PROMOTION OF HOME-BASED ORT THROUGH PLANNED HEALTH EDUCATION APPROACH
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In this Issue
swasth
hind
Page No.
Pausa-Magha
Vol.
Saka 1907
January 1986
Promotion of home-based ORT through
planned health education approach—an
experience of Christian Medical College,
Ludhiana
XXX
Dr M. L. Chugh & Dr S. C. Gupta
No. 1
1
Nutritional aspects of women with special
reference to pregnancy and lactating period
7
Dr Suresh Chandra & Dr (Smt.) K. L. Agrawal
SWASTH HIND
Hospital in community health practice
ii
Col. S. N. Bhattacharyya
D:et therapy for cancer
WISHES ITS READERS
13
Smt. Rita Bansal
Peoples participation in leprosy eradication
16
Dr V. V. Dongre
A HAPPY NEW YEAR
Add life to years
19
5. P. Pathak
The path of peace and brotherhood
21
News
24
The puzzle kavita could not solve--a story
27
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Dr R.L. Bijlani
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N. G. Srivastava
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Asftl
Promotion of Home-Based ORT through
Planned Health Educational Approach
— An Experience of Christian Medical College, Ludhiana
Dr M. L. Chugh and Dr S. C. Gupta
Oral Rehydration Therapy is one of the most important components of primary
health care, the goal of which is to provide Health For All by the Year 2000*
But how many medical colleges and institutions are really undertaking pains
taking steps to promote ORT in the rural community to which they are
responsible? The authors in this article describe their experience and the steps
being taken to promote home-based ORT through planned health education
approach at the Christian Medical College, Ludhiana in Punjab.
pproximately five million children die around the
A
world each year of dehydration caused by diarr
hoeal infection. Tn some developing nations diarrhoeal
infections may occur as frequently as once every month
in children.
It is an established fact by now that
Oral Rehydration Solution (ORT) is a very effective
weapon in the fight against diarrhoeal dieases (Barua
1980:4).
Recently, this method of therapy has been
in operation in various situations and the results
obtained from the above approach have been quite
significant (AHRTAG, 1985:7).
Many studies con
ducted by different scientists as well as international
health organizations like UNICEF (1982-83)
and
WHO (1977’87) repeatedly emphasise the contribu
tion of ORT in minimising the adverse effects of
diarrhoeal diseases throughout the world, especially
in developing countries.
However, as emphasised
by UNICEF (1982:83:4) the real problem and strategy
today before a health infrastructure is that how the
message of popularisation of ORT should get woven
into the fabric of our fraditional society.
It is a corroborative fact that the only possible
means to make ORT an essential component of pri
mary health care is to make every family member
aware of its important role, especially the mother
who is the key person.
Existing literature shows
that ORT is the simplest, easiest, cheapest and the
most practical tool for controlling diarrhoeal diseases,
January 1986
which are major causes of child morbidity and morta
lity.
Yet, the efforts made by differene organisations
to promote the acceptance of ORT among the people
and to make the same a norm, still appear to be much
lesser than the expectation.
The biggest drawback
which we face today, especially in the field of com
munity health research, is that, after reaching at cer
tain conclusions, the scholars and the workers never
try to put into practice the results and achievements
of various studies as most of us happen to be theory
oriented.
It is true that ORT is one of the most
important components of primary health care whose
main objective is to provide Health For All by the
Year 2000. But. how many medical colleges and insti
tutions are really undertaking painstaking steps to pro
mote ORT in the rural community to which they are
responsible?
This is a very searching question to
day before all of us.
It still remains questionable whether the workers are
knowledgeable about the composition and prepara
tion of ORT.
As per Medical Council of India and
Government of India Instructions, every medical col
lege has to have one to three blocks population as a
field practice area to provide
enough community
oriented experiences to the medical undergraduates.
Keeping in view the above fact, the Christian Medical
College, Ludhiana, Punjab, had various inter-departmental meetings to plan out a detailed health educa
I
tion programme for promotion of ORT in the villages
attached to the College.
Traditional customs in
many parts of the world, such as fasting the child when
he is suffering from diarrhoea, contribute greatly to
mortality from both diarrhoeal diseases and associated
malnutrition.
Hence, as reiterated by UNICEF
(1982-83), proper health education must accompany
ORT. In this article efforts have been made to
highlight the plan of action adopted by the Depart
ment of Social and Preventive Medicine to promote
awareness and acceptance of ORT through educational
approach in the villages of the community health
block attached to Christian Medical College. Ludhiyana.
What is ORT: The aim of oral rehydration therapy
is to prevent and treat dehydration, which is the main
complication in any diarrhoeal illness.
Cumulative
mortalities of 25-40% among children upto the age of
five years are common in developing nations. Forty
per cent or more of these deaths, which are caused by
dehydration or chronic malnutrition, are associated
with acute diarrhoea.
Very early replacement of
water and electrolyte losses to prevent or treat dehyd
ration is the principal objective in treating acute diarr
hoea.
The oral rehydration formulation (ORT) re
commended by WHO contains 3.5 grams sodium
chloride, 2.5 grams sodium bicarbonate. 1.5 grams
potassium chloride and 20 grams glucose (or 40 gms.
of sucrose when glucose is not available or is too
expensive) for one litre of safe drinking water.
Planning of ORT education campaign: Every plan
in its broader sense includes three main steps: (i) Plan
formulation, (ii) Execution, (ii) Evaluation. Planning
is a matter of team work and the planning team con
sists of not only specialists in this field but also in
allied fields.
Planning and management are very
essential, if higher standards of primary health care
are to be achieved.
Therefore, while planning the
educational programme on ORT on a large scale for
the whole community block, efforts were made to
implement the said programme initially through a
pilot project.
ORT education and Pilot Project: Four villages were
selected through stratified random sampling procedure.
wherein the socio-economic status of people and their
knowledge, attitudes and practices towards ORT were
assessed.
This project was assigned to one of the
postgraduate students of the Department.
The exact
title of his thesis was, “KAP STUDY ON ORT”.
About 200 subjects were chosen for the above study
through simple random method (50 subjects from each
village).
Data were collected with the help of a
structured schedule. Before administering, the schedule
was pretested in the selected population and was
modified to remove bias. Data was also collected by
the investigator from the family folders, master regis
ters, etc., maintained by the concerned male and
female multipurpose health
workers. The major
findings of the project report were as follows:
Major findings:
The lower the socio-economic
level of the mother, the lesser is her awareness towards
2
ORT. The people living in the areas adjoining to
subsidiary health centres have more awareness towards
use and availability of ORT. than those living in dis
tant areas. Data show that there are great dfferences
in the people’s knowledge towards ORT and their
actual practices.
About one-third of the mothers
(respondents) hold the different superstitions like evil
eyes, warth of God, etc., responsible for diarrhoeal
episodes among their children.
As evident from the report of the above project,
the community awareness about ORT was very poor.
Around 20 per cent of the mothers were aware of
electrolyte solution packet which were being distribu
ted by the concerned health personnel during their
home visits as well as through Subsidiary Health
Centre and other health institutions.
Before April
1984 ORT packets were commonly used and recom
mended by the Department and hence were adminis
tered in the rural community through different agen
cies. In 1982-83 UNICEF itself was supplying about
20 million packets of ORT a year to 80 countries
throughout the world
(UNICEF 1982-83).
For
making available packets of this simple remedy throu
ghout the world, WHO estimated a global need of 750
million packets a year and this was perhaps not easily
attainable target (UNICEF 1982-83).
Despite this.
as evident from our study about 90% of mothers were
not knowing its exact method of preparation.
More
over. since it was not readily available and was to
be collected from the health centres, etc., the chances
of its real utility were minimized.
As repeatedly emphasised by WHO and UNICEF,
participation and involvement of people as well as
their self-reliance in the promotion of their health by
their own efforts is a key factor, if we really want to
provide Health for AH by the Year 2000.
As sug
gested by Barua (1980-* 16) ORT should.be based on
home-made formula so that it can be easily available
and is more economical, and hence, programme cost
can be substantially reduced.
Therefore, after reviewing the report of the pilot
project the department changed its approach from the
popularisation of ORT packets to the home-made
ORT preparations.
From April 1984 onwards this
Department started discouraging the use of electrolyte
powder packet and priority was given to the home
based formula on ORT.
The results received from
this new approach are quite note-worthy.
To work
out the exact components as well as proportion of
different items, the Department arranged a . series of
meetings within the Department.
Special meetings
were also arranged with the Departments of Medicine,
Gastroenterology, Paediatrics and the following for
mula was concluded:
HOME-BASED ORT FORMULA
(i)
1 glass of clean water (J litre).
(ii)
2 level teaspoonfuls of ordinary sugar (or 1
heapful teaspoon).
Swasth Hind
till.
■i ■imunn
Dehydration - caused by diarrhoea - is the biggest single killer of children
in the modern world. Now it can be prevented by oral rehydration therapy
(ORT) using either a 5 cent sachet of salts (left) or an even cheaper home
made version. As a result, parents themselves could prevent the deaths of
several million children each year. (UNICEF)
diarrhoea deaths by 50% in villages ano
38 NATIONS
BEGIN MASS
PRODUCTION
urban neighbourhoods of:
The following nations have now
PILOT CAMPAIGNS
HAISE DEATHS
Field trials with ORT have reduced
begun mass production of oral
rehydration salts:
Afghanistan
Argentina
Bangladesh
Brazil
Burkina-Faso
Burma
Burundi
China
Colombia
Costa Rica
IUi
Kampuchea
Dominican Rep
Egypt
| fe ORT can rightly be.called the medical
El Salvador
Ethiopia
Haiti
miracle of this century.... For peoples in
Asia, Africa and Latin America, ORT holds the
promise of healthier childhoods and more 0
productive adult lives.
Honduras
India
Indonesia
Shamsul Haq. Minister for Health and Population
Control, Government ofBangladesh.
THE DO IT- YOURSELF VERSION
For preventing dehydration, an equally effective oral
rehydration solution can be made using ingredients found
in almost every household:
8 TEASPOONS
Mexico a.
Mongolia
Morocco
Mozambique
Nepal
Pakistan
Paraguay
Peru
Philippines
Rep Korea
Syria
Thailand
Tunisia
Venezuela
Zaire
HOSPITALS CHANGING SAVING LIVES TO ORT
AND GROWTH
Many hospitals in both poor and rich
countries are now changing from
Frequent diarrhoea is one of the most important
causes of malnutrition. The use of ORT can help
intravenous therapy to ORT.
to maintain a child’s growth'
OF SUGAR
DEATH RATES
BEFORE ORT
0.8%
(as % of all
OF SAIT
A Turkish study on two groups of children — one
with and one without ORT:-
diarrhoeal
cases seen by
hospital).
1 TEASPOON
AFTER ORT
0.2%
1 LITRI
OF WATEi
Iran
Kenya
Lesotho
Malaysia
AVERAGE DURATION OF ILLNESS:
With ORT-2.57 days
Without ORT - 4.97 days
MONTHLY AVERAGE WEIGHT GAIN:
With ORT - 430 gms
Without ORT - 324 gms
NOTE: Median figure for 8 hospitals
developing countries.
■ We believe that, ultimately, widespread adoption of ORT in developing countries will
I Some traditional remedies — such as rice conjee or carrot
I soup — llso m?ke highly effective oral rehydration
I solution*.
break the vicious cycle of diarrhoea, malnutrition and death - especially for the ■
principal victims: very young children.
DrWBGreenough, Director, International Centre for DiarrhoealDisease Research,
Bangladesh.
WpMmvor.l
________________ _
Dunce- V'7and Belinda Magee. The Observer. London
Photograph: Asem Ansari/ICDDR
January 1986
3
(iii)
2 pinches of common salt by using
fingers, i.e., thumb and forefinger.
(iv)
Sodium bicarbonate 1 pinch—if available.
(v)
Juice from 1/3 to 1/4 lemon.
2 dry
This solution was tested by the Biochemistry
Department of the Christian Medical College, Ludhi
ana, and was found to be of practically desired stand
ard.
Implementation oj ORT education drive: After
searching out the easiest and home-made ORT for
mula which was scientifically accepted, the real objec
tive before the Department was as how to promote
the awareness about ORT among people regarding its
importance, especially in the outreach areas.
The
subject was repeatedly discussed in the Departmental
senior staff meetings under the Chairmanship cf Dr
Betty Cowan, the then Principal of the College and
Medical Consultant
to the Department.
It was
decided to involve all categories of field health staff
in accelerating the ORT acceptance level.
Comprehensive health care and ORT: As pointed
out by Dhillon el al (1979) and Chugh (1983), the
Department developed a Comprehensive Health Care
Services scheme for its block.
Under this scheme
every name is entered in the family folder which is
maintained family-wise.
Through this scheme com
plete health profile of every family is available.
As
specified by Grewal (1985) there are three main tools
of this methodology.
(i) The family folder
(ii) The master register
(iii) The desk diary.
Under this Scheme, there is one medical officer for
a population of 5,000 who is incharge of a subsidiary
health centre and under him, there are two multipur
pose health workers—one male and one female.
These workers are the key persons in providing the
comprehensive health care to the family.
Multi-purpose Health Workersand ORT: To make
the health education process on ORT a successful one,
it was felt that the concerned male and female health
workers be properly oriented towards the proposed
educational approaches, especially pertaining to ORT
awareness and its acceptance in the indigenous form.
From April 1984 onwards every worker is being told
not to emphasise on the ORT packet but to encourage
the rural community to prepare ORT at home as
suggested above
(Home-based formula).
In all
monthly meetings which are generally presided over
by the senior medical officer of the block, the Depart
ment of Social and Preventive Medicine and Commu
nity Health is repeatedly reiterating for the promotion
of awareness and acceptance level of ORT among the
different communities.
4
The workers have been repeatedly instructed that
in each family they should actually demonstrate the
preparation of ORT-home based solution. To back
up these activities, the education of mothers in selfcare initiated by the health workers for every mild
episode of diarrhoea is the main and important com
ponent of the health programme.
The main objec
tive of this approach is that every mother must be
trained as a health educator and practical health
practitioner, because it is realised that the mother plays
a very prominent and expanded role in the cultiva
tion and promotion of good health habits and prac
tices within the family.
In addition to this we are
emphasising on the extension
approach in which
mother or any other responsible and intelligent person
in the family (if mother is not there) is askqd by the
health worker during his visit to the family to prepare
one glass of ORT in his presence and under his guid
ance.
The advice given by the worker on ORT
to the family
is recorded in the
family
folder. Ultimately through this approach we help
the community to prepare ORT themselves and by
their own efforts and actions through indigenous for
mula. Further, to make the above approach more
effective a leaflet in Punjabi language on ORT—
Home-based Formula has been prepared and printed
by the Department, and has been given to every family
through multipurpose health workers. During the
implementation of the programme, it was reported by
the field workers that around 10 per cent of the total
population was migrant population, who migrated of
Ludhiana from the neighbouring States and was resid
ing in the areas attached to the Urban Health Centre,
field Ganj, Ludhiana. To make the communication
more effective in the migrant population, it was plan
ned to prepare a copy of the guidelines in English
version also.
THE GUIDE LINES
1. Sixty three per cent of body weight is
water.
Diarrhoea may cause severe ill
ness due to loss of water and if NOT
TREATED MAY CAUSE DEATFL
2. First priority is to make up loss of water
in the body.
3. Best is water, sugar and salt solution for
child.
4. Prepare this mixture as per the procedure:
(a) Take one glass of clean water.
(b) Put 2 level tea-spoonsful of ordinary
sugar in the water in the glass and stir
tto mix it.
(c) Then put two pinches of salt, using
two dry fingers, in the water in the
glass and again stir it.
(d) Mother should
task like tears.
taste it.
It should
Swasth Hind
5. Give this mixture to the child suffering
from diarrhoea, with tea-spoon or glass.
(1 tea-spoon every 2-4 minutes till the child
accepts it)
6. Mother or some other person in home
must know how to prepare the mixture.
7. Give solution immediately after 1st loose
stool, “DON’T WAIT FOR MANY
MOTIONS”.
8. Keep giving this mixture (rough guide 1
glass for every loose stool) so long as
diarrhoea continues.
9. Even when diarrhoea stops, the child will
need extra fluid for sometime—perhaps a
day or two.
10. If baby vomits, give solution,
slowly.
but more
11. If diarrhoea still continues and the child
vomits or passes no urine in 12 hours take
the child to the health centre.
12. Use freshly prepared
mixture—do not
keep for more than 4-6 hours. DO NOT
HEAT SOLUTION.
13. Baby less than 1 month with diarrhoea
should be shown immediately to doctor.
14. Mother should continue breastfeeding or
give weak tea if breastfeeding already
stopped.
15. Start feeding small quantities of normal
diet as soon as baby can take it.
16. For next two weeks give more food than
usual to make up for loss due do diarr
hoea.
Apart from this, written instructions to different
health personnel, i.e., doctors, health supervisors,
multipurpose health workers, etc., are sent from time
to time about the preparation of ORT, its different
components and different approaches of health edu
cation through which the task is expected to be accom
plished.
NEW APPROACH TO PREVENTION OF
DEHYDRATION DUE TO DIARRHOEA
(For Health Team, Doctors at all levels, supervisors
multipurpose workers)
At Clinic
1. Packets of ORS powder will no longer be
used routinely (do not stock packets).
January 1986
2. Keep 2 glasses, 2 tea-spoons, 1 jar sugar
and 1 jar salt.
3. When mother brings child with diarrhoea,
get her to make one glass of ORS:
One glass water (4- litre), containing:
2 teaspoonsful (level) sugar and 2 pinches
of salt (use 2 dry fingers). Sir well to dis
solve sugar.
4. Start giving to the baby with teaspoon or
from glass while you give Health Educa
tion on:
(a) Continuing breastfeeding (or weak
tea if breast feeding already stopped).
(b) Starting to feed small quantities of
normal, diet as soon as baby can take
it and for next 2 weeks giving more
food than usual to make up for loss
due to diarrhoea.
(c) Finally give her educational leaflet to
take home.
At home
1. You must teach the mother or mother’s
substitute in each home to prepare the
solution and see that she makes the solu
tion.
2. She should taste it and it should be no
saltier than tears.
If there is no child
with diarrhoea, mother should drink it so
that she understands how it tastes and is
not wasted.
Teach her to give it to any
child suffering from diarrhoea immedia
tely after first loose stool.
3. Teach mother that diarrhoea kills, but
adequate amounts of the mixture save
life and that it must be given immediately,
and should keep on giving so long as
diarrhoea continues.
(rough guide, one
glass for every loose stool). Even after
diarrhoea stops, the child will need extra
fluid (mixture) for a day or two.
(a) If baby vomits, continue to give, but
more slowly.
(b) If child continues to vomit or to have
loose stools for more than two days
5
and or passes no urine for 12 hours,
take the child to Health Centre.
(c) Child under 1 month having diarr
hoea must be referred immediately
to the hospital.
(d) Leave Educational leaflet in the home,
have explained it to mother.
(e) At every home visit, ask mother to
produce the leaflet.
4. At every home visit, record exactly on
the pink card what you did regarding
above; and action taken by the mother
since your last visit.
Village Health Guides and ORT
Under Comprehensive Health Care, there is a pro
vision for one village health guide for 1000 popula
tion.
In one subsidiary health centre, there are
about five village health guides who have studied upto
5-8th class and have undergone three months training
on the basic principles of public health, maternal and
child health care services and environmental and per
sonal hygiene.
These workers are acting as a link
between the community and health personnel. Their
role in the promotion and acceptance of health care
services has been quite significant.
Health educa
tion re-orientation workshops on promotion of ORT
are being organised for these village health guides
from time to time.
Workshops are arranged with
the help of multipurpose health workers and the
senior medical officer Incharge of concerned Primary
Health Centre.
of health workers, doubts or shortfalls in the imple
mentation of the programme are often discussed as
one of the important agenda items.
Health clinics and ORT
Efforts are being made to promote acceptance of
ORT through clinic based health education approach.
Every medical officer has been instructed to keep one
empty glass, one jar of sugar, one jar of salt and one
teaspoon in the clinic.
He has also been advised to
spend at least 10 minutes on advising the patients on
ORT (home-made solution).
In the clinic also the
patient is asked to prepare a glass of ORT solution
in the presence of medical officers so that before the
patient leaves the clinic it is ensured that he/she
knows the preparation technique.
Educational
leaflets on ORT have also been given in all subsidiary
health centres for distribution to the mothers of under
five children.
Role of Medical Officers in the promotion of ORT
Medical Officer as a team leader is expected to
play a more expanded and critical role in making
ORT popular among the rural folks.
The orienta
tion meetings for the medical officers posted in the
Community Development Block, Ludhiana, under
different subsidiary health centres are also being
arranged from time to time to ensure maximum out
put with minimum input.
During monthly meetings
also every medical officer is asked to give a detailed
report regarding improvements in change of know
ledge, attitudes and practices of people towards ORT
home-based formula.
REFERENCES
During workshops every village health guide gets
the relevant literature on ORT.
Demonstrations
are also arranged by senior faculty members regard
ing home-made ORT solution.
Through this nonformal form of education, every village health guide
is asked to prepare one glass of ORT with her/his
own hands in the presence of senior faculty members
of Social and Preventive Medicine Department so that
any bias or error may be corrected.
To ensure
that the message of ORT reaches every home, every
health worker and village health guide have been
instructed to spend at least 15 minutes during their
first visit in the family having children under five
years of age, wherein they have to introduce the new
concept of ORT (home-made solution) to the families.
AHRTAG (1985), Dialogue on Diarrhoea, Issue 21, June,
1985 Barua, Dhiman (1980), “Diarrhoeal Diseases”,
World Health, Nov. 1980.
The concerned field staff has been instructed that
in the absence of worker, someone must be trained
in family, especially the mother, who can work as a
substitute for him. To ensure the proper imple
mentation of ORT promotion drive, the concerned
supervisory staff continues doing the concurrent and
consecutive checking of houses on random basis.
During field visits and monthly meetings the drawbacks
Grewal, H. N. S. (1985), “Comprehensive Health Care’,
Paper presented at NIH & FW, New Delhi.
6
Chugh, M. L. (1983), “Health for All Through medical
Education ” Paper Presented at the 27 Annual Conference
of Indian Public Health Association, Nagpur.
Cowan, Betty et al (1982), “Exclusive breast-feeding for
six months : an attainable goal for the poor communities,
Nutrition foundation of India, Oct. 1982.
Dhillon, H. et al (1979), “Reaching the Child in Need”,
Health and Population : Perspectives and Issues, 2 (1):
5:25.
UNICEF (1982—83), “Simultanious Health Education is a
Must” The State of World Children, Background Materials,
1982—83 W.H.O. (1977), “Oral Fluid—A Simple Weapon
Against Dehydration in Diarrhoea”, WHO Chronicle,
Vol. 31, No. 3.
Swasth Hind
NUTRITIONAL ASPECT OF WOMEN
With Special Reference to Pregnancy. and
Lactating Period
Dr Suresh Chandra and Dr (Smt.) K. L. Agrawal
When the mother’s diet is not nutritionally adequate she cannot transfer the
required nutrients to the foetus. Foetus then tries to draw its nourishment from
mother’s body reserves.
This can affect the mother’s health, if she is already
malnourished then both mother and infant will be affected.
of important points have emerged from
a series of consultations held by United Nations
and concerned groups, especially some workshops
held at the Vienna International Centre and the Inter
national Women’s Conference, Nairobi. The focul
point of the International year of women—1975
(which was latter extended to a Decade—1975-1985)
was the World Conference at Mexico city. It was here
that world plan of action was announced to achieve
the goals of equality, development and peace.
number
A
In the recent years several issues relating to women
have been brought out of the lumber room of value
judgement and into the forum of serious academic
enquiry.
Poverty, malnutrition, uneven development
and other women’s problems are some of the topics,
now claiming considerable
attention.
In March
1983 a Workshop was held on women and poverty
at Calcutta. Eminent scholars from different parts
of India and abroad concluded and explored several
broad themes which were of intrafamilial bias against
women’s well-being, discrimination against women in
the labour benefit, opportunities for gainful activities
and possibility of less than equal access for women in
public services to alleviate poverty.
Ultimately they
emphased the basic problems of women, i.e., malnu
trition, health and development.
The Joint Work
ing Conference of IUNS, UNICEF and ICMR in
October 1977 also fixed the priority of nutrition
among women.
January 1986
Malnutrition is like an iceberg as most of the people
in the developing countries live under the burden of
malnutrition.
Pregnant women, nursing mothers and
children are particularly vulnerable to the affects of
malnutrition directly or indirectly.
Most of nutri
tional problems are related to women.
The adverse
affects of maternal malnutritions have been well docu
mented, i.e. low birth weight, anaemia, toxaemia of
pregnancy, post-partum haemorrhage, all leading to
high mortality and morbidity. Now it is realised that
intrauterine period of life is very important period
from nutritional stand point.
To over-come the
nutritional problem, best approach is to develop
knowledge, awareness and attitudes about nutrition
among the women so that they are able to take proper
care of themselves and their children which are the
main vulnerable group.
Women require various nutrients in their different
physiological and physical state.
These facts should
be considered while devising any nutritional policy.
NUTRITION IN PREGNANCY
Every pregnant women dreams of giving birth to a
chubby, healthy infant. The foetus solely depends
upon mother for its nourishment.
Its nutritional
needs gradually increase as pregnancy progresses.
Weighing just about 15 gms around the 12th week,
the foetus develops into a fully grown baby of about
3,200 gms. by the 40th week.
Mother has to supply,
7
through blood stream, all nutrients needed for this
growing foetus.
Several bodily changes lake place during pregnan
cy.
A healthy and well fed expectant mother puls
on 10-12 Kg. of weight during pregnancy. She is to
store enough fat and several other nutrients in her
body to meet her own needs and those of the infant.
When the mother’s diet is not nutritionally adequate
she cannot transfer the required nutrients to the
foetus.
Foetus then tries to draw its nourishment
from mother’s body reserves. This can affect the
mother’s health, if she is already malnourished then
both mother and infant will be affected.
ANALYSIS OF THE WEIGHT GAIN IN
PREGNANCY
the normal requirements.
One can obtain this addi
tional energy by adding cereals, oils, sugar or Jaggery.
Protein is required for body building.
Iron and the
B. Vitamin, folic acid (Part of B. Complex Vitamin
group) are required for the blood formation and cal
cium for the bones.
An extra 15-20 gms. of Protein
daily will be adequate for proper growth of the foetus.
It will be well and good if animal foods such as eggs,
meat or fish and milk are consumed.
The nutrition
has direct relation with still birth rate which was
realised long before during second world war.
During the policy of food rationing in Britain during
second world war, the pregnant women were kept in
priority class which received extra rations of milk,
cod liver oil and fruit juice, which greatly improved
the diet of women belonging to that group, causing a
fall in still birth rate from 38 to 28/1000.
Nutrition in nursing mothers
UPTO
10 wks.
20 wks. 30 wks. 40 wks
gms.
gms.
gms.
gms.
FAErUS,
PLACENTA
AND LIQUOR
55
720
2530
4750
UTERUS
BLOOD
170
765
1170
1300
&
BREAST
1200
EXTRACELLULAR WAIER
FAT
....
TOTAL GAIN
.
325
1915
3500
4000
650
4000
8500
12500
Due to malnutritioin during pregnancy, outcome of
pregnancy may not be fruitful.
Abortion can take
place.
Infant may be born before full term.
In
fant may be smalJ in size with less than 2,500 gms.
of body weight.
Infants with such low birth weight
will not have enough nutrient stores in their livers.
They easily become malnourished.
They have poor
resistance against diseases.
A poorly nourished
mother cannot withstand the stress and strain of preg
nancy and child birth.
If she is well nourished, she
has more chances of successfully going through her
pregnancy and child birth. If her diet lacks in nut
rients, the mother becomes a victim of serious nutri
tional disorders. She may suffer from iron deficiency
anaemia.
Her blood will lack the vital elements.
She becomes weak and exhausted.
Bone disorders
caused by calcium deficiency are also seen in malnou
rished pregnant women.
Balanced diet in pregnancy
Scientists have recommended that a pregnant women
needs to have daily 300-400 calories of energy above
8
Even after birth, the new born continues to depend
on the mother for its nourishment. Breast milk pro
vide all the nutrients for the first 4-6 months. Com
pared to pregnancy, breastfeeding imposes greater
stress on the mother because the infant is older and
rapidly growing.
Therefore, he needs more nourish
ment than the foetus in the womb. Mother must be
able to secrete adequate quantities of breast milk.
The nutrients that go into breast milk are to be pro
vided by the mother. If her diet is adequate then the
RECOMMENDED DIETARY INTAKES OFj
WOMEN
Sedentary
Worker
Moderate Hard
Worker
Worker
CALORIES (K CAL) .
1900
2200
3000
PROTIENS (GMS)
45
45
45
400
400
400
CALCIUM (MGS)
.
* .
IRON (MG).
32
32
32
VIT.A. (jiG)
750
750
750
B. CAROTIEN (mG)
3000
3000
3000
1.0
1.2
1.5
.
1.1
1.3 •
1.8
2(KQs
THIAMINE (MG)
RIB0FLAV1M (MG)
NICOTINIC ACID (MG)
13.0
15.0
VIT. B6 (MG)
2.0
2.0
V1T. C. (MG)
40.0
40.0
FOLIC ACID (/xG)
100.0
100.0
100.0
1.0
1.0
r io
V1T. B12QxG)
40.0
additional nutrients consumed can be diverted for
formation of milk without affecting her own body
resources.
Even a mother with unsatisfactory diet
Swas th Hind
can produce the same quality of milk, but this is
being done at the cost of her own health.
Such a
situation cannot and should not last long.
The mother’s diet ought to be more nutritious than
what it was when she was not nuising. But in practice
it is not so. The nursing mother needs more proteins,
since high quality proteins have to be synthesised by
her for producing milk.
If animal foods such as
meat, eggs or fish are consumed that would be much
helpful. Scientifically it is proved that if the mother
will increase intake of proteins, she can produce more
breast milk.
Calcium and Vitamin A.
are other
nutrients which need to be supplemented during
lactation. Leafy vegetables like amaranth, .drum
stick leaves help in supplying the nutrients. It is
better that the mother consumes only minimum of
condiments and. spices otherwise breast milk may
carry these odours making it unpalatable to the baby.
Drinking of more water helps in compensating for
the loss of body water through the milk.
As the mother herself is involved in the child’s care
her confidence improves.
Her changed nutritional
outlook helps, to prevent relapse of infection in the
child.
She changes her attitude about the nutrition
towards the family diets also.
Thus whole commu
nity will be benefited indirectly.
In the same refer-
RECOMMENDED DIETARY INTAKES OF NUT
RIENTS DURING PREGNANCY & LACTATION
LACTATION
----------------------------0-6
6-12
months
months
PREGNANCY
CALORIES (K CAL)
.
PROTEIN (GM) .
.
4- 300
.
+
CALCIUM (MG)
15
+ 500
4-
25
4- 400
4-
1000
1000
1000
25
IRON (MG).
40
32
32
VIT. A. (/xG)
750
1150
1150
3000
4600
4600
B. CAROTJEN (/xG)
.
THIAMINE (MG)
RIBOFLAVIN (MG)
.
NICOTINIC ACID (MG)
.
4-
0.2
4-
0.3
4-
0.2
.
4-
0.2
4-
0.3
4-
0.2
.
+
2.0
4-
3.0
4-
3.0
VIT. B6 (MG)
2.5
2.5
2.5
VIT. C (MG)
40.0
80.0
80.0
FOLIC ACID (/xG)
300.0
150.0
150.0
1.5
1.5
1.5
B12 QxG)
Jariuary 1986
once a study has^bcen carried out in Sucheta Kripalani
Hospital, New.Delhi.
The mothers of poorest com
munity have shown that hey can dramatically reduce
malnutrition among their children by using the know
ledge of nutrition with the help of growth monitoring
charts and by learning how to make better use of
locally available foods.
The mothers were attending the clinic attached to
Sucheta Kripalani Hospital, New Delhi.
120 child
ren were under-nourished. Each mother was given
a road to health growth chart to maintain at home and
its use was demonstrated. At every visit a child
was weighed and- its growth curve was plotted on the
chart.
Progress of all the 120 children was followed
over the periods ranging from five months to one year.
In all 103 (85%) showed a significant improvement
reaching the least 80% of the average weight for their
BALANCED DIETS FOR ADULT WOMEN
(In grins/day)
Sedentary Moderate Heavy
Worker
CEREALS ....
410
440
575
PULSES
40
45
50
LEAFY VEGETABLES
100
100
100
OTHER VEGETABLES
40
40
100
ROOTS & TUBERS
50
50
60
....
100
150
200
OIL & FAT
20
25
40
SUGAR & JAGGERY .
20
20
20
MILK
.
age.
This approach is very feasible, cheap, adminis
tratively easy to organise and to avoid the risk of
hospitalisation.
No new set up is required for this
purpose.
Any out patient clinic such as primary
health centre, Employees State Insurance (E.S.I.) dis
pensary and Nagar Palika Health clinic can be utilized
effectively by this approach.
Lack of food is not the only cause of malnutrition.
Some times people choose poor diet even when good
one is available due to cultural influences, food habits,
customs, beliefs, traditions and attitudes.
Papaya
is avoided during pregnancy because it is believed to
cause abortion but it is not scentifically correct.
It
is a good source of Vitamin A. In few communities
of India valuable foods like Dhals, leafy greens, rice
and fruit are avoided by nursing mothers which are
main ingredients of nutritive food for pregnant women.
Some Hindus and Jains do not eat meat, fish, eggs
9
ADDITIONAL ALLOWANCES DURING
PREGNANCY AND LACTATION
During Calories During Calories
Prcg.
(K.Cal.) Lacta- (K.Cal.)
tion
Food Items
gms.
•
•
gms.
35
118
60
203
PULSES .
15
52
30
105
MILK
100
83
100
83
10
90
10
40
CEREALS
FAT
SUGAR
.
TOTAL
10
40
293
521
and certain vegetables like onion. Due to these food
taboos people avoid the consumption of such nutri
tious food, even though they are easily available. In
most of our communities men eat first and women eat
the left over food afterwards, though they require
more nutritious food.
Consequently the health of
women may be adversely affected.
Overall malnutrition has to take note of hunger,
poverty, insanitation, illiteracy and superstitions. In
the same reference Pt. Jawaher Lal Nehru said, “It
is the science or knowledge only that can solve the
problem of hunger in poverty, of insanitation and
illiteracy, of superstitions, customs and traditions, of
vast resources running to waste of a rich country in
habited by starving people”.
10
By considering these facts Government has given
much emphasis to mother and child health services
and nutrition.
It is the main components of health
under 20 point programme.
National Iron and folic
acid distribution programme is running to fulfil the
above objectives.
Integrated child development
services scheme is also providing maternal and child
health services.
Problem of malnutrition could be solved only by
the active participation and awareness of mothers
about the nutritional aspects of food.
A
REFERENCES
1.
Beaton, G.H. & Bcngoa M. (1976): Nutrition in Preventive
Medicine, W.H.O., Geneva.
2.
Gopalan, C et al (1984) : Nutritive value of Indian foods;
National Institute of Nutrition, Hyderabad.
3.
Health for all : An alternative strategy (1981) : Joint publi
cation I.C.S.S.R. & I.C.M.R., New Delhi.
4.
Health statistics of India (1983) : Central Bureau of Health
Intelligence : Ministry of health and family welfare :
Govt, of India, Delhi.
5.
Helsing, E. & Savage King F. (1982) “Breast feeding in
practice” Oxford University’s Press, Delhi.
6.
I.C.M.R. (1981) : Recommended Dietary Intakes for
Indians : Indian council of Medical Research, New Delhi.
7.
Primary Health Care (1978) : Joint report by DG-W.H.O.
& DG - U.N.I.C.E.F., Geneva, New York.
8.
Tulpulc. et al (1971): Proceedings of the 1st. Asian Congress
of Nutrition. National Institute of Nutrition, Hyderabad.
Swasth Hind
a very vital role
to provide comprehensive heal
th care to the community. For
long time, hospitals were consider
ed as “Ivory tower of diseases” and
common people had an impres
sion that hospitals were no place
to get well and once in, there was
hardly any chance to come out
alive. In fact, before the era of
antiseptics and antibiotics, the high
mortality rate in hospitals used to
justify such impression. With im
proved scientific knowledge, avail
ability of modem diagnostic facili
ties and more trained paramedical
personnel, the out look for hospi
tals have completely been changed.
Wjith the concept of comprehensive
health care, hospitals can play a
vital role in community health
care, and image of hospital can be
completely changed if the manage
ment and the staff of the hospital
change their out look from merely
curative
role to
comprehensive
health care role.
ospitals play
H
HOSPITAL IN
COMMUNITY HEALTH
PRACTICE
Community participation
Col. S. N. Bhattacharyya
Hospital can play an important role in providing the
preventive, promotive and rehabilitative services to the
local community including training and research, besides
the restorative functions. General practitioners must be
involved by the hospital for these functions. By esta
blishing peripheral health centres and with the help of
medico-social workers all these functions can be done
satisfactorily by a well organised hospital.
January 1986
It must be realised that the hos
pital is a medico-social organisa
tion of the community and this
should serve them in a manner to
satisfy not only the health need
but also the other social require
ments. To do these functions eff
ectively, active community partici
pation is a must, which can be achi
eved by:
(a) Inviting the community lea
ders to serve in the hospital
management committee. In this
way hospital comes much closer
to the people and it also comes
to know the felt need of the
community.
(b) Encouraging
the
hospital
visits by the friends and relatives
of the patients and making avail
able the medical and paramedi
cal staff to satisfy their queries.
(o) Reducing the waiting time in
th'e outdoor and emergency to
11
—physical^ mental or vocational. be started first at the hospital it
Long term cases, chronic illnesses self and then to be extended to the
these health
and geriatric patients can be treat community through
centres
in
the
form
of
nutritional
ed in “half way homes”, “day hos
pitals”, “night hostels” etc. which supplement and prevention of spe
could be built up. For all these, cific deficiency. Nutritional educa
collaboration between medical and tion to the family on the local
auxiliary workers with that of vo available food is also very import
Functions of the Hospital
cational, educational and social ant. The general practitioners and
Like earlier days hospital func workers are essential to have a family physicians must be brought
tions are not to be limited to res team approach to obtain most under the fold of health centre
torative sphere alone. It has to be gratifying result.
scheme where they can have their
organised to serve also the promo
An emergency ambulatory ser professional fulfilment. Other as
tive,
preventive,
rehabilitative. vice arrangement to tackle all pects of health care which hospi
educational and research need of types of emergency on the spot tals can take care of are, school
the community. For this it is al should always be kept ready.
health services and occupational
ways better to have a medical
health services of the local com
person
trained in “Community Prevention and health promotion: munity.
Medicine” in all large hospitals to All hospitals are already practising
An epidemiological unit must be
preventive medi
co-ordinate all the above mention promotive and
established
in each hospital to con
ed activities as well as activities cine through their MCH services,
trol
any
outbreak
of any commu
of different
specialities/depart- radiological services and laboratory
nicable
disease.
services.
Public health laborato
ments.
ries which are working independ Training and research'. All hospitals
Health Restoration'. This is the ently should be integrated with hos
prime function of the hospital. pitals or their work to be coordi are potential training and resear
ch units. All facilities available in
Early diagnosis and treatment is nated with hospital laboratories.
a hospital can be utilised for train
essential for this. Most of the in
ing of medical, paramedical nurs
Preventive
and
curative
services
vestigations should be done from
ing and health personnel. Each
in
a
hospital
must
be
fully
inte
outdoor as it reduces the hospital
grated.
These
combined,
services
bed of the hospital is a source of
occupancy of bed. Quick turn over
research
and all members of the
should
be
decentralised
in
the
of the bed is essential specially in
staff
and
trainees should be en
community
by
establishing
“
Heal
our country as the cost of hospita
couraged
to
carry out research
Centres
”
at
the
periphery
of
the
th
lisation is rising very fast. Inter
work
however
trivial
it may be. It
hospital
within
the
community
departmental consultation causes
is
the
analytical
mind
if encourag*
where
all
preventive,
promotive
great delay which need to be cut
cd
to
develop,
improve
the resear
and
curative
services
will
be
avail
down to minimum by better co
ch
activities
which
is
ultimately
ordination and availability of basic able. Specialists of different disci
plines
are
to
visit
these
centres
beneficial
to
the
whole
community.
diagnostic facilities. As it has been
pro
established that all diseases have periodically Immunisation
Participation of general practitioner
gramme
for
the
local
population
both psychic and somatic factors—
Hospital should give full facili
a psychiatric department must be and domiciliary treatment is to be
ties to the local general practition
implemented
through
these
services.
there in all general hospitals to
ers for active participation in hos
take care of the psychic aspect of Medico-social workers, physiothe
pital activities. They can provide
rapists
should
work
through
these
all diseases. Besides, this depart
information about the sociomedical
centres
for
rehabilitation
and
treat
ment can practice preventive psy
and emotional problems of the soment
of
long
term
cases.
MCH,
chiatry in the community.
•
family planning, preventive psych ciety which acts as a guide for
Medical rehabilitation which is iatry can all be practised through modifying the health care system.
also a part of health restoration, these centres.- Medico-social wor Meetings should be organised bystarts with early diagnosis and kers play a very, important role in the hospital where all the general
up of cases, practitioners and local administra
treatment. After that part is com home care, follow
plete, patients should be transfer and health education of the com tive medical officers can participate
red to outpatient department as munity including environmental exchange their views and augment
A
early as possible for rehabilitation sanitation. Nutritional services to their professional knowledge.
a minimum. Appointment of a
“lady receptionist” to receive the
patients and their relatives and
in case of their difficulty guid
ing them to their respective
places, plays a very important
role.
12
S was th Hind
DIET THERAPY FOR CANCER
Smt. Rita Bansal
In Cancer, apart from all medicines and the surgery of the affected part, only
changes in dietary habits can show a miracle. The author says that diet has
a great curative effect for cancer patients with no cost.
studies have related dietary and nutri
ent excesses, deficiencies or imbalances to the
development of cancer in the oesophagus, stomach,
colon, pancreas, liver and breast. Nutrients may
affect in either of these three ways:
xtensive
E
1.—Certain dietary constituents may themselves be
carcinogenic in nature,
2.—Whereas others may act as nutritional modi
fier in carcinogenic process, or
Iodine deficiency leads to development of thyroid
enlargement and ultimately to tumour, followed by
cancer.
The diet low in fibre is associated with colon cancer
while high fibre diet initiates against it. This is
because:
(i) It shortens intestinal transit time of food, there
by shortens residence time of potential carcino
gens.
3—As a vehicle for transportation of carcinogens.
(ii) Intestinal flora interact with fibre to produce
volatile fatty acids which exert laxative effect.
Once the carcinogens enter the body, the follow
ing may be the repercussions:
(iii) Fibre converts deoxycholic acid (a carcinogen,
product of bile acid metabolism) to methylcholanthrene.
1.—They may either be detoxified of converted to
active form depending upon how the body
handles them.
2.—They may sometimes bind themselves with cri
tical cellular target.
3.—They may develop into clinically observable
tumours from progenitor cells.
Role of different nutrients in carcinogenesis
Excess of starch and sugar may lead to induction
of cancer by providing sufficient energy for tumour
growth. Whereas limiting its intake has shown reduced
incidence.
Vitamin A deficiency leads to squamous changes in
number of epithelial tissues like oesophagus, bladder,
respiratory track However, its high level has been ob
served to be protective, against hydrocarbon induced
tumours. Stiff results are contradictory.
The diet rich in Vitamin C contents helps to reduce
the incidence of tumours.
January 1986
In normal condition, CO2 released during respira
tion remains in blood as sodium carbonate to combine
with some suitable acid, e.g., lactic acid. On reaction
a harmless lactate salt is formed which is washed
away through urine. Thus both poisonous substan
ces—CO2 and lactic acid—are released from body.
But in abnormal condition there is increased alkalinity
with low calcium content around the body cells. This
abnormal quality of fluid irritates the simple cell, for
ming a lump. Same thing happens in cancer. Due
to increased alkalinity, body serum has subtle amount
of sodium which acts as irritant (caustic soda). Hence,
to counteract the effect of alkalinity low salt or salt
restricted diet has been advised with sample amount
of potassium. This will help in maintaining acid
base balance of body serum.
Diet Therapy
Chemotherapy and radiotherapy are extensively
used as measures to cure the cancer. In spite of this,
no one can ignore their serious side-effects like diarr
13
hoea, constipation, vomiting, nausea, anorexia, altered
taste, hepatic dysfunction, etc. But nutritional mani
pulations are seen to alter the incidence ,of spontane
ously occurring tumours. Fat being as the sole factor
in carcinogenesis it is essential to restrict fat intake to
the level of 20% calories. Cholesterol level should
also be maintained 100 mg/day. Whole milk should
be replaced by skim milk. Egg intake should also be
restricted twice a week as it supplies 60 per cent on
cholesterol intake. The lists of foods are given below
from which a person can freely choose, and also those
he should restrict or withhold:
Foods that one can eat freely:
1. Salt free yoghurt/curd.
2.
Raw fruit.
3. Skim milk or little milk.
4. Unsalted porridge with no cream or
ghee.
5. Salt free bread and butter.
6. Sultana or onions.
7. Soaked and dried
banana.
fruit, groundnuts or ripe
8. Citrus fruit taken after one hour of ingestion of
starchy foods.
9. Greens and onions.
10. Peas and dry beans.
W.H.O. Workshop on Control of
Tobacco-Related Diseases
\AZ1TH Sowing evidence of the direct relationship
* * between smoking and lung cancer, many coun
tries are considering measures to curb the habit, parti
cularly among the young.
Similarly, it is recognized that the use of tobacco
also has adverse effects on health and that tobacco
smoke is carcinogenic to humans. Yet, the manufac
ture of cigarettes and other tobacco products and
their consumption are increasing in the South-East
Asia Region.
To review ongoing national activities, policies and
strategies in relation to smoking and health in the
WHO South-East 'Asia Region, a five-day regional
workshop on control of tobacco-related diseases was
held from 22 July, 1985, in New Delhi.
Addressing the participants, which included senior
health administrators and officials from related Minis
tries, the WHO Regional Director for South-East
Asia, Dr U Ko Ko, cautioned that there was evidence
of an increase in the number of cases of cancer of the
lung, chronic pulmonary diseases including emphy
sema and ischaemic heart diseases. “The global
figures for the mortality from lung cancer alone have
already risen to one million annually. It has been
estimated that this figure will increase to 2 million by
the year 2000 and continue to rise unless effective
action is taken now to halt the smoking epidemic”
he added.
Foods that one should restrict or omit:
1. Meat, Fish, cheese or egg white,
2.
Fruit drinks containing preservatives,
3. Nicotine, i.e„ smoking,
4. Cane sugar,
5. Tea, coffee, alcohol or coke,
6. Condiments,
7. Table salts or alike,
8. Sodium like baking powder,
9. Aspirin preparation,
10. Borax (Sodium sulphate),
1 I. Acid fruits (citrus).
12. Fruit preserved in syrups.
Thus, diet has a great curative effect for cancer
patients with rip cost.
14
Besides lung cancer, smoking and chewing of to
bacco are responsible for the vast majority of cases of
oropharyngeal and laryngeal cancers. Other cancers
related to smoking are those of the pancreas, urinary
bladder and oesophagus. The cure rates of lung
cancer are extremely low, even when treatment is
started early. The only effective method presently
available for the control of lung cancer is prevention
of smoking.
The risk of lung cancer is particularly dependent
on the duration of smoking; the earlier the age of
onset of the habit, the greater is the risk to the indi
vidual. Furthermore, the longer the duration which
a major proportion of the adult population has been
smoking, the higher the incidence and mortality from
lung cancer in that population.
The habit of chewing tobacco which is associated
with an. increased risk Of oral and oropharyngeal
cancers is also an area of concern in the South East
Asia Region.
U. N. Weekly Newsletter 3 August, 1985
Swasth Hind
SHR1 S. KRISHNAKUMAR
TAKES OVER AS DEPUTY
MINISTER, FAMILY WELFARE
I
Ur
K
y*
Qhr) S. Krishnakumar, who was appointed as Deputy
Minister for Health and Family Welfare on 25, September
1985, brings rich experience, youthful energy and dynamism
to his office. He had resigned from the prestigeous Indian
Administrative Service in 1980 and joined the Congress (I)
Party. Within a short period of five years, he has carved
out a place for himself in the Congress Party by the sheer
dint of his hard work, perseverance, organising capabilities
and understanding of men and matters. Shri S. Krishnakumar
was elected to the Lok Sabha in December 1984 general elec
tions from Quilon constituency in Kerala which was considered a stronghold of the CPM, CPI and the Revoluntionary
Socialist Party (RSP). Shri Krishnakumar has been an out
standing engineer, administrator, manager, grass-root level
worker and political leader. He had a consistently excellent
record of formulating and implementing numerous projects
and development programmes in a wide spectrum of national
endeavour.
Shri S. Krishnakumar was born on 6 September, 1939.
He had a brilliant academic record. He passed B.Sc (En
gineering Hons.) in First Division with distinction and topped
the University of Kerala in Mechanical Engineering. He had
a stint as lecturer in Mechanical Engineering in the University
of Kerala before his selection to the Indian Railway Service
of Engineers in 1961. He worked as a Mechanical Engineer
in the Indian Railways till May 1963 when he was selected
to the Indian Administrative Service. As an IAS Officer he
held several senior positions. These include District Collector,
Ernakulam (1969-73); Director, Civil Supplies and Managing
Director of Kerala State Civil Supplies Corporation, Kerala
(1973-74); Industrial Development Commissioner of Kerala
and Executive Chairman, Kerala State Small Industries Deve
lopment and Employment Corporation Ltd. (1975-1978);
Chairman, Greater Cochin Development Authority (1971-80)
(concurrent post). Secretary to Government of Kerala, Local
Administration (including Urban Development), Social Wel
fare and Fisheries (1979-80). He was also Chairman/Chief
Executive of a number of Public Sector Corporations under
the Government of Kerala.
Shri Krishnakumar has won several awards for outstanding
service. He was given FICCI National Award, 1973 in re
cognition of individual initiative in economic and social deve
lopment, especially for his work in the national family plan
ning programme. He was also honoured with the Award by
the National Alliance of Young Entrepreneurs for his contri
butions to the development of small scale industries in the
country.
Shri Krishnakumar has a number of publications to
credit, published both in India and abroad.
P
I *
f
er
his-
Although Shri Krishnakumar’s experience ranges from
urban development to fisheries and fishermen’s welfare,
Family Welfare remains his first love. In fact, it was his
initiative and drive in the family planning that won him national and international acclaim. His pioneering work in
1970-73 as District Collector of Ernakulam succeeded in
breaking the resistance to family planning all over Kerala and
was responsible for achieving an irreversible decline in popu
lation growth rate in Kerala poising the State towards achiev
ing a potential zero growth rate in the next two decades.
The Ernakulam Family Planning experiment set a world
record in sterilizations performed for a given population
group in a given length of time. The approach .was later re
plicated in other parts of the country with remarkable success.
His efforts in the field of family planning are one of the most
outstanding contributions of a single person to -the family
planning programme not only in India but probably anywhere
in the world. His contribution to a massive communication
strategy based on propaganda and motivation supported by
incentives and fully backed by requisite services, have demon
January 1986
strated the way for early realization of targets and ultimata
educational goals of a successful family planning programme.
Several national and international studies have testified to and
commended Shri Krishnakumar’s leadership qualities in or-.
ganising voluntary and governmental agencies in generating a
massive programme of social engineering and change.
Whether it was family welfare, urban development, small
industries, community development, land reforms, management
of public enterprises or service to the weaker sections of
society, Shri Krishnakumar made his mark as an administrator,
manager and a social worker. As honorary Chairman, from
1981 to 1984, of Hidustan Latex Limited, Trivandrum, the
premier public sector manufacturer of Nirodh for family
planning programme, he transformed the perpetually losing
concern into a profit making company setting a new record
in capacity utilization, production, quality and profits.
Shri Krishnakumar resigned from the IAS after 17 years
of distinguished service in 1980 with the blessings of Smt.
Indira Gandhi when Congress (1) was in {opposition in Kerala
State. He worked from J 980 to 1984 at the grass-root level
of the Congress in Kerala organising the Cashew Workers,
Fishermen, Government and public sector employees. He
had worked as an executive member of the KPCC. the
Convenor (Publicity) in 1982 State election and as Chairman
of the relevant front organisations of the Congress in the
State. Shri Krishnakumar was selected for the Quilon seat in
Kerala in recognition of his popularity among the workers of
the traditional industries in that worker dominated consti
tuency and he had won handsomely this seat which was con
sidered a traditional leftist stronghold.
Shri Krishnakumar has been a keen sportsman and a stu
dent leader. He was the University and State Tennis Cham
pion, President of the Trivandrum Engineering College Stu
dents Union and Student President at the National Academy
of Administration, Mussoorie.
Trained in various aspects of management, Shri Krishna
kumar has also been abroad for advanced training in Plann
ing and Management of Population under the U.N.D.P. in
Washington in 1971. He obtained special training in Metro
politan Planning, Development, Administration and in control
of Environment at the International Union of Local Autho
rities, the Hague, in Netherlands in 1974. At the Indian
Institute of Public Administration, New Delhi, he completed
the training in 1978 organised on “Finance For Non-Finance
Executives”, and World Bank Course in 1979 on Urban
Management”. Besides, he has to his credit professional
training in Railway Engineering and Management and Public
Administration. He is a fellow of the Economic Development
Institute of the World Bank on Urban Development.
Shri Krishnakumar has travelled extensively around the
world and shared his experiences at various international
forums on a variety of developmental issues. He had also
served as a resource person for two international Conferences
on Family Planning held at Geneva and New Delhi.
Shri Krishnakumar is married to Usha and has a son and
a daughter. His hobbies include, reading, tennis, golf and
travel.
Q
15
PEOPLES PARTICIPATION IN
LEPROSY ERADICATION
DRV. V. DONGRE
Health education is the weapon to enlist peoples participation. It helps
in case detection, case holding, regularity in treatment, prevention of de
formities, prevention of dehabilitation, rehabilitation, doing away with un
necessary unscientific legal codes, and research.
large will not be successful unless there is active
participation by the people themselves. It is very
true in health programmes of all kinds.
A
in short what is peoples participation. The essential
part of the process is proper understanding of the
scientific concepts and procedures to solve the pro
blem.
In a disease
like leprosy, having medical and
social aspects, peoples active participation is a must.
Leprosy patients come from all walks of life and are
found in all strata of the society. Leprosy is every
one’s concern. The master key of the problem lies in
the health educational aspect of the problem.
Health education is the weapon to enlist peoples
participation. It helps in case detection, case hold
ing, regularity in treatment, prevention of deformi
ties, prevention* of dehabilitation, rehabilitation, doing
away with unnecessary unscientific legal codes, and
research.
The roots of the social stigma are in the progres
sive deformities which arise as a result of the disease
process. It is one of the reasons of dehabilitation of
leprosy patients and may lead to genesis of leprosy
beggars. These deformities can be prevented if re
gular treatment is availed of in the early stages of
the disease.
As a result of impact of imparting scientific know
ledge to community, its attitude and practice can be
guided on proper lines.
ny programme which is meant for the people at
The source of infection of the disease is an open
case of leprosy who is not taking, treatment. If such
an open case is converted into a closed case by ade
quate regular treatment, then the chain of transmis
sion can be curtailed. This can be acquired by early
detection and regular treatment.
Community participation
The concept of community participation is as anci
ent as community life.
The community identifies
its common problem and through cooperative efforts
uses local resources to solve the problem. This is
16
The involvement of leprosy patients and non-leprosy patients including medical practitioners is neces
sary to solve the problem in toto.
Almost all the anti-leprosy projects and organisa
tions are running on SET pattern (Survey, education
and treatment) and few try for the rehabilitation part
of the problem.
Surveys are done
to detect leprosy patients in
slums, schools, industrial settlements, etc.
Health
education is done for the various purposes already
mentioned. Treatment is provided free of charge as
far as possible and anti-Leprosy Centres are establi
shed in different parts of localities for the convenience
of the patients. Colonization of leprosy patients is a
thing of past and should not be practised for the
Swasth Hind
fear of adding to the social stigma which is already
existing. Instead, leprosy patients should be encour
aged to stay in their respective families and take re
gular treatment while undertaking their normal trades
or professions.
GUIDE LINES
1. Teachers and parents should give cooperation
for the screening
of students for leprosy.
Children with leprosy should not be debarred
from the schools. Regularity in treatment by
such children should be checked by the tea
chers and parents.
2. Social workers can arrange for sponsorship
(fees, uniforms and books) for leprosy affli
cted- children or
for children
of leprosy
patients.
3. (a) Panel discussions, lectures in vernacular
languages with coloured slides can be arranged
with an arrangement of check-up Centres in
the vicinity of schools, colleges, slums, etc.
Such programmes can be arranged in the soical
meetings and annual get-togethers.
(b) Proper quickies, strips, slides on leprosy
can be projected on Television and in Cinema
Houses. Interviews of leprosy patients/workers
can be telecast. People concerned with these
media can help in this direction.
(c) Entertainment programmes during festivals
can be sandwiched with a film on leprosy for
the benefit of the people.
(d) Kirtankars can narrate stories of Renukamata, Raja
Rukmangad to the audience.
Puppet-shows can project a story on leprosy
patients.
(e) Writers, poets can select leprosy as a sub
ject for their work and project optimistic views
of the whole problem. People good at pen,
can write articles on leprosy in press.
(f) Artists and painters can help in creating
new health education materials in the form of
posters, pictures, etc.
(g) Housewives can spread the facts of leprosy
by word of mouth.
A simple instruction like,
cover the mouth and
nose while sneezing,
January 1986
FACTS AND FIGURES
ABOUT LEPROSY
1. Leprosy is caused by a specific germ.
mildly infectious disease.
It is
2. Approximately 20% leprosy patients are open
cases (infectious).
3. Leprosy is not hereditary.
4. 80% of the people have natural resistance
against leprosy infection.
5. Leprosy patients are found in all the strata of
society. They come from all walks of life.
6. A light coloured or redish patch with numb
ness, shiny, glossy, oily skin could be early
signs of leprosy.
7. Consult the doctor if there is frequent ants
crawling sensation in the limbs.
8. Deformities can be prevented if early and re
gular treatment is acquired. Only 20% leprosy
patients get deformities because of negligence
in taking regular and adequate treatment.
9. Leprosy is curable.
10. Free treatment
is available in Government,
Municipal Dispensaries and Hospitals as well
as in Voluntary Organizations all over the
country.
coughing, etc., will help in the prevention of
dissemination of the germs in the atmosphere.
(h) The professionals in the field of communi
cations can promote the ideas like “Leprosy
is ourabfle”
better
than ordinary leprosy
worker. So, there is a scope for such experts
in the health educational aspect of leprosy.
4. Medical faculty members can modify'syllabus
for leprosy training in the Medical Colleges
and Nursing colleges. General medical practi
tioners can treat leprosy patients in their own
clinics instead of referring
them to special
Leprosy Hospitals. This will lessen the stigma.
The Para-Medical and Nursing staff of General
Hospitals should
not object
to nursing a
17
leprosy patient in a General Ward* Admissions
to leprosy patients in General Hospitals should
not pose a problem.
5. (a) The employers should not deject the em
ployee with leprosy. In exceptional cases, re
lative of the said employee should be given
employment. Special allowance may be given
for modern treatment and for sustenance. Al
ternate jobs may be provided to such patients
so that rent, ration, education and medical
care is made possible.
(b) Products
of rehabilitation
centres and
Leprosy Homes should be purchased on prio
rity basis.
(c) Whatever we preach must be followed in
practice. Therefore, employment to a leprosy
patient in well-known organizations will help
in doing away with the social stigma.
(b) A definite amount while celebrating wedd
ings. birth anniversaries,
death anniversaries
may be ear-marked for anti-leprosy work.
(c) Donations can be specific, e.g., for exhibits,
leaflets, booklets, banners, stickers, goodwill
advertisements in the Press, display of posters
and hoardings on leprosy.
(d) Individuals can purchase Leprosy Seals to
boost up funds raising.
8- Public enterprises like Life Insurance Corpo
ration (L.I.C.) should not charge double premia
rate from leprosy patients.
9. (a) Pleaders can study different legal proce
dures and help to rescind or repeal unneces
sary, unethical, unscientific legal codes, obs
tructing social justice to the leprosy patients,
e.g., matrimonial acts.
(b) Legislators can help in modifying leprosy
acts.
6. (a) Service Clubs like Lions, Rotarians, Giants,
etc., can arrange detection camps with follow
up of patients, give appliances and instruments
to leprosy rehabilitation centres, arrange for
modern treatment, crutches, M.C.R. Shoes.
10. Administrators can help in giving accommoda
tion to Offices to Leprosy Organizations, place
for treatment centres and housing for leprosy
workers.
(b) Railways
and
transport corporations
should religiously follow the concessions given
by them to leprosy patients.
11. Research Workers can
take up leprosy for
their research and find out new techniques to
treat or to detect leprosy patients.
(c) Leather Industrialists can make the M.C.R.
Shoes available at a cheaper rate to the leprosy
patients.
7. (a) Philanthropic people should not give sweet
meats only to leprosy asylum but should see
the actual needs in terms of drugs, instruments,
of the institutions concerned. Alms to beggars
should be organised.
In all the above mentioned areas there is scope to
expand work. But the principle should be well re
membered that prevention is better than cure.
Mere progress in the technology will not help but
the people at large will have to be alerted to feel the
need to identify the priority of the problem and to take
initiative to use local resources to the extent that is
possible to control the problem
and thereafter to
eradicate it.
A
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Kot la Marg, New Delhi-110 002.
18
><
Swasth Hind
ADD LIFE TO YEARS
S. P. Pathak
Older people are at greater risk in confronting hostile elements in the
environment and the ticking of the biological clock.
Therefore, they
require a wide range of preventive, curative and rehabilitative care, in
addition to having a feeling of belonging.
A fter a number of experts belonging to a variety
of disciplines made their presentations at an
international conference on the problems of aged
people, in London during 1970s, a grey haired delegate
from Japan who was a medical doctor took the floor.
His suggested definition for the old age was fascinat
ing. This is what he said: “Old age is that in which
the person recalls and remembers clearly and vividly
everything that had happened in his youth but does
not remember what he had for the breakfast that
morning”.
May be there is an element' of exaggeration in this
statement but it provides a solid facet of the multi
faceted old age—that is, living in the past, the nostal
gia. Indeed, the most significant aspect of suffering
of the old in any society, is its daily withdrawal into
a life lived decades earlier. The several points that
are thrown up in this nostalgic world include not only
the gay and happy days of early married life but also
the moments of discontent and despair caused by
domestic disharmony added to various other factors.
That is why social scientists indicate that basically
the problems of the old age are problems of psy
chological readjustment.
Let us first see at what age a person really becomes
old? The Indian tradition has it that life is lived in
four stages—balya, kishora, yauvan and vriddha.
These significant stages are known as avasthas. Each
stage or avastha gives rise to the next stage—in other
words when we analyse the phenomenon behind these
stages we sec that the childhood stage ends or withers
January 1986
up giving way to youth, youth stage giving way to
middle age, the middle age dries up and the old age
creeps in. Finally that stage also dies when body
disintegrates in death.
W.e consider here a stage prior to the death; that
is the old age. It can be termed as the culmination
of the three earlier stages of life, that is the childhood,
adolescence and the youth. Social scientists of the
West say that in a normal life-span human beings
go through a series of three stages from birth until
death. The first, the time of progress, development
and evolution, is youth; the second, the time of stabi
lization and equilibrium, is adulthood and maturity;
and the last is the time of retrospection, or old age.
Gerontology
Lately, the study of the problems of the old has as
sumed important dimensions and a distinct academic
discipline known as “gerontology”
has come into
being. A French gerontologist designated the last
stage of life as the “Third Age”. Now while the ad
vanced countries have taken considerable strides in
concretising ideas and policies in the form of projects
and programmes for the total well-being of the aged,
developing countries like India have not given much
thought to the problem. This stance has to be consider
ed in the background of the rigid traditional rules of
orthodoxy that give respect to the old in society, and
also the family structure where the patriarch has
paramountcy.
But
unfortunately, urban growth
which is upsetting all calculations are throwing to the
19
four winds time-honoured traditions and values. The
ageing have
been considerably affected
by this
phenomenon.
responsibility of the family is now becoming an im
perative state responsibility.
Communicators of culture
It is generally agreed that old age creeps in at the
60th year of a person. Now, the population of India
being about 700 million, an estimated 5.5 per cent of
the people constitute the old in the country. The
various developmental projects and welfare program
mes undertaken by the government have led to a
drastic fall in child mortality and increased the life
span of the average Indian. Thus it may be expected
that the percentage of the old in the population will
rise steeply by the turn of the century. Increasing
numbers of old people will add to the problems of
the nation. In some western countries population
strategists point out that, the young (below 14) and
the old (above 65) will constitute about 60 per cent
of the total population and that the remaining 40
per cent will have to look after them by the turn of
the century.
It is, therefore, imperative that the
nation invests a sense of urgency into this important
social problem and take necessary steps before the
problem of the old assumes an enormous stature.
Problem and its aspects
The problem has two aspects: one, the legitimate
right of the old who have given decades of service
to society to expect to being cared for in the twilight
years of their life, and two, tapping of a great nation
al resource of “memory and experience”, the two
unique qualities the old could bring to bear on the
present generation with their store-house of wisdom
and standards of ethical conduct. It has been a part
of our tradition to accord a privileged place to the
elderly and seek their valuable guidance and advice
on matters covering the entire gamut of human acti
vity. Whether it is a point on when to start the
sowing activity for the next crop, or marriag of the
young in the family or settling a dispute in society
or prescribing a home remedy for stomach ache, the
advice of the old is invariably sought. At least, this
was the practice in the ideal joint family set up.
With.the increasing endeavours of industrialising the
country with the advent of concomitant problems like
urbanisation, the traditional joint family system is
slowly on the way out. What has been the exclusive
20
Now, what is the state doing for the old? Can we
continue to depend on the conventional sources of
succour for the old? Can state medical aid program
mes meet the typical requirements of old people? Can
we provide for their social, emotional and psycho
logical needs? The answers to these questions lie, in
attempting a multi-disciplinary approach towards pro
viding a comprehensive policy frame work and im
plementation mechanism if only we are keen on ame
liorating the suffering of the old as also harnessing
the untapped resource of their experienced and wisdom.
In 1982, the WHO focussed the attention of the
people everywhere on the health of the elderly
people. The slogan selected for the ‘Year of the Aged’
was “Add life to years”.
The accent of WHO was naturally on health care
of the old. And rightly. During that year the world
was told about the several dimensions of the problem.
For instance.. the image of the aged person is that
of one who is tottering towards the grave, battered
by illness and shattered by disease, beyond all feel
ings and incapable of taking care of himself, much
less rendering service to others. It is false. Another
factor of great importance that the United Nations
took note was the significance of the old as communi
cators of culture. It is more from the grandma and
the grandpa rather than from the pa and ma that a
child learns about the myths, legends and symbols
of a society, of dos and donts.
However, older people are at greater risk in con
fronting hostile elements in the environment and the
ticking of the biological clock. Therefore, they re
quire a wide range of preventive, curative and rehabi
litative care, in addition to having a feeling of belong
ing.
The aged can contribute to national progress in
many ways. It is necessary that all should be careful
not to establish situations that cut off the aged from
the work they want to do and are able to perform.
The main contribution of the aged is that they can
add something to those around them by their presence
and experience.
®
Swasth Hind
INTERNATIONAL PEACE YEAR- 1986
THE PATH OF PEACE AND
BROTHERHOOD
The Leon Bernard Foundation Prize and Medal for 1985 have been
awarded to Professor Raoul Senault (France) for his outstanding services
in the field of social medicine.
The laureate, in his acceptance speech, expressed the hope that at the
dawning of the third millenium, international cooperation for health would
finally lead men along the path of peace and brotherhood.
11 'here have been striking variations on the theme
•* of the history and philosophy of organizations
devoted to the health sciences. If there is little room
left for originality, that is because of the very truth
of the fact that WHO, as heir to the Hygiene Com
mittee of the League of Nations—whose activities it
has amplified and diversified—has established the link
between what was done yesterday, what is being done
today, and what remains to be done between now
and the year 2000 to demonstrate “the importance
of the continuity of effort in the perpetuation of acti
vity” for health.
Important developments
National and international trends regarding health
affairs have undoubtedly been influenced throughout
the world during this second half of the twentieth
century by two important developments, one of which
is political, the other scientific.
In political terms, the accession of many states to
independence has led them, in taking responsibility
for the health of their peoples, to assess requirements
in an attempt to define priorities through objective
analysis of needs and available resources. The choices
involved are often difficult because of the magnitude of
the problems to be solved in other, equally essential
sectors of the national economy. These situations have
led young states to seek technical and financial assis
tance in order to build up programmes of bilateral and
multilateral cooperation which supplement the support
January 1986
requested from the United Nations family, among which
it is undoubtedly WHO that gives the greatest support.
Fifteen years of a policy whose watchword has been
assistance, has been followed by the institution of a
policy of technical cooperation. Thus, what might have
seemed to be intellectual and material dependence, be
comes a responsibility shared between partners in a
collaboration freely agreed upon.
Another factor of a geopolitical nature was the
setting up of a real decentralized organization at the
regional level better able to satisfy the needs of the
peoples while respecting the culture, economy and
social potential of each people. Although this region
alization was not always able to mitigate the mistakes
arising from transposition of structural or technologi
cal outlines from the developed countries in which
most of the doctors and the new decision makers had
received their training, it did nevertheless act as a
useful curb on the tendency towards such transfers,
which have almost invariably proved to be unsuita
ble and often to be fraught with consequences for the
delicate economies of the developing countries.
Scientific progress
In scientific terms, considerable progress has been
realized over the same period in biology and in phy
sical and chemical sciences, making possible real ad
vances in all areas of curative medicine (often at the
expense * of a preventive policy). The parallel deve
lopment, thanks to the media, of means of infor
21
malion and scientific popularization has brought to
many people a knowledge and understanding of pro
blems which were for a long time the exclusive pro
vince of culturally privileged social groups.
This situation has often led to a feverish upsurge
in medical consumption and to an increasingly intru
sive technology, the cost of which is tending to be
come too great a burden on the economy of most
countries.
Health systems organized on the basis of provision
of care and compensation are leading to situations
in which countries no longer have the means to meet
the increases in expenditure. There is a need, there
fore. for a more rational use of health and social
security systems and a fairer distribution of available
resources must be encouraged. This is far from being
the case generally.
Lastly, faced with the legitimate wish of indivi
duals to see better management of their “health capi
tal”, we are obliged to consider ways and means of
reconciling reasonable demands of the people with
technical and financial resources in the existing socio
economic context, since neither material well-being,
nor the refinement of techniques suffice to reduce the
increasing chronic deterioration, even in the most
economically developed countries. We would be well
advised to admit that the remedies are to be found
elsewhere.
Consequently, medicine should become a “cultural
matter” in health policy without abandoning its scien
tific basis. It was not by chance that the Alma Ata
Conference in 1978. in advocating a primary health
care approach after careful consideration of obser
vations. studies, and hard experience, defined such
care as “essential health care based on practical scien
tifically sound and socially acceptable methods and
technology made universally accessible to individuals
and families in the community through their full par
ticipation and at a cost that the community and. coun
try can afford to maintain at every stage of their deve
lopment”.
New approach
This new shift in policy advocated by WHO is too
well known to everyone for there to be any need to
linger over it, but it is obvious that it is well justified
when we analyze the extent of the health problems
still to be resolved in the world, problems that tech
nology alone is incapable of resolving.
22
In some places we have the vicious circle of poverty
and disease, and in others, opulence, each with its
concomittent somatic disorders and psycho-social ill
nesses. Everything points clearly to the fact that the
gap between rich countries and poor countries becomes
daily wider, to the extent where poor countries run
the risk of becoming increasingly trapped in a state
of despair and distress caused by disease, poverty and
famine together with illiteracy, whilst in the rich coun
tries, groups at risk, known as the “new poor”, are
appearing as a result of difficulties brought about by
the world economic crisis. Important health problems
which arc difficult to detect for psychological reasons
are emerging among these groups.
We really do need to come to grasps with the
troublesome question of how to overcome forces hos
tile to life that are upsetting health. Despite the spec
tacular advances already made in the control of com
municable diseases, not least amongst which we have
the worldwide eradication of smallpox, the contin
uation of research in this field remains an essential
requirement justified by the continued existence of
epidemic scourges and strengthened by the emergence
of new diseases. The appearance of AIDS on the
medical scene is a clear example. It is no less impor
tant to continue research on the basic problem of
protection of human health in the human physical
and social environment, since it is noted that socio
economic and socio-cultural factors govern the reali
ties of health in such a way that the effectiveness of
progarmmes aimed at reducing inequalities in health
founders on the rock of social inequalities. Many
other areas in which WHO is interested could be
mentioned, but it is important to recognize that WHO’s
commitment to the coordination of biomedical res
earch has been beneficial to Member States as a
whole. It is not immaterial that the research carried
out in industrialized
countries enables devolping
countries, who are building up their industrial
infrastructure, to benefit
from the experience
acquired by others thus avoiding the growing
pains of development being added to the problems
that they are already combatting.
It is to be hoped that the well-known saying “pre
vention is better than cure” will soon be replaced by
the formula “foresight for prevention”. This aim,
which was still unrealistic yesterday, may perhaps
become a reality tomorrow thanks to advances in
molecular biology and research on HL A (Human
Swasth Hind
Leucocyte Antigen) systems. However, although such
progress embodies hope, it also includes risks that
cannot be overlooked both for the individual and for
the community.
That the international scientific community is con
cerned with this matter has been shown by the recent
bioethical conference held in Paris.
, WHO should be an important contributor to this
exercise in which doctors and others must pool their
abilities so as to take into consideration all the moral
and legal aspects that are already being raised today,
and will be raised even more so tomorrow on the
relationship between science and ethics, especially in
the field of human biology.
Medical schools tend to be inward looking
Rene Dubos has written : “In tomorrow’s world,
as in yesterday’s, health will be dependent on the
creative activity of men and on their ability to face
up to the unforseeable situations to which they are
exposed in a world that is continually changing.”
This remark, which is widely applicable, should
lead those responsible for the training of doctors to
examine their responsibility
towards the medical
generation of the year 2000.
Although interesting projects in the improvement
of teaching are being undertaken on the instigation
of WHO in industrialized and developing countries,
all too often they remain pilot projects that unfortu
nately fail to break through the conservatism of the
majority of medical schools.
It is to be regretted that, as a general rule, these
schools still tend to be inward looking, with the result
that teachers and students are deprived of organized
contact with external realities, whilst it is in the mut
ual. interest of teachers and pupils, as well as health
professionals and members of the community, to
benefit from experience in the field.
Team work
would subsequently be more fruitful since experience
gained early on in the course of study would remove
many obstacles, especially that of excessive profes
sionalism. which always makes it difficult to share or
hand over responsibility.
January 1986
The gap between discussion and reality is far from
being bridged. The willingness to give priority in
education to primary health care, to prevention, and
to individual and community participation is not
sufficiently apparent in curricula. The doctor must
forsake his position of technical magician in favour
of the more difficult role of technical educator and
health adviser so as to establish a new relationship
with people based on dialogue and the sharing of
knowledge. Development of medical training in the
spirit of the Alma Ata Declaration would have more
chance of making this effective.
Having been involved for many years in educa
tional projects for health, I cannot fail to applaud
the approach taken by WHO in this area. However,
as we have been reminded during recent technical
discussions, this determination will not be effective
unless national bodies affirm their will at the highest
level and there is a profound cultural transformation
in the behaviour of individuals and in their mode of
life in existing societies, which caused Rene Sand to
say “you cannot give people health, they have to par
ticipate”.
Society is faced with delicate problems due to the
encounter between modern health requirements and
the new mentality of individuals increasingly en
amoured of freedom. How can we reconcile the in
escapable requirements of promoting the health of
peoples with the specific demand of individuals to be
informed and to decide for themselves?
It is this awareness of participating to the full in
their own fate and in that of the community that
gives individuals a feeling of their forth and leads
them gradually to a sense of individual responsibility
towards the common good constituted by health.
Health education can assist them.
Convinced that we must
exemplify the precise
thinking of Aristotle who said that “if health is the
supreme good, the most sublime joy is the fulfilment
of an idea”, let us hope that humanity will have the
wisdom not to compromise or destroy the successes
so laboriously achieved, and that at the dawning of
the third millenium, international cooperation for
health will finally lead men along the path of peace
and brotherhood.
/\
23
NBWS
HEALTH EDUCATION AND INFORMATION CRUCIAL
IN THE FIGHT AGAINST AIDS
T
he key to slowing the spread of AIDS (Acquired
Immune Deficiency Syndrome) virus is education
and information of health workers, individuals at
high risk of infection, and the general public, accord
ing to an article published by the World Health
Organization (WHO) in the WHO Chronicle, Vol.
39, No. 3 (1985).
Physicians and other health workers need a basic
understanding of the clinical features of AIDS and
of the mode of transmission of the virus to be able
to counsel patients and those at risk. They must be
aware of the precautions to take in caring for AIDS
patients and in handing their specimens, and the
Chronicle article summarizes the guidelines that have
been developed and endorsed by the World Health
Organization. The article also stresses the importance
of changing the attitudes of health workers, who are
are often_ hostile to
patients
with sexually
transmitted diseases. In Australia, Europe and the
USA, where AIDS is most common in homosexual
men, the problem may be compounded by introlerance of homosexuality.
Both health professionals and the public need to
know that:
— Like the virus of hepatitis B, AIDS is also
transmitted via blood and other body fluids.
— Among the various types of sexual contact,
anal intercourse is by far the most dangerous because
of the possible exchange of blood. Oral-anal and oral
genital contact and open-mouth kissing have not been
proved to be especially harmful by the risk of infec
tion cannot be. ruled out.
— The use of condoms decreases the risk of trans
mission but does not give full protection.
24
— Any other activity involving the possible ex
change of blood—such as the sharing of razors and
toothbrushes—should be avoided. Especially danger
ous is the sharing of hypodermic needles and the use
of needles and syrines of suspect streility . Intrave
nous drug abusers, in Europe and the USA, are the
group at next highest risk after homosexual men,
and the medical use of improperly sterilized or un
sterilized syringes and needles is thought to play a
role in AIDS transmission in some parts of the world.
Women suffering from AIDS or at high risk
of infection should avoid becoming pregnant, since
the infection can be transmitted to the unborn or
newborn baby.
With, by the end of August, some 14,000 people
reported as having the disease, and several million
more carriers of the virus who are symptom-free but
capable of infecting others, the immediate task is to
provide moral support and whatever treatment is
available tb those already suffering from the disease,
and to ensure that they and the millions of “silent”
carriers avoid spreading the virus still further.
There is no known specific cure for AIDS but a
number of antivirals are at present under test. Scien
tists are not optimistic about the changes of develop
ing a vaccine in the immediate future.
Early in the AIDS epidemic, the World Health
Organization recognized the need for coordinating the
research and surveillance that was going on indepen
dently in many centres, and for disseminating the
information being gathered.
Following the WHO—
sponsored international conference on AIDS held
last April in Atlanta, Georgia, USA, the Organiza
Swasth Hind
tion convened a group of experts to review the data
presented at the conference and propose further action
to be taken by WHO and its Member States. WHO’s
role in the health education of the public and of
health care workers was deemed crucial.
The Organization is also acting, as recommended
by the experts, to coordinate global surveillance of
AIDS, assess the risk of the disease country by coun
try, assist in the development of a vaccine, and set
up a network of collaborating centres to be respon
sible for staff training and specialist advice as well
as for epidemiological research. A number of colla
borating centres have already been designated.
International cooperation on Aids
The World Health Organization (WHO) convened
the first meeting of the directors of WHO Collabora
ting Centres on AIDS, and of experts and public
health workers, in Geneva, on 25-26 September, 1985
in order to strengthen international cooperation in
the fight against Acquired Immune Deficiency Syn
drome (AIDS). The importance of the meeting was
underlined by Dr Halfdan Mahler, Director-General
of WHO, who asked the participants for their sup
port to WHO in this area. Returning from several
WHO Regional Committee meetings, Dr Mahler
voiced the concern of almost all 166 Member States
of WHO over the syndrome and the public fear it
'generates. He pledged full support to international
cooperation, so as to assist Member States in con
taining the spread of the disease.
Thanking Dr Mahler for WHO’s commitment on
this issue, the Chairman of the meeting, Professor
Friederich Deinhardt (Max von Pettenkofer Insti
tute, Munich) said that the dissemination of accurate
information was essential on (a) the ways in which
the virus is transmitted, and (b) prevention methods.
He noted that the public had mistakenly been com
paring AIDS to the great plagues of the Middle Ages
and stressed that in no way should the AIDS virus
be compared to any of these infectious diseases, since
there is no evidence that it is spread through casual
contact with an infected person. AIDS is primarily a
sexually-transmitted disease. In the USA and Western
Europe, the majority of cases have occurred among
homosexual males, but in other areas of the world,
heterosexual transmission is more common. Because
the infection is blood-borne, transmission of the virus
also occurs in drug addicts and to a lesser extent
January 1986
blood transfusion recipients and hemophiliacs. The
latter group is disappearing as screening tests for
evidence of infection are introduced in blood banks.
The Collaborating Centres pledged their full sup
port to the WHO programme. Major recommendations
call for the development of therapeutic substances for
AIDS patients and research to find a common antigen
that would enable the development of a vaccine. In
view of the multiple strains of the virus, this is a
long term proposition. Furthermore, the participants
recommended:— That more data be collected on the
incidence of AIDS and communicated to WHO on
a regular basis: that WHO assist Member States in
providing authoritative information for the public,
the health professions and the media; and that a sim
ple and inexpensive test for detecting the infection
be urgently developed for use in the field.
A
NEW APPROACHES IN THE
CONTROL OF MALARIA
A significant and long-lasting improvement in the
global malaria situation is urgently needed as we
approach the final decade of this century, Dr
S. K. Litvinov, Assistant Director-General of the
World Health Organization (WHO), told the Expert
Committee on Malaria, which concluded its work 17
September, 1985, in Geneva.
The 18th Expert Committee on Malaria has been
convened at an important stage in the work of WHO
as well as in the history of malaria. A resolution
adopted by the World Health Assembly in May 1985
urged Member States to undertake an immediate re
view and appraisal of the malaria situation and re
commended that malaria control be developed as an
integral’part of national primary health care systems.
Unfortunately, the implementation of malaria control
strategies as part of primary health care has been
slow, and it is becoming increasingly difficult to cope
with the disease. As a result, the malaria situation
worldwide continues to deteriorate steadily.
During the meeting, experts stressed the need for
an epidemiological approach to the problem, taking
into account the local variability not only in the in
tensity of malaria but in its response to control mea
sures. But the Committee recognized the limitations
that might be imposed on such an approach by the
lack of resources and the potential of the infrastruc
ture to maintain control activities.
25
Two substantially different approaches were identi
fied at extreme ends of the spectrum. The first would
require as an absolute minimum the provision of dia
gnosis and treatment, prophylaxis throughout preg
nancy, and improved education of the public. The
second approach, calling for planned interference in
malaria transmission on a large scale, should only be
considered if it will produce a significant improve
ment in the malaria problem that could be maintained.
This will involve designing appropriate strategies,
identifying suitable control measures, monitoring and
evaluating results, managing problems such as para
site resistance to drugs, or vector resistance to insecti
cides, and developing malaria control activities within
the framework of primary health care in consideration
with other disease problems.
SHRI. SURAIN SINGH DHANOA
Since operational responsibilities will be transfer
red to the general health services, the district medical
officer must be in a position to decide on the approach
and the appropriate technology to be used in malaria
control in his area, bearing in mind socio-economic
and behavioural factors.
0hri surain singh dhanoa has taken over as
^Secretary to the Ministry of Health and Family
Welfare on 29 September, 1985.
The experts also recommended that training of
health w'orkers should provide them with precise lines
of action, not only in performing control activities
but also in educating people and stimulating commu
nity involvement, including some contribution by the
community towards the resources needed for malaria
control operations.
Shri Dhanoa, who was born on 12 August, 1930,
obtained B.Sc (Botany & Chemistry) Degree from
Punjab University in 1950. He did M.A. (Political
Science) and L L.B, from Aligarh Muslim University,
Aligarh, in 1953. Tn 1968 Shri Dhanoa studied at the
Graduate School of Public and International Affairs
(GSPIA), and the Institute of Development Adminis
tration, University of Pittsburg, U.S.A.
All this will require research and development stu
dies to ascertain how best to apply the principles of
malaria control as part of primary health care to the
wide variety of ecological and social situations where
malaria is a serious problem. This will include ques
tions such as how best to mobilize community re
sources, how far village workers can be trained, and
what are the limits of their capabilities and respon
sibilities to cope with these extra tasks in addition to
their regular everyday work. They will need to have
guidance and supervision from the first referral level
in the health infrastructure, which, in turn, will need
to be advised by experts in malaria.
Shri Dhanoa joined the Indian Administrative Ser
vice on 21 June, 1954, and has held a number of
important offices. Shri Dhanoa was Collector and
District Magistrate, Shahbad during 1960-61; Deputy
Commissioner, Dhanbad from 1961-64. Deputy Com
missioner. Ranchi from 1964-67: Registrar. Co-ope
rative Societies. Bihar from 1967-68: Deputy Direc
tor. Shri Lal Bahadur Shastri National Academy of
Administration. Mussooric from 1968-71; GeneralManager, Super Bazar, Delhi from 1972-75: Com
missioner. Food and Civil Supplies, Govt, of Bihar
Patna from 1975-76: Commisioner, Health, Govt, of
Bihar from 1976-77: and Joint Secretary, Department
of Agricultural Research and Education and Exofficio Secretary, Indian Council of Agricultural Res
earch from 1978-80. Shri Dhanoa was on deputation
with International Crops Research Institute for SemiArid Tropics, Hyderabad from 1981-82. He was Deve
lopment Commissioner, 20-Point Programme. Bihar
in 1983: Additional Chief Secretary. Govt, of Bihar
during 1983-84: Chief Secretary, Govt, of Punjab in
1984-85; and Adviser to Governor of Punjab, in
1985.
Malaria can be cured completely through prompt
diagnosis and adequate treatment with appropriate
antimalarial drugs. Reducing the toll and death cau
sed by this disease will require the development of
appropriate diagnostic, therapeutic and preventive
action against malaria as an integal part of a com
munity-based health programme.
26
OUR NEW SECRETARY
Shri Dhanoa is at home in many languages.
SwaSth Hind
STORY
THE PUZZLE
KA VITA COULD NOT SOLVE
Dr. R. L. Bijlani
was a popular girl. She had several friends
**-but one of them was very special. The special
friend was Sarita. Kavita and Sarita were quite differ
ent from each other in so many ways. They were
neighbours but they went to different schools. Kavita
was conscientious whereas Sarita was careless. Kavita
was strong while Sarita looked sick. But there was
one thing which fascinated them both and made them
feel specially close to each other. They shared the
same birthday. “How is it that Sarita was bom on
the same day of the same month in the same year”,
wondered Kavita. Kavita had been told that at every
birthday we grew a year older, and a little taller. She
had also been told that food made us grow up. “If
Sarita has had the same number of birthdays, she
should be just as big as me”, thought Kavita. As for
food. Sarita ate quite a lot. But still Sarita was full
ten centimetres shorter than Kavita. Although Kavita
was very good at solving puzzles, this was one which
she could not solve. Kavita nicknamed this puzzle
‘The puzzle of slow Sarita*.
avita
Kavita’s mother had a friend, Kusum, who was a
doctor: She was a specialist in children’s diseases.
One evening she came to Kavita’s place. Kavita
thought ‘The puzzle of slow Sarita’ was just the right
thing for Kusum aunty. She found a suitable moment
when she could get close to the aunty without • dis
January 1986
turbing anyone, and then she asked,“Aunty, may 1
ask you to solve a puzzle?” Kusum aunty was a bit
startled, but she smiled and said. “What sort of
puzzle, Kavita?” Kavita spoke, “I have a friend
Sarita who was bom on the same day of the same
month in the same year. She also eats a lot. But she
is full ten centimetres shorter than I am. Can you
tell me why it is so?” Aunty wanted a few clues.
“Are her parents shorter than yours?”, she asked.
“No”, said Kavita.
“Is she sick very often?”, asked aunty.
“No”, said Kavita.
“Has she passed worms?”, the doctor wanted to
know.
“No, I don’t think”, replied Kavita.
With negative answers to all clues, the puzzle
became really difficult even for aunty. She finally
told Kavita, “Why don’t you send your friend to my
clinic? And, one thing more.
Tell her that when
she comes, she should bring a sample of her stool—I
would like to have it tested.”
The very next day, Kavita told Sarita to go to
Kusum aunty’s clinic with a sample of her stool.
Sarita felt it was all an unnecessary botheration. But
27
Kavita kept goading her. and finally one day when it
was a school holiday, they both went to the clinic.
Aunty asked Sarita a few questions, checked her up,
look her height and weight, kept her sample of stool.
and told her to come back a few days later with
another sample of stool. When Sarita went with the
second sample, aunty had not found anything wrong
with the first one. However, aunty again told her to
come back a few days later with yet another sample
of stool. When Sarita went with the third sample.
aunty had not found anything wrong with the second
one cither. However, aunty told her to check up on
the report of the third sample a few days later. When
Sarita went to collect the report of the third sample.
she was quite sure that nothing wrong would have
been found with that too. She prepared herself for
having a good laugh at the doctor as well as Kavita.
She repeated in her mind over and over again the
most biting words with which she would come
and tell Kavita how useless the whole exercise had
been, and how much time she had wasted for nothing.
On the other hand, she was also a bit sad that she
was going to stay short for ever. With these thoughts.
she reached the clinic. But how it all changed when
aunty told her that in the third sample, she had
found the eggs of roundworms. “O God! Now, what
shall I do!” said Sarita. The doctor aunty told her
a course of tablets which would paralyse the worms
in her tummy and throw them out with the stool. And
she further said. “Now we know why you have been
growing slowly. Although you eat quite a lot, the
worms in your tummy share your food.”
“If I have the tablets you told me. the worms will
pass out. Will I, then, grow faster?” asked Sarita.
The doctor said. “Perhaps you would. But you may
not make up for all the slowing that you have suffer
ed over the last few years. And moreover, having the
tablets is not enough. If your life style does not
change, you will keep getting fresh worms inside. To
prevent new worms from growing up inside you. two
things are most important. First, eat only clean food.
Dirty food may have eggs of worms in it. which
would hatch inside you and grow up into full-fledged
worms. Dirty food means ‘gol-gappas* and cut-fruit
which have been kept exposed to flies, fruit that
has not been washed, or washed with dirty water, or
food that has been handled with dirty hands or in
dirty utensils. Secondly, wash your hands before you
touch food. If your hands have been soiled with stool.
28
directly or indirectly, your fingers may have eggs of
worms, which would get into the food that you eat
or handle. If you are not careful, you could keep
getting the eggs of your own worms into your mouth
again and again, and also give them to others who
take food handled by you.”
“Aunty, I didn’t follow that bit about dirtying my
hands directly or indirectly. Please, can you explain
that”, asked Sarita.
”Of course, I am glad you asked that”, replied
aunty, and continued, “When you go to the toilet,
you wash yourself, and dirty your hands with your
stool. That is dirtying them directly. If you do not
wash your hands immediately and thoroughly, you
might get the eggs into food. But suppose, you or
anybody else who has worms inside goes to the toilet,
and then touches the door handle, the surface of a
table, and a few other things before washing hands,
you leave the eggs of worms on these articles. Later,
anyone who touches that door handle or table, will
get the eggs on the fingers indirectly. To get rid of
worm eggs that have come to us indirectly, it is im
portant to wash hands every time we eat, just before
eating. That reminds me of two more important
things. First, your nails should always be short. Long
nails collect dirty stuff, including worm eggs, which
may get into food. Secondly, develop the habit of
washing your hands as soon as possible after leaving
the toilet, and* make it a point not to touch anything
with the dirty hand till you have done so. Perhaps
you wash yourself with the left hand in the toilet.
After that, touch the flush chain, the door handle, the
tap, and anything else that you use, only with the
right hand. The first thing that should touch the left
hand is the soap. In this way you will prevent the
indirect spread of worms and several other pests that
live in our tummies”.
“Thank you ever so much, Aunty. I will definitely
remember all the nice things you told me”, said
Sarita.
“That’s a good girl. Remember them, act on them,
and tell them to your friends”, said aunty.
Sarita took the tablets, and did everything else that
she learnt from aunty. And, she is growing up faster.
She is about to match Kavita. and now anybody
would belteve that they were bom on the same day. A
Swasth Hind
PUBLICATIONS OF NATIONAL
Authois of the Month
DOCUMENTATION CENTRE
1.
2.
3.
4.
RELATED TO HEALTH SCIENCE
Dr M. L. Chugh
An Annotated Bibliography of Indian
Research Reports in Health Population &
Family Welfare 1982.
Cumulative Index to the background
papers of the Hospital Administration on
Courses—1966-1977, 1982.
Communication in Health Population &
Family Welfare (1975-1982), 1983.
Documentation Bulletin Health & Family
Welfare Vol. 1(3, 4) 1978.
Dr S- C. Gupta
5.
Health Care Services Bibliography of
Indian Literature (1975-1982), 1983.
6.
Indian Contribution on Sociological Orga
nizational Aspect of Leprosy with Special
reference to Indian Leprosy Control Pro
gramme: A Bibliography, 1978.
7.
Indian Contribution on Sociological and
Organisational Aspects of Tuberculosis
with special reference to Indian Tubercu
losis Control Programme, 1978.
8. Infant Mortality—1970-1983: A Biblio
graphy, 1984.
9. Journal of Family Welfare: A Cumula
tive Index (1955-1982), 1983.
10. Library Accession List Vol. 1(3) 1983.
11. Library Accession List Vol. 1(4), 1983.
12. Library Accession List Vol. 2(4), 1978.
13. An Annotated Bibliography of M.D.
(CHA) Dissa„ster—1969-80,1983.
14. Population. Education—An Annotated Bi
bliography of Indian Literature (19751982), 1983.
15. A Selected Bibliography on Infant Morta
lity in India.
Prof & Head
and
Reader in Health Education & Family Welfare,
Depth of Social and Preventive Medicine and
Community Health,
Christian Medical College, LUDHIANA.
Dr Suresh Chandra
Lecturer
and
Dr (Smt) K. L. Agrawal
Reader
Deptt- of Social and Preventive Medicine
G. S- V. M. Medical College,
KANPUR.
Col. S. N- B hat tach ary ya
Prof. & Head
Deptt. of Preventive & Social Medicine
Armed Forces Medical College
PUNE-411040.
Smt. Rita Bansal
3330, 19-D.
CHANDIGARH
Dr V. V. Dongre
Hon^ Secretary
The Society for the Eradication of Leprosy
C/o Mrs. Leela Moolgaokar.
Bombay House, 24; Homi Modi Street
BOMBAY-400023.
S. P. Pathak
Researcher on Social Development
C/o Press Information Bureau
Shastri Bhavan, NEW DELHI.
Dr R. L. Bijlani
Asstt. Professor
Deptt. of Physiology
All India Institute of Medical Sciences
NEW DELHI-110029.
WORLD HEALTH DAY
7th APRIL, 1986
Theme:
HEALTHY LIVING;
EVERYONE A WINNER
—National Institute of
Health and Family Welfare,
New Delhi.
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 PRES.', COIMBATORE-641 019.
_ Regd*
D-(C) 359
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