stops bleeding5.
2. No prelactral feeds (local preparations given, to the
newborn before the breastfeeding is started) should
be given to the baby:
Any feed given to the baby interferes and weakens
the let down reflex as the baby will suckle less on the
SEPTEMBER 1985
breast. There is also the danger of aspirating the fluid
into the air passages and lungs. These fluids may
introduce infection as most of the times these are pre
pared in an unhygienic way3,3,5.
3. Colostrum (the yellowish fluid which comes during
the first few days) should be given to the child:
Colostrum is essential for the baby as it is extremely
nourishing and very rich in anti-infective substances.
Its yellow colour .is due to the high concentration of
Vitamin A. It also has a laxative effect to facilitate
early clearing of meconium3,4,5,6.
4. The baby should be breastfed on demand through
out the day and night:
The baby should be fed whenever hungry and not
by any fixed time schedule. The baby may get hungry
early or late depending upon the activity of the baby.
Infants on demand feeding gain weight and grow faster
than those who are fed on rigid schedule. Frequent
vigorous suckling of the breast maintains a good
amount of milk flow by stimulating a higher produc
tion of prolactin (a hormone which maintains milk
flow in lactating women)4,6.
219
5. Breastfeeding should be continued even when the
mother is sick:
During minor sicknesses of the mother, breastfeeding
should be continued. The breastmilk contains antiinfective substances which, will protect the baby. Even
in mothers suffering from leprosy and tuberculosis
breastfeeding should be continued and the mother put
on regular treatment. If the mother has open pul
monary tuberculosis (i.e. bringing out bacteria in
sputum), the baby should be put on isoniazid and
ideally should be immunized with isoniazid resistant
BCG and breastfeeding should be continued. If mother
has lapromatous leprosy3 (i.e. infectious type which
is about 20% of all leprosy cases) close prolonged skin
to skin contact should be avoided. Baby should be
breastfed by the mother and given dapsone. With
breastfeeding and these precautions there is very little
chance that baby will get infected!.
Breast engorgement, nipple trouble, mastitis and
breast abscess are not considered a reason for stopping
breastfeeding. Breastfeeding the baby will relieve en
gorgement and mother should be treated with proper
antibiotic. Severe illnesses may be a rare contra indi
cation to breastfeeding for example—congestive heart
failure. In these conditions doctor should be consult
ed.
6. Continue breastfeeding the baby when he is suffer
ing from diarrhoea, cough and cold or fever:
The breastmilk provides anti-infective substances
and adequate nutrition which helps the baby recover
faster. During diarrhoea breastfeeding should be con
tinued alongwith the oral rehydration solution. Baby
should get fluids—breastmilk provides fluids as well as
nutrition. During an attack of cold; baby’s nose may
be blocked hence baby may not suck, on the breast.
The nose should be cleared and baby put on breast.8
The baby may need some nasal decongestant drops.
If the baby is not able to suck, a doctor should be
consulted.
7. There is no harm to continue breastfeeding during
pregnancy:
Breastfeeding does not do any harm to the mother,
foetus or the suckling baby. The extra dietary require
ment of the mother due to pregnancy, and lactation
should be provided for in her diet. Extra requirement
during second and third trimester of pregnancy
220
is 300 calories and 14 grams of protein per day and
during lactation 550 calories and 24 grams of protein
per day.7
8.
Mother can breastfeed the child lying or
whichever is convenient to her :
sitting
The mother may feed the baby sitting or tying, me
latter being almost universal at night. If the mother
is relaxed and baby comfortable, with easy access to
the breast, irrespective of the fact whether mother is
lying or sitting—the baby's head should be supported8.
9. A lactating mother needs to adopt a suitable con
traceptive method to space the next pregnancy :
The traditional belief that lactation delays onset of
menstruation after childbirth and provides some degree
of protection against pregnancy has been proved correct
by scientific studies. It has been shown that 5 to 10
per cent of women may conceive,, during lactational
amenorrhoea. In communities where lactation is con
tinued for 24 to 30 months no less than 30 per cent of
pregnancies occur while lactating and most of these
occur after menstruation. Broadly, introduction of
contraceptives can be delayed until just prior to the
anticipated return of menstruation if information on
duration of lactation and lactational amenorrhoea in
the community is available. It is a must to introduce
appropriate contraception at least after the onset of
menstruation.8
10. Mothers from poor socio-economic status have
enough breastmilk for their babies :
Lactation seems to be physiologically well protected.
The volume of breastmilk in mothers from poor socio
economic status is slightly less than in well nourished
mother but the quality remains more or less unaffected.
In such mothers the exclusively breastfed infant may
stop gaining weight and supplementation may be need
ed before six months of age. The best alternative
for these mothers would be to eat more of what she is
already eating to improve her milk rather than spend
on artificial feeding which on an average costs about
one third of national minimum wage.2
11. Breastfeeding should be continued for as long as
possible :
It is difficult to establish a precise ideal duration of
breastfeeding. Bottle feeding is almost always harm
ful before six months of age and more so in the poor
SWASTH HIND
221
September \9%5
environments. Even during second year of lactation
the breastmilk output among poorly nourished mothers
is about 300 to 500 ml per day5 which is sufficient .to
meet about half of the protein and calorie requirement
of a child in the second year of life. In view of good
quality protein and substantial contribution to calorie
intake the mothers especially in poor environment
should breastfeed their children as long as possible.
Bottles and niples are difficult to keep clean and are
an added expenditure hence feeding with cup
spoon is preferable.
and
If, however, bottle is needed,
the mother must be taught in detail how to clean it and
if possible should have at least 2-3 bottles and nipples
so that she does not have to resort to boiling a bottle
before every feed. The bottles and nipples should be
cleaned with a detergent water and brush then boiled
12. Start supplementary feeding when the baby is 4
to 6 months old :
in water for at least ten minutes. The hole in the teat
should permit only a thin stream of milk to flow.
At around four to six months of age the baby out
grows the milk supply from the breast. Breastmilk
alone is no more sufficient hence supplementary feeding
has got to be started to ensure proper nourishment of
the baby. If road to health card is being maintained
for the baby one can decide exactly when it is needed.
When the growth curve slackens or becomes flat (and
other causes like infections are ruled out) supplementa
tion should be started. Supplementation before four
to six months is harmful4,5, predisposing the child to
various types of infections, allergy and malnutrition.
Animal milk is preferable than powder milks.
The
milk should not be diluted and if buffalo’s milk is
being used the thick cream on top should be removed.
One tea spoon of sugar may be added to about 50-75
ml. of milk.
The baby should not be left alone with
the bottle, he may choke with excess of milk or keep
sucking air if bottle is not held properly.
The milk
should be lukewarm which can be checked by touching
the bottle with back of the hand.
The bottle should
be held so that the nipple is full of milk otherwise
baby may keep sucking air which
The traditional practice of ‘Annaprashan’ around six
months, being followed in many communities needs to
be encouraged and supplementation should be adequate
in quantity as well as in quality. To start with give
the baby one or two tea spoons of a new food at a
time over the first few days until the baby gets used
to it and then start the second fopd. By the age of
one year the child should be accustomed with the
family diet.
13. If the baby cannot be breastfed due to separa
tion from the mother, mother's death, insanity
or malignancy, the baby may have to be arti
ficially fed but it should be done with great
care:
The requirements of artificial feeding may be sum
marized as good knowledge of the mother about
various aspects of infant feeding, facility for boiling
and sterilizing of bottles and nipples, safe source of
water, reliable milk supply, adequate washing facilities,
sufficient money and time to prepare feeds. All these
may not be available to an average Indian mother
hence artificial feeding should be resorted to only if
breastfeeding is not possible at all.
222
distends abdomen
and causes baby to vomit or regurgitate milk5.
REFERENCES
1.
Human milk in the modern world. D-B. Jclliffe and
EFP Jclliffe. First ELBS Edition 1979.
2.
Breastfeeding—The Biological option* GJ. Abrahim
First ELBS Edition*
3.
Breastfeeding in Practice—E.
Oxford Medical Press 1982.
4.
Infant and young child feeding*
WHO/UNICEF WHO Geneva 1981*
5.
Manual on feeding
infants and
young children.
M* Cameron Y* Hofvander* Third Edition Oxford
University Press 1983.
6.
Feeding and care of young infants and children.
Shanti Ghosh UNICEF Fourth Edition 1981.
Helsing F. S. King
Current
issues.
7* Recommended dietary intake for Indians* ICMR 1981*
8. Prema R. The effects of contraceptives during lacta
tion on Maternal and child health* ICMR Bulletin
13(12) : 121-124 Dec. 1983.
SWASTH HIND
Food hygiene covers all measures necessary to prevent contamination of food with
harmful micro-organisms and toxic compounds, and ensures the safety and wholesomeness
of food at all stages of its production, storage, handling, transport, etc., till it is consumed.
This will prevent food poisoning and other food-bome illnesses.
FOOD HYGIENE
Smt. K. Sheela
\V holesome food is many a time adulterated by unr v scrupulous persons by adding harmful substances.
Also residual effects of pesticides used for destroy
ing insects or pests may be present in food and may
make it harmful to use. The food may contain harm
ful micro-organisms or substances produced by the
micro-organisms, and this problem is most common in
(India. Food hygiene covers all measures necessary to
prevent contamination of food with harmful micro
organisms and toxic compounds, and ensure the safety
and wholesomeness of food at all stages of its pro
duction, storage, handling, transport, etc., till it is
consumed. This will prevent food poisoning and
other food borne illnesses.
Micro-organisms
The term micro-organism is applied to bacterial
yeasts and molds all of which are forms of plant life.
So small are they that they cannot be seen without a
microscope. The word germ is frequently used to
refer to any micro-organisms which cause diseases.
The items commonly
responsible for food borne
diseases are milk and milk products, meat, fish, eggs
and raw vegetables and are liable to be contami
nated with faecal borne bacterial amoebae and ova
of parasites especially when they are grown in sewage
farms and where night soil is used as manure. Fresh
milk is contaminated with harmful bacteria such as
mycobactarium tuberculosis and brucelle if the
milch animals are infested with these organisms. Meat,
poultry and eggs are more often contaminated with
•several types of pathogenic micro-organisms such as
bacillus anthrax. Fish and shell fish get contami
nated with pathogenic bacteria. The warm and
SEPTEMBER 1985
humid climate, characteristic of many parts of India,
encourages the growth of molds, yeasts and bacteria.
Many of these grow on the surface of food and result
in spoilage. Many fruits and vegetables which grow
in abundance at certain seasons of the year in areas
far removed from markets are spoiled in transit. Un
fortunately some of the food products lost in this
way are especially of high nutritive value, i.e., papaya,
mangoes and green leafy vegetables.
The greatest waste from micro-organisms occurs
when cereal grains, dry pulses or oilseeds become
wet.
This may occur because of monsoon rains,
floods and unsuitable methods of storage. The pre
sence of certain types of micro-organisms in food can
•make it harmful and in some cases dangerous. Harm
ful bacteria act in one of the two ways—causing in
toxication or infection.
Intoxication results not from
bacteria themselves but from poisonous substances
called toxins which are produced by the bacteria as
they grow. This toxin is quite resistant to heat and
survives the temperature of ordinary cooking. When
food containing such toxin is eaten the gastro-intes
tinal tract is irritated and within 4 to 6 hours violent
vomiting results.
Diarrhoea is sometimes an ac
companying symptom.
The disease lasts for a rela
tively short time and does not usually has serious
lasting effect on the healthy adults. However, it is
extremely dangerous for infants and for elderly and
me sick.
Contamination by rodents
Food is likely to be contaminated with filth and
micro-organisms during storage by rodents, cockro
aches and insects through their excreta.
Newspapers
223
and banana leaves used for wrapping bread and
other cooked food are not hygienic.
They may be
contaminated with dust and
filth during handling.
Foodstuffs displayed in open trays for sale in the mar
ket place or by the roadside are contaminated with
road dust and flies.
Community or Institution feed
ing may present major food hygienic problems. Dan
gers arise from the kitchen premises not being main
tained in clean way and from the spoilage of foods
of animal origin stored for long periods at room tem
perature.
Hygienic conditions of a market
Markets have to be kept clean to prevent conta
mination of food offered for sale.
The principal
requirement for maintaining hygienic conditions in a
market are: adequate space, sectioning, ventilation
and lighting, concreted floors with proper drainage,
adequate and safe supplies of water for draining and
washing, daily cleaning of stalls meant for animal
foods and fish, prompt collection and disposal of
garbage and proper sanitation and control measures
for flies and rats.
a number of ways. The depositing of human feces
by roadside, fields and streams, washing of clothings
of sick persons near wells and the use of improperly
operated latrines and sewage systems are responsible
for large number of infections and deaths in India
each year.
The construction and use of properly
built latrines in both private and public places is
the best solution to this problem. It is important that
every school is provided with well maintained lat
rines and children are taught to use them properly.
Insects
Flies and cockroaches are sources of contamina
tion for they also carry disease germs on their bodies
and infect not only the food over which they crawl,
but also utensils and grinding stones in the kitchen.
Many cases of infections resulting in diarrhoea and
dysentery have been traced to cockroaches.
Also
the harm done to the food supply by rat and mice is
not limited to the loss of the food they eat.
These
rodents are susceptible to infection by bacteria
harmful to health.
They in turn spread these bac
teria over food by the droppings and urine.
Water-borne diseases
Persona] hygiene
The sanitary conditions of rural and urban areas of
the developing countries constitute the larget single
health problem in the world today. It has t>een estimat
ed that three fourth of the population of India has un
safe drinking water and that water borne diseases affect
about 50 million people each year and kill about two
million. When water is in short supply, every source,
good, bad or worse is used.
Use of untreated river
water results in widespread water borne diseases.
The harmful micro-organisms which contaminate
food are often transferred to the food by a person’s
hands.
This gives us good reason for the very im
portant rule that hands should be washed thoroughly
and regularly before handling foods.
Since diseases
can be spread from one person to another by dishes
and glass-ware, it is important that they be cleaned by
sanitary methods.
The methods used for the disposal of human waste
are some of the greatest causes of contamination of
water and the spread of certain diseases.
An indivi
dual who is sick or who is a carrier of any of the seve
ral diseases of the intestinal tract, sometimes called
enteric, diseases, discharges germs in the feces. If
the feces are not disposed of in a proper manner, the
germs may enter the body of other human beings in
To conclude, proper drainage, sanitary latrines,
availability of safe water supplies for drinking and
washing, facilities for garbage disposal, food storage
and preservation free from infestation
by insects
and flies, proper housing of domestic livestock and
maintenance of standard of personal hygiene are a
few important factors to be kept always in mind for
a healthy and happy living. Q
To ensure prompt supply of the Journal quote your Subscriber Number and intimate the change
of address.
For all enquiries, please write to:
The Director
Central Health Education Bureau
Kotla Marg, New Delhi-110 002
224
S'WASTH HIND
WORLD ENVIRONMENT DAY CELEBRATED
Respond to Challenge of Development without
Degrading Environment
f N his message on the occasion of the World En•J-vironment Day, 5 June, 1985, the UN SecretaryGeneral, Mr. Javier Perez de Cuellar, said “the ob
servance of’ the Day should mean a renewal of com
mitment of all peoples to respond to the challenges
of development without degrading the environment.
“The tragic situation in Africa which has been, and
continues to be, the cause of great concern for the
United Nations, contains lessons which can be ignored
only at great peril to the health of human society.
“The calamity has been undoubtedly the result
of a number of circumstances, but the deterioration
.of the environment in that continent is certainly a
major cause. This should alert the world.
A crisis
of this nature and magnitude should not be repeated
in Africa or elsewhere on our planet.
“The world will need to increase food production
by half of the current level to sustain the population
projected for the turn of the century.
In develop
ing countries, which contain the majority of the
human race, the natural resources we need to boost
production—soil, fresh water and forest cover—are
being exhausted at a rate faster than ever before. The
world is losing a great quantity of irreplaceable soil
each year.
“The continuance of this depletion is by no means
the ineluctable fate of this earth and its inhabitants.
The United Nations Environment
Programme has
shown feasibility of environmentally sound agricul
tural development to achieve yields that are sustain
able. This calls for a dual approach.
First, nations
must invest in new farming methods and technologies
to increase production of food and of high-yielding
crops that are resistant to pests and less reliant on ex
pensive chemical fertilizers.
“Second, they must apply our new understanding
of how ecosystems can be managed to support in
creasing human populations.
With proper manage
SEPTEMBER 1985
ment and wise investment, more people need not suffer
from destruction, nor lower levels of living, nor en
vironmental despoliation.
“The world disposes of sufficient resources, human,
natural and technological, to provide for a decent
quality of life for a global population much larger
than the present.
World Environment Day
this
year should focus our awareness on the need to ini
tiate steps suggested by the UNEP, among others.
“In the sphere of industrialisation also, we have by
no enough knowledge to pay greater respect to the
environmental dimension.
What is needed is to
translate that knowledge into sound policies assur
ing the care and protection of the natural surround
ings of human and animal life, which is a condition
for continuous economic growth for all the peoples
of the world,” the Secretary-General said.
—U. N. Weekly Newsletter, June 15, 1985.
SOUTH ASIA CONGRESS
ON ADVANCES
IN RESPIRATORY MEDICINE
South Asia Congress on Advances in Respi
ratory Medicine—1985, conducted
by the
Society for Advanced Studies in Medical Sciences
and sponsored by Centre of Applied Medicine—
Nepal, Association of College of Chest Physi
cians & World Family Society’s Institute of
Macrobiochemy, will be held from 6-8 DECEM
BER, 1985, in NEW DELHI.
Advance re
gistration by 16th November, 1985. For registra
tion and details please contact:
Organising Secretary
Post Box 6564
New Delhi-110 027
Phone: 502204 Cable: ASTHMA
Telex: 31-3809
“ALL FREE PAPERS WELCOMED”
225
Hypertension or high blood pressure is considered to be a primary risk factor in the
development of cardiovascular disease. Control of hypertension can lead to improved
management of cardiovascular disease. Sodium has long been implicated in the etiology
or development of hypertension but in recent years more discerning evidence has clarified
the relationship between sodium and blood pressure.
IS SODIUM AND HYPERTENSION
RELATED?
Smt. Kamal G. Nath
Q
alt was one of the first international food
additives. The addition of salt to a food system helps
to prevent bacterial growth.
Furthermore, salt can
act as a functional food ingredient providing speci
fic technical effects during food processing.
More commonly, however, salt serves as a flavour
enhancer.
These multiple uses of salt—preservative,
functional ingredient and flavour enhancer plus the
naturally occurring sodium in food stuffs results in
a per capita salt consumption in India of approxi
mately 10-12 gms/day.
In spite of the fact that for centuries salt has been
used in home and commercial food preparation, salt
consumption is not risk free.
Under certain circum
stances, sodium can be an etiologic factor in the deve
lopment of hypertension or high blood pressure. In
simple terms, the rationale relating sodium to hyper
tension is that excess salt consumption in sodium
sensitive individuals elevates blood pressure.
The general consensus is that the sodium ion, as
opposed to -the chloride ion, is the component of the
salt implicated in hypertension.
Although sodium
is recognised as a factor in the etiology of hyperten
sion, its role in the pathogenesis of hypertension is
not well understood.
General points of consensus relating sodium and hyper
tension
1. Salt, or sodium chloride is composed of two ele
ments that are required by the human body.
Of the
■two, only the cation sodium, has been implicated in
the pathogenesis of hypertension.
226
2. Physiologically, sodium is found in higher con
centrations
extracell ularly
than
intracellularly.
Sodium is the primary extracellular ion in maintain
ing osmotic balance.
3. The adult human requirement for sodium is
less than 1 gm. salt/day (400 mg sodium); on the averrage, adults consume ten to twelve times this amount
daily.
4. Sodium influences fluid or blood volume. To
achieve a constant concentration of sodium in
the blood, endocrine or hormonal factors influence
the resorption of sodium and water from the kidney
tubules.
Aldosterone, a mineral corticoid hormane
of the adrenal cortex, enhances sodium resorption,
similarly, the renin angiotensin system enhances up
take of both sodium and water.
5. With few exceptions, cultures that ingest mode
rate amounts of sodium have a low incidence of hyper
tension whereas cultures with a generous intake of
sodium are prone to hypertension.
In general, cul
tures with modest sodium intake are developing coun
tries, whereas those with high intakes are industriali
sed countries.
Modes of action
A number of genetic and environmental factors are
considered to be predisposing to the development of
hypertension including nutritional factors. Factors
proposed as having primarily a genetic component in
clude rare or ethnic background, family history, and
variations in endocrine and kidney function.
Envi
ronmental factors implicated in hypertension include
SWASTH HIND
psychogenic stress as well as several nutritional fac
tors, with excess sodium intake being strongly im
plicated.
Nutritional factors
In addition to the ingestion of excess dietary sodium,
nutritional factors that have been implicated in the
pathogenesis of hypertension include excess sucrose,
excess calories and limited linoleic acid intake. Sodium
has been considered the most detrimental of these
various nutritional factors.
Carbohydrate intake and hypertension
Several investigators have determined
the rela
tive effect of sodium and carbohydrate intake on
blood pressure.
Sucrose and sodium are inter-related
with insulin being the link.
Insulin enhances the renal resorption of sodium as
well as the resorption of potassium and phosphate
but inhibits calcium resorption.
Aparently, a high
level of simple carbohydrate intake stimulates insulin
release, which increases renal handling of sodium.
Quite possibly then, an individual might ingest only
a moderate amount of sodium, however a high intake
of simple carbohydrates would stimulate insulin pro
duction, causing enhanced renal absorbtion of sodium
and a subsequent rise in blood pressure.
Linoleic acid and hypertension
Experiments suggest that dietary linoleic acid in
take lowers blood pressure.
Since the fatty acid
composition of adipose tissue tends to reflect dietary
fat intake, the data suggest a relationship ' between
linoleic acid intake and blood pressure.
A positive correlation is noted between dietary lino
leic acid intake and urine volume and sodium con
centration and a negative
correlation with serum
sodium concentration suggesting that linoleic acid
might lower blood pressure by increasing urinary
sodium excretion.
Obesity and hypertension
The effect of sodium intake and excess body weight
on hypertension has been debated for some time. A
higher percentage of obese individuals than normal
weight ones are hypertensive, since the obese in
dividuals consume more sodium as a result of increa
sed calorie intake; increased calories —> increased
sodium—> increased blood pressure.
Sources of sodium intake
Dietary sodium can be classified as either discre
tionary or nondiscretionary.
Discretionary sodium
is that which consumers voluntarily add to food,
that is at their own discretion.
The remainder of
sodium intake is nondiscretionary.
The consumer
has limited discretion as to whether to consume
sodium, as it is either added by the manufacturer
during food processing or is naturally occurring
sodium.
The reviews estimated that only one-third
SEPTEMBER 1985
of dietary sodium intake is discretionary, the majority
being nondiscretionary. Thus, if an individual
consumes approximately 10 gm. salt/day, ap
proximately 3 gms. would be from discretionary sources
and the remaining 2 gm. would be non-discretionary
sources. There are limited data to indicate that daily
sodium intake has significantly changed during this
century.
Rather, the significant change has been in
a shift from discretionary to nondiscretionary intake.
As consumers purchase more convenient style foods
which have already been seasoned, the discretionary
use of sodium decreases.
Since the majority of sodium intake is nondiscre
tionary, the individual needs some knowledge of food
composition to make judicious
food choices, and
thus reduce nondiscretionary sodium intake.
Nondiscretionary sodium intake
The definition of low, moderate and high sodium
containing foods is quite arbitrary.
Foods that con
tain less than 100 mg. sodium per serving are low
DISORDERS CAUSED BY DEFICIENCY
OF IODISED SALT
Iodine deficiency disorders in the human
body
include goitre—an enlargement of the thyroid gland,
mental retardation and physical disabilities such as
stunted growth, defects of stance and gait, squint,
lack of muscular coordination and deaf-mutism.
Another serious iodine deficiency disorder is certinism which is a condition of mental retardation com
bined with some of the other infirmities.
The total requirement of iodised salt for the hy
per-endemic zone has* been estimated at 10 lakh
metric tonnes. At present the public sector is pro
ducing 1.92 lakh metric tonnes per annum. In order
to bridge the gap between demand and supply the
Government have permitted the private sector also
to produce iodised salt It is expected that the
country’s requirement of iodised salt will be fully
met by the end of the Seventh Plan.
The endemic goitre belt in India covers the en
tire Sub-Himalayan Region and includes the States
of Jammu and Kashmir, Himachal Pradesh, Uttar
Pradesh, Bihar, West Bengal, Sikkim, Assaim, Arunachal Pradesh, Nagaland, Manipur, Meghalaya and
Tribura apart from Punjab, Haryana, and the Union
Territory of Chandigarh. Endemic goitre is also
found prevalent in certain districts of Madhya Pra
desh, Gujarat and Maharashtra.
The National Goitre Control Programme is an en
tirely Centrally Sponsored Scheme and the
entire
expenditure towards iodisation of salt is met by the
Government of India. A sum of Rs. 20.66 lakhs was
spent on iodisation of salt in 1983-84 and Rs. 17.00
lakhs till December, 1984.
(Information given by Smt. Mohsina Kidwai,
Minister of Health and Family Welfare, in Lok Sabha on25
March, 1985.)
227
sodium foods, foods with moderate sodium content
are those containing 100-250 mg. per serving, and
those with more than 250 mg. per serving are high
sodium foods. As calories of foodgrain products,
meats and dairy products have moderate to high
sodium content whereas vegetables and fruits con
tain moderate to low amounts.
Although most grain products individually contain
only moderate amounts of sodium, as a category they
are the targets contributor of non-discretionary
sodium, primarily because of the quantity of grain
products being consumed and not because they are
particularly concentrated sources of sodium.
Meat, poultry, fish, eggs, milk, etc., contain mode
rate amounts of sodium*
Sodium content tends to
increase with processing.
Cheese and condensed
milk are also examples of proceesing which result in
elevated sodium content.
These are essentially con
centrated milk products and, consequently, the sodium
content is also concentrated, furthermore, salt is added
during cheese production.
Incidentally, human breast milk contains 15 mg.
sodium/100 ml. The sodium content of breast milk
is only one-third that of cow’s milk.
A breast fed
infant consumes a low sodium food compared to one
who consumes cow’s milk.
Many of the foods in fat category, however, contain
moderate .to high amounts of sodium.
Butter for
example is traditionally salted to retard spoilage.
. Fruits generally contain insignificant amounts of
sodium and thus the sodium conscious individual can
consume fruits liberally.
Most of the fruits contain
less than 25 mg. per serving.
Processing, including
canning, glazing or candying and drying all tend to
increase the sodium content.
Sodium content of the
dried fruit is elevated because the naturally occurring
sodium is concentrated as a result of the fruit being
dehydrated and because the compound sodium sul
phite is used in the drying process.
Fresh vegetables like fresh fruit contain insigni
ficant amounts of sodium.
Exceptions to this, how
ever, include several leafy vegetables, which edge into
the moderate sodium range.
Freezing, canning and
brining progressively increase the amounts of sodium.
Discretionary sodium intake
As previously said, discretionary sodium is that
which an individual voluntarily adds to foods during
home food preparation or in seasoning food. Since
the salting of food is largely a habit, the first step in
reducing discretionary sodium intake might be to
stop voluntarily additions of salt.
Another approach to curbing discretionary sodium
intake is to substitute other seasonings for salt, that
is herbs, spices and garnishes can be an alternative to
salt.
Substitutions cannot, however, be made indis
criminately, as several flavouring aids are high in
sodium content and would not be effetive substitutes.
Hypertension is the most prevalent and most dan
gerous precipitating factor in the genesis of cardio
vascular disease, and the cardiovascular disease, in spite
of a recent decline in mortality incidence, is the
leading cause of death in developed
countries.
Sodium intake is thought to play a strong role in the
pathogenesis of essential hypertension.
A synthesis
of current literature on the pathogenesis of hyper
tension indicates that dietary sodium may be involved
in the pathogenesis, both from a genetic and an en
vironmental perspective.
Thus, some individuals
may, infact, have a genetic basis for sodium sensiti
vity. and a generous dietary sodium intake would ex
acerbate this defect.
A
NATIONAL NUTRITION WEEK CELEBRATED
T
collect information on dietary attitudes and beliefs
about various foods, and balanced low-cost diets were
evolved for different age-groups and areas.
The Union Minister for Food and Civil Supplies,
Rao Birendra Singh, in a message on the occasion
said that the misconception that nutritious food was
costly food should be removed from the minds of
the people through practical demonstrations by the
mobile extension units of the Food and Nutrition
Board. He said that since 1973, nutrition surveys
were carried out in different parts of the country to
The theme of the National Nutrition Week this '
year was “dietary iron in human nutrition”. Iron
deficiency is common problem among pregnant women.
Care of pregnant women is not only important for
women but also for growing foetus and the new born
baby. In the programme, balanced diets and nutrition
recipes from locally available low cost foods, scien
tific methods of cooking, food and water hygiene, de
ficiency diseases and their prevention, home scale pre
servation of fruits and vegetables, weaning foods,
food source of nutrients and their requirements were
demonstrated. The emphasis was laid on informing
and educating the vulnerable groups, i.e., young
children, expectant women and lactating mothers.
he fourth National Nutrition week was celebrated
throughout the country by the Food and Nutrition
Board of the Union Food Department with coopera
tion of State Governments and national and interna
tional organisations from 1-7 May, 1985. The purpose
of the celebration was to highlight the activities of
the Government in combating malnutrition and creat
ing nutrition awareness among the masses.
—P. I. B.
228
SWASTH HIND
The time is not far away when the methods like genetic engineering, or some chemical
substance which are now underway, would become practicable measures in slowing down
the process of ageing.
BIOLOGY OF AGEING
Dr Hemant Kumar
is a unique, inevitable, universal, natu
ral and biological phenomenon. It used to be
considered a disease entity in the past, or a sequela
of toxic reactions within the body due to infections,
but now it has been established that ageing is essen
tially a biological condition or “process” and that it
is associated with certain specific and well-defined
changes which involve both soma as well as psy
che.
geing
A
To explain how and why ageing occurs, several
theories have been advocated.
Goyal’s (1966) view is that the process of ageing
starts just after conception; from here evolution
(growth) and involution (atrophy) run concurrently
in earlier life, but in the later part of life, the latter
gets upper hand as different organs may have diffe
rent biological age, involution may not progress with
the same pace in all the organs. Sir James Paget
said, “It is an error in the chronometry of life”.
Vakil (1966) also advocates a similar theory. He
says, “Throughout life two main types of phenome
non, sowewhat contradictory in nature are demon
strable side by side in every single individual. They
are the changes of growth or evolution on the one
hand and that of atrophy or ageing on the other.
While the former changes are far more obvious or
prepondant in infancy and childhood, that of ageing
or involution become dominant in middle aged and
elderly”.
SEPTEMBER 1985
Specific protein changes
Rao (1969) suggests a different theory. He points
out that certain specific protein changes occur at
different stages of life. He says, “Various kinds of
protein biosynthesis differing in their turn over rate
during different phases of ontogenesis have been disco
vered with the help of tracer methods. These are (i)
growth synthesis, (ii) functional synthesis, (ii) regen
eration synthesis, (iv) stabilization synthesis, and (v)
stimulated synthesis.
He further explains that the rate of growth syn
thesis is 42 times lower in old (540 days) than in
young (60 days) rats, while the rate of stimulated syn
thesis is only decreased ten fold. Regeneration syn
thesis also decreases but not so much in olds. The
rate of stabilization synthesis is not much affected.
The functional synthesis is fairly high in second half,
but low in late ontogenesis. Ageing process is also
associated with physio-chemical changes in the body
proteins. Their iso-electric point changes, their in
hibition capacity is decreased. With age, the con
centration of albumin decreases and concentration of
globulin, gamma globulin especially, increases.
In
man and animals, the protein content of serum goes
up in the first half of ontogenesis and with advanc
ing age decreases. Protein fraction in skeletal mus
cles also changes with advancing age. Amount of
actinomycin increases while sacroplasmic protein de
creases. Stroma protein also decreases, leading
to
shortening of muscle fibre in aged.
229
It is suggested even dopamine has a role to play in
the process of ageing.
At Sloan-Kettering Cancer
Centre, New York, it has been confirmed that ani
mals on heavy doses of L-dopa experience a gain
of 19% in their life span beyond their normal life.
But scientists do not wish to conduct such experi
ments on human beings for fear of serious side-effects
such as mental imbalance. Nevertheless, the efficay of L-dopa in prolonging life in mice is signifi
cant.
tain the body’s immune responses in oid age. In
1975, Takashi et al, succeeded in transplanting thy
mus and bone marrow from young mice to older
ones. As a result immune system of 19 months old
mice were successfully rejuvenated to the level of
4-month olds. Some of the these mice are still alive.
Dr. W. Donner Denckla of the Harvard Medical
School thinks, “If we can reproduce the immune
competence of a ten year old, when man is at his
healthiest—your expected life span will go up to
200, 300 or even 400 years”.
Immune system
Neurohumoral changes
Another focus of new researches on ageing centres
on immune system. Many new studies now implicate
the thymus as a key to the ageing of the immune
system. There appears to be a link between the
hypothalamus, the pitutory and the thymus. The
slow atrophy of the thymus during ageing seems to
be paralleled by a decrease in the number of T-cells.
As a result older people become more disease prone.
Today immunologists are exploring avenues to main
Chebotarev (1982), Director, Institute of Gerontor logy, Soviet Academy of Medical Sciences, believes
that leading mechanism of ageing depends on neu
rohumoral changes, which determine mental changes,
changes in behaviour and human working capacity
and deviations in the control of many organs. Ex
periments also have proved that changes due to age
in the mechanism regulating the nervous regulation
can weaken the nervous control of tissues, change
GROWTH THROUGH PLAY
ne of the major values of play, be it make-believe
O
or structured competitive games, is that it
allows for a reversal of daily contingencies. In play,
the child is able to impose himself or herself on ex
ternal conditions, rather than being subject to them.
There is a reversal of social control: during playtime
the children, not their parents, are in charge, and the
roles can be reversed. Creating the opportunity for
reversals has important implications as a motor of
the psychological development of the child, affective
social and cognitive. On the emotional plane, play
allows the child release from the tensions that arise
from restrictions imposed by the environment; play
provides the opportunity to work out frustrations,
and is therefore highly therapeutic. Through playing
with others, the child learns to share, to give, to take,
to cooperate through the reversibility of social rela
tions.
According to Swiss, developmental psychologist
Jean Piaget, reversibility is the essential cognitive
conquest of middle childhood, the main tenet of the
concrete logical thinking typical of that stage of
development. Play certainly contributes in many
ways to help the child gain mastery of the environ
ment, to construct the structures of knowledge that
mark the successful adaptation to this environ
ment. There is recent evidence from psychological
studies that children are developmentally
further
ahead, at least in terms of cognitive complexity, in
play than in other situations.
If health is not only the absence of disease, but the
fulfilment of each individual’s developmental poten
tial in the physical, social, emotional, moral and cog
nitive spheres, in other words the attainment of a
happy mental life, then the fostering of play is clear
ly part of preventive medicine. Play is fun, but not
only fun, it is not nonsense, it is not a waste of time.
It is truly a basic right for each child.
From: DASEN, PIERRE R. The value of play.
January/February 1984, p. 13-
230
World health,
SWASTH HINfc
their sensibility to hormones and in the end cause
secondary disorders of tissue metabolism and func
tion. He further points out that the key role in the
process of ageing is played by changes in the hypotha
lamus, particularly during the male and female cli
macteric periods. Disorders of neurohumoral control
system and* a pathological climacteric period as a
consequence, seem to be a prologue to the rapid de
velopment of atherosclerosis and hypertension.
MORE TREATMENT FACILITIES FOR CANCER,
MALARIA AND LEPROSY IN SEVENTH PLAN
FACILITIES FOR TREATMENT of cancer are being ex
tended to 20 more medical colleges during the current finan
cial year The allocation for cancer treatment facilities has
been doubled for this year. Sophisticated equipment such as
whole body cat scanners, linear accelerators, remote control
treatment and planning systems would be purchased for the
various regional cancer centres- *
Heredity
It has been observed that heredity also influences
longevity. From a study of 5000 family trees, which
revealed that in the group of people aged between
80-84 years,’ the frequency of family longevity was
52%, while in the age group 105-pIus, it increased to
71%. It was further observed that those who enjoy
long lives, their relatives show a certain bioelectric
activity of the brain which distinguishes them from
rest of the population. They have a higher frequen
cy of spectrum of E.E.G. rhythm, while the rate of
change due to age in term of activity of brain is
slower.
Experiments have succeeded in increasing the life
span of animals by 25-50 per cent by means of
certain physical, chemical and biological factors
which prolong the active oeriod of life span when
the animals produce off-spring.
Optimistically, it may be said that time is not
far away when the methods like genetic engineering,
or some chemical substances which are now under
way, would become practicable measures, and may
be then we succeed in slowing down the process of
ageing.
REFERENCES
1.
Chcbc.tarcv, D. (1982). The Biology of Ageing.
Health, May Issue.
2.
Patel, J.C., Bagadia, V.N.. Cooper, R.N., Gogal, B.R.,
Jhivcr, C.L., Rao, M.V.R. and Vakil, R-J. (1966) Grow
Old Gracefully. Panel Discussion. The Bombay Hosp. J.,
Vol. 8, No. 3, pp. 118-131.
3.
Rao, A.R. (1969). Protein changes Ageing Process.
J. Geront. Vol.l, No. 1, PP- 15-19.
SEPTEMBER 1985
World
The limited figures available from the six Cancer Regis
tries operating under Indian Council for Medical Research
indicate an increase of about 1.2 million cases of cancer.
About five lakh new cases are added every year. The trend
will continue for decades to come with the increasing moder
nisation and industrialisation which will create the presence
of innumerable envionmental carcinogens. The changes in
life style and habits like smoking, tobacco chewing and
drinking have aggravated the situation.
Another situation peculiar to India is that cancer occurs
in India at a considerably younger age than it does in deve
loped western countries. It occurs 10 to 15 years earlier in
India. The most common cancers in our country are cancer
of uterine cervix in women and the oral cancer in men.
These types of cancer represent about forty per cent of all
cancer cases in the country. They are predominantly environ
ment-related and have a strong socio-cultural relationshipBut these are preventable.
By disseminating information
about symptoms of the disease through health education
and mass media, prevention of the disease and early treat
ment of cases would be ensured.
For early detection arid' treatment of malaria cases and
to prevent deaths due to malaria, 1.28,376 fever treatment
depots and 2,52,523 drug distribution centres have been esta
blished. Further, 80 districts are under P- falciparum con
tainment programme covering six million people.
The anti-leprosy vaccine developed by the Indian Cancer
Research Centre, Bombay, will be put on human trials
during 1985-86 under the auspices of TCMR. A few more
Regional Leprosy Training and Research Institutes of Teetalmari (Bihar), Pagiri (Andhra), Magadi (Karnataka) and
Baroda (Gujarat) will be set up during the year- Three
centres are already functioning- Leprosy patients have been
cured with the application of multidrug regimen therapy
within two to three years. Twelve districts have been taken
up for this treatment. Three more districts will be taken
up shortly.
Ind
All the 98 highly endemic leprosy districts will be brought
under the multi-drug regimen treatment during the Seventh
Plan, period. .This will help in arresting the disease in
60 per cent of the known leprosy cases.
Courtesy : YOJANA
1—15 July. 1985
231
A Historic First for Antibiotic Development Team
John Newell
he world’s first hybird antibiotic has been de
veloped by British scientists using complex gene
manipulating techniques, and it could prove as im
portant in treating infections as the original disco
very of penicillin.
T
Although the hybrid developed by a team under
Professor David. A Hopwood, FRS, of the John Innes
Institute in Norwich, eastern England, is of no medi
cal value, it opens the way to the production of
others that should prove far more potent than exist
ing simple types.
The hybrid results from a mixture of two antibio
tics, and its creation should enable pharmaceutical
companies to manufacture a new generation of or
ganisms for countering bacterial and fungal infec
tions not only in people but in agricultural crops and
animals. One of the increasing problems m dealing
with these infections has been the evolution of disease
causing organisms that are resistant to existing anti
biotics.
It is reasonable to expect that existing bacteria will
have no resistance against some of the hybrid anti
biotics that can now be made using Professor Hop
wood’s genetic engineering techniques. An additional
advantage is that these methods, once perfected, will
be employed quickly to produce new antibiotic mix
es when bacteria do build up resistance to an exist
ing hybrid.
Cloning the answer
Scientists hope to produce more selective anti
cancer agents, with fewer side effects on normal
tissues in a patient’s body. Another possibility is the
large scale production of anti-leprosy and anti-tuber
culosis vaccines using a combination of genetic engi
neering and cloning techniques.
232
Professor David A. Hopwood views test tubes
of micro-organisms at the John Innes Institute in
Norwich, England,
This method is expected to result initially in or
ganisms producing a greater amount of the antibiotic
rifamycin than occurs naturally. Once this has been
achieved, the resultant organism could be reproduced
simply by cloning.
The work of the Norwich team involved transferring
genes from one strain of streptomycete, an antibiotic
producing organism, into another type. Streptomycete
varieties are responsible for some 70 important anti
biotics, including rifamycin, used against tuberculosis
SWASTH HIND
and leprosy; adriamycin, for treating some forms of
cancer; and various widely employed antibacterial drugs
such has erythromycin and the tetracyclines.
In its previous work the team had shown that the
amount of antibiotic made by a streptomycete could
be greatly increased by implanting into it additional
genes, ordering the organism to further produce its
antibiotic. This was done by using a plasmid—best
described as a little circlet of DNA coding material
that is separate from the main DNA of a chromo
some—as the gene carrier.
Bright colours
However, although this early work was a useful
starter, the method of inducing a streptomycete to
make a new hybrid antibiotic was far more complex.
Instead of transferring the complete set of antibiotic
making instructions into a streptomycete, the team
transferred only those for making part of one antibio
tic, actinorhodin, into a streptomycete that itself makes
another, medermycin.
The team, comprising Professor Hopwood, Dr Paco
Malpartida and Mrs Helen Kieser, selected actinorho-
din and medermycin for the hybrid because of their
bright colours. Actinorhodin is blue and medermycin
brown, which could prove useful in distinguishing bet
ween streptomycetes producing either of the strains.
To the team’s delight, some of the “doctored” organi
sms started to produced a purple antibiotic.
Professor Hopwood sent samples to his colleague
Professor Satoshi Omura at the Kitasato Institute in
Tokyo, Japan, for analysis. This indicated that the
purple antibiotic was a hybrid. It was intermediate in
its chemical structure as well as its colour between
actinorhodin and medermycin. Because of this, it
was named meder-rhodin.
The gene splicing/adding experiment at the John
Innes Institute has proved that portions from two sets
of genes representing two different streptomycetes can
be used to produce a complete antibiotic with some
of the features of each of its parents. Using this
method, it is now up to the pharmaceutical companies
to come up with a new and effective series of “hybrid
treatments” to combat infections in humans as well
as fight crop pests and fungal diseases.
RESEARCH INTO DUST-MITE ALLERGIES
Researchers are looking to the tannic acid in tea
to help them solve the problems of allergies carried
by the. common household dust-mite. They have
found in laboratory tests that tannic acid is the only
substance discovered so far to completely neutralise
the allergic effect of the mite.
In an interview with the University of Sydney News,
Mr, Wes Green, a professional officer in the Univer
sity’s Department of Medicine, said the allergens in
the mite had long been associated with either trig
gering or exacerbating such diseases as asthma, hay
fever, eczema and urticaria. “The problem is that
simply killing the mite was not enough as the dead
•mite remains allergenic,” he said. “The allergen itself
has to be neutralised.”
He had decided to experiment with tannic acid be
cause of its effect on changing proteins as used in the
SEPTEMBER 1985
leather tannic industry. “Essentially, the tannic acid
makes the allergen insoluble by replacing its water
groups with phenol groups,” he said.
Researchers were still unsure of the exact prove.
but the effects were known. Because the allergen
was now insoluble, people who breathed in the aller
gen “cannot absorb it into their system”.
He said two species of mite from the genus Dermatophagoides were the target for the'research. These
were Dermatophagoides farinae/commonly called the
American dust mite, and D pteronyssinus, or Euro
pean dust mite, both of them prevalent in house dust
and prime carriers of allergens.
The two species are also often found in large num
bers in clothing, blankets, mattresses, curtains and
carpets, feeding mostly on human skin scales which
—AIS
humans shed continuously.
233
TDR--the Special Programme for Research and Training in Tropical Diseases—is a
coordinated attack by the world’s scientific community upon diseases of the tropics,
and is jointly sponsored by the un Development Programme, the World Bank and
who. TDR stimulates and supports research on new and improved methods to
control six major diseases (malaria, schistosomiasis, filariasis, trypanosomiasis, leish
maniasis and leprosy) by funding research projects world-wide, and by giving special
assistance to research institutions in tropical countries.
TROPICAL DISEASES RESEARCH
Dr Adetokunbo O. Lucas
rTn he long struggle against malaria and other tropical disease is taking a new turn. It has been a see
saw battle, with periods of high hopes and great ex
pectations yielding to moments of despair and des
pondency. Time was when malaria retreated under
the pressure of chloroquine and DDT; when dazzling
successes in some parts of the world generated the
hope that this infection could be totally eradicated
from the globe. But malaria fought back: drug
resistant strains of the parasite emerged, in collusion
with insecticide-resistant vectors. Much ground was
lost, but some of the gains were consolidated.
Other tropical parasitic and infectious diseases have
similarly resisted efforts to bring them under control.
In some cases, as urban areas became free of schisto
somiasis, for example, there was an increase in the
prevalence and intensity of the disease in rural areas,
234
where irrigation schemes and new intensive farming
methods expanded the breeding sites of the water
snails that transmit the infection.
«
The toll on human life and the debilitating effects
of these diseases strengthened the resolve of govern
ments to improve control efforts. A two-pronged
strategy was evolved, entailing vigorous application
of existing technology and the search for new power
ful remedies for prevention and control.
At the 27th World Health Assembly in May 1974
the Member States passed a resolution calling on the
Director-General to intensify who’s activities of re
search into tropical diseases, with the stipulation that
such research was to be carried out as far as possible
in the endemic countries.
SWASTH HIND
Thus was born the Special Programme for Re
search and Training in Tropical Diseases (TDR), ini
tiated by who and co-sponsored by who, the un
Development Programme (undp) and the World
Bank. The diseases—malaria, schistosomiasis, filaria
sis, the trypanosomiases, the leishmaniases and lepro
sy—were the prime targets, firstly, because of the su
ffering and death they cause but also because of their
adverse effects on development. Furthermore, para
doxically, the projects designed to promote develop
ment—the creation of man-made lakes, irrigation sche
mes and similar agro-engineering projects—tended to
increase the distribution and the intensity of some of
these infections. Putting a dam on a river in Africa
may increase snail breeding and schistosomiasis
around the shores of the lake behind the dam. while
in the fast-flowing spillways below the dam the black
flies that spread river blindness find ideal breeding
grounds. A no-win case!
Exploiting a revolution
The past forty years have witnessed a major revolu
tion in the biological sciences. New methods of stu
dying living creatures and their products now make
it possible to find out a lot more about the parasites—
how they live, grow, multiply, enter and leave the
human body, and their specific vectors—and thus to
identify and exploit their weaknesses. Now that some
of the parasites can be grown in test-tubes, we can
.study them more closlely, test directly the effects on
them of potential drugs and discover their responses
to a variety of changes and challenges in the environ
ment.
The information from this research is being used
to desien and fashion new, powerful weapons against
these diseases. Many of the existing control tools
arc not highly effective: in some cases their effective
ness has been blunted by use and abuse; and diag
nostic methods arc often antiquated and not suitable
for use outside specialised laboratories. Some drugs
and insecticides have too narrow a margin of safety
for the individual and the environment, and hence re
quire high levels of technical experience and super
vision to use them safely. Some require complex, longdrawn out schedules which cannot be conveniently
administered on a mass scale for the control of com
munity-wide diseases. We need new, highly effective
tools which can be safely administered with minimal
skilled supervision, which can be applied in simple
schedules (single-dose regimes for drugs, single appli
cations of biological agents to control vectors), and
SEPTEMBER 1985
which the communities and the governments can afford
to acquire and maintain.
As the executing agency of the Programme, .who
has mobilised resources and expertise from academia.
industry, public health departments and other institu
tions from all over the world. The strategy of the
Programme has been to use the scientific resources
of existing research institutions rather than to create
new ones. Scientists from all over the world have
helped to identify needs and opportunities for research,
to establish realistic goals and to plan as precisely as
possible the specific steps that should lead to attain
ing these goals. They are then funded to do the work,
mainly in their own institutions. So the very best
scientific minds in the world are addressing the com
plex technical problems posed by these diseases. By
having the tasks performed in existing institutions, re
sults have been achieved more rapidly and more chea
ply than if new institutions had been established and
fresh scientists recruited. So far, more than 4,000
scientists from 125 countries have participated in the
planning, execution and evaluation of the Programme’s
activities.
The Programme’s scientific net-works are operating
efficiently and its results have been reported in some
4 000 scientific publications. More significantly, there
is now a steady stream of new products ready for use
in the control of these diseases, and many more are
in the pipeline. Some of these products originated from
work supported by the Programme. Others stemmed
from research conducted outside the Programme and
where then “adopted” by TDR-supported investigators
and further developed into usable or potentially usa
ble products.
Some examples of the new products which have
resulted from TDR support:
—Mefloquine—a new potent antimalarial drug discover
ed in 1971 by the Walter Reed Army Institute of Re
search in Washington, DC in the United States, and
effective against chloroquine-resista nt malaria para
sites—has been developed by the Programme in colla
boration with industry and registered for human use
in several countries.
•—Bacillus' thurin]giensis H-14, a bacterium discovered
outside the Programme in 1976, has been developed
with the collaboration of industry into an effective bio
logical larvicide for the control of blackflies, and is
now used as an alternative larvicide in the Onchocer
ciasis Control Programme in West Africa.
235
—Multidrug regimens for the treatment of leprosy,
based on a combination of existing drugs, have been
carefully evaluated within the TDR network and shown
to be more consistently and more rapidly effective in
healing patients than the standard regimen using dapson alone.
—Test kits have been devised to measure the sensi
tivity of malaria parasites to chloroquine and other
drugs in common use. They are helping malaria con
trol programmes to use drugs more rationally, based,
that is, on precise knowledge of the areas affected by
the new epidemic of drug-resistant malaria.
—A simple card test for African try-panosomiasis, ide
ally suited for use at dispensaries and health centres, and
in the field, gives reliable results within a few minu
tes: a drop of blood is placed on the card and the
reaction examined with the naked eye.
New and exciting scientific discoveries already in
the pipeline are being processed into usable tools for
/disease control. Vaccines are under development
against malaria and leprosy. New drugs are being
developed. Some were identified through the tradi
tional screening of large numbers of compounds but,
increasingly, new agents are being “hand-picked” or
“tailor-made”, using clues from studies on the che
mical processes within parasites. Innovative vector
control methods are being tested—from mechanical
traps to the use of the vectors’ natural enemies and
diseases.
Even with new tools, however powerful, the Pro
gramme could fail to achieve the desired objectives
unless the tools- are used in ways appropriate to the
local situation. It is therefore important to study the
distribution of infection and disease in the popula
tion, to determine the most important factors which
influence occurrence of the disease and to design a
strategy geared to the circumstances of the local com
munity.
The role of human behaviour, of the social and
cultural factors which influence the patterns of disease,
must not be forgotten. Control measures must be
socially acceptable and should involve to the fullest
extent the people they most affect, who can partici
pate, not as objects of outside measures, but as sub
jects sharing in the efforts to deal with their own
236
disease problems. This is the rationale of the Special
Programme’s epidemiological and social science re
search activities.
If TDR has achieved nothing else, it has demonstrat
ed the value of international collaboration in tackling
a common threat to humanity. Scientists have colla
borated in this venture across barriers of race, lan
guage, politics and geography. Many of TDR’s acti-f
vities have, in addition, been conducted with the col
laboration of other agencies, including the Edna Me
Connell Clark Foundation, the International Labora
tory for Research on Animal Diseases (ILRAD), the
Onchocerciasis Control Programme (OCP), the United
States Agency for International Development (USAID),
the Walter Reed Army Institute of Research (WRAIR),
the Wellcome Trust, the Swedish Agency for Research
Cooperation with Developing Countries (SAREC),
the Office de la Recherche Scientifique et Technique
d’Outre-Mer (ORSTOM), the South-East Asian Mini
sters of Education Organization—Tropical Medicine
and Public Health Project (SEAMEO-TROPMED),
and the Rockefeller Foundation.
WHO offers a neutral platform where exchanges of
ideas and resources can take place. A chemical com
pound, synthesised in Europe, tested in laboratories
in the United States, the United Kingdom, the Fed
eral Republic of Germany and Australia, is subsequ
ently tried in man in West Africa and Mexico, and
may turn out to be a powerful drug for the treatment
of onchocerciasis. Nine-banded armadillos are caught
Central America and infected with leprosy bacilli;
the bacilli are harvested two years later arid the pro
ducts banked in deep-freeze storage in London; spe
cimens are then distributed to scientists all over the
world and some are used to make a vaccine, evaluat
ed first in Norway and now being tested in Venezuela
and in Africa.
As Rudyard Kipling might just have written:
“East is East and West is West.
And never the twain shall meet:
But there is neither East nor
West, Border, nor Breed, nor Birth
When two TDR scientists stand face to face,
though they come from the ends of the earth.”
Courtesy: World Health, May 1985.
SWASTH HIND
_ BOOKS.
PRIMARY HEALTH CARE
Evaluating Primary Health Care, WHO
Regional
Publications, South-East Asia Series, Technical Pub
lication Series No. 4, 220 pages, price Sw. fr. 7.—- /'
I
( Primary Health Care (PHC) has been recognized by
the Member countries of the South-East Asia Region as
ibeing the key approach to achieving the goal
of
•“Health for All by the year 2000*’. Many countries
have implemented this approach, and some have even
monitored and evaluated its success, as a part of
■their national managerial process. The. stage * has
thus been set to consider the evaluation techniques
adopted by these countries and discuss simultaneously
{other possibilities in order to arrive at an integrated
{methodology that could be adopted by the countries
jof the Region for evaluation. This publication reports
.on a regional seminar that met to discuss the possibi
lities of developing such a methodology.
: It reflects the findings and observations of the various
’experts who attended the meeting. Some of the topics
Jdiscussed are: the purpose of evaluation of PHC and
'advantages of the survey methodology; indicators of
PHC; basic considerations in survey design; data col
lection methods and related considerations; organi
zation of evaluations using sample survey methodology;
selection, training and support of field interviewers;
{and data analysis, promotion and support of PHC
Assessment using survey methods.
|. i
j Written; in a simple, readable style, the book pre
sents the objectives of each topic and the merits, con
straints and other observations made by the experts.
It should be useful to public health administrators,
'statisticians, health planners, managerial
personnel
from the primary health centre onwards, and those
connected with evaluation research. A
'Financial Planning for Health for AM by the year 2000
'—Report of an inter-country seminar. New Delhi, 7-11
March 1983, 236 pages, WHO Regional Publications,
South-East Asia Series (Technical Paper Series, No.5),
price Sw. fr. 7—
j Having accepted the goal of Health for All by the
•year 2000, the Member countries of the South-East
.Asia Region are now seriously engaged in realigning
•their health planning in the context of total socio*
economic, development, and particularly hi health in■frastructure development. Howsoever carefull} the
health planning might be drawn, it will be rendered
•ineffective if it is unaccompanied by an appropriate
financial backing. Thus, financial planning assumes
’equal importance in such an endeavour, and only
•the absolute synthesis of health and financial plann
ings can germinate a programme that can be imple•mented in its totality.
This book records verbatim the discussions and
‘findings of a professional consultation that was con
vened in WHO-SEARO, New Delhi, at which health
.planners, administrators, health professionals, econo
mists and financial experts at the decision-making levels
AUTHORS OF MONTH
Dr D- Tejada-Rivero
Assistant Director-General,
World Health Organization,
GENEVA
Dr C. R. Trivedi
Associate Professor,
Department of Preventive &
Social Medicine,
Municipal Medical College,
AHMEDABAD-380006
Dr Halfdan Mahler
Director-General,
World Health Organization,
GENEVA
Dr Sanjiv Kumar,
Resident
&
Dr V. P. Reddaiah,
Asstt. Professor,
Centre for Community Medicine,
All India Institute of Medical Sciences,
NEW DELHI-110029
Smt. K. Slieela,
Asst. Professor,
Rural Home Science,
Department of Home Science,
University of Agricultural Sciences,
Hebbal,
BANGALORE-560024
Smt..Kamal G. Nath,
Assistant Professor,
Rural Home Economics Department,
University of Agricultural Sciences,
Hebbal,’
BANGALORE-560024
Dr Hemant Kumar,
Rural Health Training Centre (RHT),
P.O. Jawan.
Distt. ALIGARH (U.P.)
John Newell,
Editor,
Science, Industry and Exports,
BBC External Services,
LONDON
Dr Adetokunbo O. Lucas,
Director,
Special Programme for Research &
Training in Tropical Diseases,
C/o World Health Organization,
GENEVA
took part to deal with the methodology to analyse
health care expenditure; to formulate new financial
policies and mechanisms; and to identify, acquire and
mobilize resources to finance them.
Apart from country presentations and discussions
on them, the book also contains an overview of health
care and financing studies, and analyses of overall
health costs and planning, resource distribution, deve
lopment of health insurance schemes.
The Member countries have recommended to them
selves that each country should produce a “Financial
Master Plan”, and have drawn guidelines for its pre
paration. They have also identified topics for fur
ther studies.
This book will be useful for health administrators,
health professionals, health planners, financial experts,
economists, statisticians and social scientists at the
decision-making levels.
®
ISSUED BY THE CENTRAL HEALTH EDUCATION BUREAU (DIRECTORATE GENERAL OF HEALTH SERVICES), KOTLA
NEW DELHI-110 002
AND PRINTED BY THE MANAGER, GOVERNMENT
MARG,
OF INDIA PRESS, COIMBATORE-641 019.
Re?d. No. D-(C) 359
Regd7No'RN:4504/57
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