HUMAN NUTRITION FOOD ENERGY REQUIREMENT AND MALNOURISHED STATUS
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In this Issue
Page No.
swasth hind
Asvina-Kartika
Human nutrition : food energy
and malnourished status
Vinod Singh
October 1986
Vol. XXX, No. 10
Saka 1908
OBJECTIVES
Swasth Hind (Healthy India) is a monthly journal
published by the Central Health Education Bureau.
Directorate General of Health Services, Ministry of
Health and Family Welfare, Government of India.
New Delhi. Some of its important objectives and aims
are to:
REPORT and interpret the policies, plans, pro
grammes and achievements of the Union Ministry
of Health and Family Welfare.
ACT as a medium of exchange of information on
health activities of the Central and State Health
Organizations.
FOCUS attention on the major public health
problems in India and to report on the latest trends
in public health.
KEEP in touch with health and welfare
and agencies in India and abroad.
workers
REPORT on important seminars, conferences, dis
cussions, etc., on health topics.
OUR COVER
In India, nearly 50 per cent of the total number of deaths occur
among children under five years of age. The major underlying
factor responsible for such a high child mortality rate is malnutri
tion. Malnutrition is also responsible for high mortality of mothers
in our country.
Man’s health and his social life are tied intimately and everlas
tingly to what he eats and how he eats it. October 16 is the World
Food Day. Our Cover shows a nutrition worker giving a demon
stration on balanced diet.
[Photo PIB].
EDITOR
N. G. Srivastava
Sr. SUB-EDITORS
M. L. Mehta
M. S. Dhillon
COVER DESIGN
B. S. Nagi
requirement
229
Iodine deficiency disorders in India
Dr Untesh Kapil
233
Malnutrition : the killer
Prabha Arora
236
The party Kavita will never forget
Dr R. L. Bijlani
239
Message and media in neo-natal care
Paras Nath Garg
240
Is chlorinated water safe to drink ?
P. K. Ray and B. S. Khangarot
245
Priority diseases for epidemiological surveillance
7?. S. Sharma
247
Behavioural sciences and community heath
problems
Dr S. C. Gupta and Dr M. L. Chugh
249
Laboratory moves in the fight against multiple
sclerosis
Prof Alan N. Davison
254
Articles on health topics are invited for publicath n in this
Journal.
State Health Directorates arc requested to send in reports of
their activities for publication.
The contents of this Journal are freely reproducible.
acknowledgement is requested.
Due
The opinions expressed by the contributors are not neces
sarily those of the Government of India.
SWASTH HIND reserves the right to edit the articles sent
for publications.
Editorial and Business Offices
Central Health Education Bureau
(Directorate General of Health Services)
Kotla Marg, New Del hi-110 002
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HUMAN NUTRITION:
Food Energy Requirement
And Malnourished Status
Vinod Singh
Knowledge about food and its relationship to health is the best way
to bring about a change towards appropriate eating patterns in adults
and to introduce youngsters to good eating habits that should last a
life-time.
October 1986
229
ood and meals are man’s best
friends.
His health and his
social life are tied intimately and
everlastingly to what he eats and
how he eats it.
Of all the physio
logical functions
which maintain
his life, eating and all that it entails
is the one in which he most expres
ses his personal preferences and the
cultural traditions of his ancestors.
F
Most people develop eating habits
early in life that accord with family
patterns
and modify them only
slightly over the years.
Some
times these habits conform to ideal
food
recommendations from the
view point of maintaining and fos
tering good health.
More often,
however, they do not.
Knowledge about food, and its
relationship to health is the best
way to bring about a change towards
appropriate
eating patterns in
adults and to introduce youngsters
to good eating habits that should
last a life time.
Basic Nutritional Requirements
The material for tissue cells in
human beings
during the period
from conception to birth, comes
from the food eaten by the mother
and after birth, from what they
eat.
ways the most important.
This is cerol (a sweet, oily alcohol) and fatty
Fats exist in several forms
so because much of the body’s struc acids.
ture is made up of proteins.
For and come from a variety of sources.
example, the typical 160 pound man One way to think of them is to group
is composed of about 100 pounds them as visible fats, such as butter,
of water, 29 pounds of protein, 25 salad oil, or the fat seen in meat,
pounds of fat, five pounds of mine and as invisible fats, which are
rals. one pound of carbohydrates mingled, blended, or absorbed into
and less than one ounce of Vitamins. food, either naturally, as in nuts,
Since the muscles,
heart, brain, meat, or fish, or during cooking.
lungs, and gastro-intestinal organs Another way is to think of them is
are made up largely of proteins, and as solid at room temperature (fat),
since the protein in these organs is or as liquid at room temperature
in constant need of replacement, (oils).
its importance is obvious.
Chemically, proteins are mixtures Saturated and Unsaturated
of aminoacids
which
contain
Fats are also classified as saturat
various elements including nitrogen. ed or unsaturated. This is a chemi
There are 20 different aminoacids cal distinction based on the diffe
that are needed for the body’s pro rences in molecular structure of
tein needs.
Eight of these must different kinds of fat. If the carbon
be provided in the diet, the rest can atoms in a fat molecule are surroun
be synthesized by the body itself. ded or boxed in by hydrogen atoms,
The eight that must be provided in they are said to be saturated. This
the diet are- called essential amino type of fats seem to increase the
acids.
cholesterol content of the blood.
Polyunsaturated fats, such as those
Meat, fish, eggs and milk or milk
found in fish and vegetable oils
products are the primary protein
foods and contain all of the neces contain the least number of hydro
sary aminoacids.
Grains and vege gen atoms and do not add to the
blood cholesterol content. In gene
tables are partly made up of pro
ral,
fats in foods of plant origin are
tein, but more often than not, they
do not provide the whole range of more unsaturated than in those of
aminoacids required for proper animal origin.
nourishment.
Fats play several essential roles
in the metabolic process.
First of
In a somewhat over simplified Carbohydrates
all, they provide more than twice
way, a person can be compared
Carbohydrates are another essen the number of calories on a com
with a working mecchanism such tial food component.
They are parative weight basis than do either
as a car.
During growth and also called starches or sugars and proteins or carbohydrates.
They
thereafter, the human cells must be are present in large quantities in also can be stored in the body in
repaired and replaced just as a car grains, fruit and vegetables.
They large quantities and used later as
has new tyres, parts and paint from serve as the primary source of calo an energy source.
They serve as
time to time.
And like the car, ries for muscle contraction and must carriers of the fat soluble vitamins
the human has an engine—his mus be available in the body constantly A, D, E, K, and they add to the
cular activity—which requires fuel. for this purpose.
taste of the foods.
This fuel is provided by food in the
It takes one pound of carbohyd Vitamins
form of calories.
rate to provide a 160 pound man
In the humans the process by with the fuel for about half a day.
Vitamins which are present in
which food is used by the body is Therefore, if he is not getting new minute quantities in food, in their
called metabolism.
It begins with carbohydrate supplies during the natural state are essential for normal
chemical processes in the gastro day from his food, he will begin to metabolism and for the develop
intestinal tract which change plant convert his body fat or protein into ment and maintenance of tissue
and animal foods into less complex sugar.
This is not desirable unless structure and function.
In addi
components so that they can be he has an excess of body fat, and tion to fat soluble vitamins noted
absorbed to fulfil their various func in any event, this also could not above, there are a number of B
tions in the body.
go on indefinitely.
vitamins, as well as vitamin C, also
called ascorbic acid.
If any parti
Proteins
Fats
cular vitamin is missing from the
Fats are a chemically complex diet over a sufficiently long time,
Of the several essential compo
nents of food, protein is in many food component composed of gly a specific deficiency disease will
230
Swasth Hind
result, for example nightblindness
resulting from lack of vitamin A.
The understanding of the compli
cated role of vitamins in maintain
ing life and health has come about
during this century with a develop
ment of highly specialised research.
It is likely that continuing research
will shed more light on their im
portance.
Minerals
Minerals are another food com
ponent for basic nutritional needs.
All living things extract them from
the. soil, which is their ultimate
source.
They are needed for nor
mal metabolism and must be present
in diet in sufficient amounts for the
maintenance of good health.
The
essential minerals are copper, iodine,
iron, manganese, zinc, fluorine,
cobalt, calcium and phosphorus.
The body contains about 24 mine
rals which are needed for (1) the
formation of bones and teeth, (2)
maintenance of the osmotic pressure
of body fluids, and (3) for securing
specific functions such as blood for
mation by iron and normal function
ing of the thyroid by iodine.
When the normal diet is deficient
in certain minerals, these minerals
need to be specially added to the
diet, or water supply, e.g., iodine
for thyroid function and fluorine for
protection against dental caries.
Human body requires fuel for its muscular activity. This
Additional iron for
heamoglobin
fuel is provided by food in the form of calories.
formation may be indicated when
[Photo : CHEB]
the diet is deficient in it, or when
there has been an excessive loss of
red blood cells, as some women Food energy requirement
fats and proteins in them which are
experience with their menstrual
The body requires energy for its as follows:
periods.
4.1 cal/gm
internal and external work.
This Carbohydrate
is provided by oxidation, in the tis
Water
9.45 „ „
sues, of the three proximate princi Fat
4.35 „ „
ples of food, e.g., carbohydrates, Protein
Water is not really a food, but it fats and proteins.
is in every way a crucial component
Malnourished status
of nutrition.
It makes up from
This energy value is most conve
55—65% of body’s weight and is niently measured in calories accord PROTEIN CALORIE MALNUTRI
constantly being eliminated in the ing to requirement.
TION, KWASHIORKAR & MA
This quantity.
form of urine, sweat and expired of heat is very small, hence, in nut
RASMUS
breath.
It must, therefore,-be re rition it’is customary to use the term
Protein calorie malnutrition of
placed regularly, for while a person kilo calories.
early childhood is an inclusive ter
can live for weeks without food, he
The caloric value of foods depend minology thAt has been used to em
can live for only a few days without
on the amount of carbohydrates, body a spectrum of nutritional diswater.
October 1986
231
have typical wizened features which
make them appear prematurely old
Considerable evidence has accumulated that proves that
(“The little old man”). The edema
and apathy that characterize kwa
significant impairment of intellectual performance may be
shiorkar are not present.
How
one of the long-term consequences of protein-calorie mal
ever, minor dyspigmentation of the
hair may occur and associated vita
nutrition of even a mild to moderate degree.
min deficiencies have been observed.
Between the extreme advanced
orders of varying severity which that provides insufficient protein. kwashiorkar and marked marasmus
range from the protein deficiency A similar syndrome can be induced lies a continuum -of intermediate
syndrome known as kwashiorkar at in pigs and monkeys by feeding a syndromes which inturn range from
one extreme to overall deprivational low protein diet in which the calo latent and marginal to forms of mar
syndrome of marasmus at the other. ries are derived principally from ked severity (marasmic kwashior
Because marasmus appears to be carbohydrates.
The clinical fea kar).
much more prevalent world-wide tures of the syndrome are variable,
than kwashiorkar, the suggestion has depending on the extent of the die
Laboratory findings in protein
been made that the term energy tary imbalance, the age of onset, calorie mal-nutrition are highly
protein malnutrition be substituted the duration of the deficiency state variable depending in part on the
for protein calorie malnutrition. and the severity of conditioning patient’s location in the kwashiorThis form of malnutrition is the factors.
kar-nutritional marasmus spectrum
major cause of infant and childhood
and the severity of the disorder.
Hair changes are variable and The plasma protein concentration,
mortality and morbidity in the world
because of its very high prevalence may include dyspigmentation with notably albumin, is greatly reduced
in many developing countries.
It lightening of colour; straightening in kwashiorkar.
However, hypohas been estimated that at any given of curly hair, silkiness of texture, albuminiamia is a relatively rarer
time approximately 400 million pre and easy “pluckability”.
complication and measurement of
school children throughout the
this parameter is of a debatable
Although fatty liver is an almost value in the detection of marginal
world suffer from some degree of
invariable pathologic finding, hepa cases.
protein calorie malnutrition.
tomegaly occurs inconstantly. Asso
ciated
disorders include anaemia and
The west African term kwashior
Although aminoacids ratios are
kar was introduced by Williams in vitamin deficiency, especially defi usually abnormal in kwashiorkar,
1933 to describe a syndrome most ciencies of Vitamin A and folic they are frequently normal in mara
commonly observed in children bet acid as well as a variety of infec smus.
The relative usefulness of
ween the ages of one and three tions and infestations.
several simple methods such as
years.
However, the disorder can NUTRITIONAL MARASMUS
measurement of height, weight, head
occur at later stage in childhood and
circumference and mid-arm circum
occasionally in adults.
The term
It is comparable with severe semi ference is currently under investiga
is said to denote an illness in one starvation in adults, resulting from tion.
Considerable evidence has
child displaced from its mother by very low intake of all nutrients, accumulated that significant impair
a subsequent pregnancy.
A num including proteins.
This disorder ment of intellectual performance
ber of conditioning factors such as most commonly affects infants during may be one of the long term conse
parasitism, infections, diarrhoea and the first year of life and its most quences of protein-calorie malnu
childhood exanthems contribute to conspicuous features are marked trition of even a mild to moderate
precipitation of florid stage of the wasting of muscle and fat and re degree.
Lastly psychological fac
disease.
However, the principal tardation of growth.
Infants with tors can also have to be kept in
cause. is a high carbohydrate diet nutritional marasmus are tiny and mind. O
Adding Life to Years
Moderate exercise in adult life—regular walking, for instance—has been shown
to reduce death rates from a quarter to a third in some 17,000 graduates of Harvard
University, who were followed from the early 1960s through the late 1970s.
‘6There are a lot of sceptics who say people are active because they are
healthythe New York Times quotes Dr Ralph S. Paffenbarger Jr., the study's
director, as saying. However the findings, reported recently in the New Journal of
Medicine, indicate the contrary—that “ you're healthy because you are active
232
Swasth Hind
IODINE
DEFICIENCY
DISORDERS
IN
INDIA
Dr Umesh Kapil
Studies in recent years in different countries
have indicated that contrary to the common
belief that iodine deficiency is found in the
hilly and mountainous areas, it is equally
prevalent in plains, riverine and coastal
areas. India has initiated research surveys
in different states to assess the extent ana
magnitude of iodine deficiency outside the
conventional sub-Himalayan region.
goitre and endemic cretinism have been
known to occur the world over for thousands of
years.
In fact, endemic goitre was so common in
certain hilly and mountainous regions of some coun*
tries that those without any enlargement of the thyroid
gland were considered to be slightly abnormal.
The
condition is widely prevalent in a large number of
countries in Africa, Latin America and the South East
Asia. The developed, countries like Switzerland and the
United States have controlled the problem almost to
ndemic
E
October 1986
a stage of eradication. However, these conditions con
tinue without any sign of abatement despite the avail
ability of low-cost simple technology for its control.
Endemic goitre and cretinism are the effects of a
deficiency of an important mineral, iodine, which is
found in soil, water and foods.
Earlier studies re
vealed that in various regions of the world, espe
cially in the hilly and mountainous regions, iodine in
the soil was leached out through millions of years of
glaciation or being washed away through heavy rains.
The leaching resulted in the soil becoming extremely
poorer in iodine and leading to a reduction of iodine
content of the water present in that soil strata and the
vegetation which soil maintains.
In other words,
Iodine Deficiency of soil is the primary cause of
Iodine Deficiency Disorders (IDD). The low Iodine
content of water and foods in the endemic area is the
secondary effect of deficiency in the soil. Thus IDD
233
depends almost entirely on geochemical characters of
soil.
The possibility of goitrogenic foods—those
which cause goitre—like cabbage, radish, etc. produc
ing IDD is rather remote in normal situations.
Human body requires a very small amount of the
precious mineral. The ingested iodine is almost en
tirely used by the thyroid gland in producing an
essential hormone known as thyroxine.
When less
amount of iodine is available for the thyroid gland, it
enlarges in size causing a swelling in front of the neck,
a condition known as endemic goitre.
On
an average, a man needs 150 micro gram of iodine
per day which is easily available through water and
foods if the soil on which foods are grown has ade
quate quantity of iodine.
On the other hand people
living in areas where the soil is poor in iodine will
be unable to get the required amount of idoine that
manifests a series of effects, the commonest being the
enlargement of the thyroid gland. The areas, extremely
poor in iodine result in iodine deficiency manifested
in the form of retarded growth of the body and mind
and with impairment of physical and mental capabi
lities.
This extreme form of iodine deficiency is
called endemic cretinism.
How important is IDD in India
Since 1952, studies in India by a team of workers
led by Professor Ramalingaswami revealed that iodine
deficiency is extremely common in the regions occupy
ing the foothills of the Himalayas range. The later
studies revealed that the entire sub-Himalayan region
stretching from Jammu & Kashmir in. the West to
Mizoram in the east is extremely deficient in iodine
and was designated as the Goitre Belt of India. This
is the biggest endemic goitre area in the world stretch
ing to about 2000 kms from east to west and inhabited
by about 120 million people.
Surveys conducted in
later years revealed that almost 40 million people living
in this area have iodine deficiency leading to endemic
goiitre and endemic cretinism.
The beilU includes
the northern regions of Jammu & Kashmir, Punjab,
Haryana, Himachal Pradesh, Uttar Pradesh, Bihar,
West Bengal, Assam, Arunachal Pradesh & Mizoram.
Studies in recent years in different countries have
indicated that contrary to the common belief that iodine
deficiency is found only in the hilly and mountainous
areas it is equally prevalent in plains, riverine and
coastal areas. During the last few years research
surveys in different States of the country have been
initiated to assess the extent and magnitude of iodine
234
deficiency
region.
outside
the conventional
sub-Himalayan
Preliminary data from such surveys have indicated
that IDD is equally prevalent in the States of Gujarat,
Madhya Pradsh, Maharashtra, Andhra Pradesh, Tamil
Nadu, Orissa and Bihar.
Tn several areas of these
States, endemic goitre
prevalence varies between
25-35% and a significantly low iodine content of
ground water.
It is now getting increasingly clear
that these areas outside the Himalayan belt have iodine
deficiency possibly due to heavy rains or recurrent
floods with the result that the soil gradually gets poorer
in iodine.
Thus the endemic areas in India are
not only the hilly and mountainous areas, but the
plains, the riverine areas and even in coastal strips.
This is rather unexpected because sea has the richest
source of iodine and it is generally thought that people
living near the sea will not have any iodine deficiency.
These studies have also indicated the possibility of
other factors in the epidemiology of TDD, eg. certain
foods and chemical characters of soil.
How is IDD
Cretinism?
different from Endemic
Goitre and
Recent studies have indicated that endemic goitre
(enlargement of the thyroid gland), is only one mani
festation of iodine deficiency. Deficiency of iodine in
pregnant women produce harmful effects in the unborn
child within the uterus and especially affecting the
development and functioning of the brain. When the
child is bom, it is already suffering from iodine de
ficiency i.e., neonatal hypothroidism.
With con
tinued iodine deficiency, the child will develop
various
manifestations—impairment
of mental
and physical capabilities
including
deafness,
speech impairment, dumbness and other physical dis
abilities.
It is rightly stated that endemic goitre
is only the tip of the TDD iceberg. What is commonly
observed as endemic goitre is only a small fraction
of the manifestations of iodine deficiency and major
adverse effects, more sinister than endemic goitre
are neither recognised nor their mode of action has
been properly understood.
Ironically, these are
equated with manifestations of under development,
and are not seriously considered.
Even now, iodine
deficiency in many developing countries is synonymous
with endemic goitre, and hardly get a high priority
within scarce financial resources for its control. It is
therefore, urgently necessary to make everyone aware
of the tragic affects of iodine deficiency on the well
being of human beings so that immediate action is
taken for it’s control.
Swasth Hind
H<>w can IDD be controlled?
Obviously, the simplest measure is to add the missing
iodine to the human body through either oral or
parenteral route. The oldest method for the control
of IDD is the fortification of common salt with iodine.
This method has been able to control and even to
some extent eradicate IDD
from many developed
countries.
There are of course other methods of
adding iodine to the body.
Studies in other coun
tries have shown that iodine can also be added to
water and even to the bread. However, such methods
have not been very successful. In recent years, iodine
is being introduced into the human body through in
jection of iodised oil, a method which gives protection
to the human body for a period of 3-5 years. In other
words, an injection every 3-5 years will protect the
person from IDD.
At present, efforts are being
made to use iodised oil orally and the preliminary
results have shown that this method can also be effec
tive in controlling IDD.
Iodised oil approach is
much njore expensive than the iodated salt approach.
Usually, the iodised oil approach is considered as an
interim measure whereas iodised salt is a long-term
solution. Iodised oil, cither as an injection or for oral
route, is not produced in India and has to be im
ported. Efforts are being made in research Insti
tutes in India to produce iodised, oil. Even for iodised
salt, the iodine, has to be imported from outside, and
then converted into potassium iodate for fortifying
salt. The conversion of iodine to potassium iodate is
done in India.
logistic problems have produced this unsatisfactory
condition regarding the impact of this programme.
One important lapse has been the highly inadequate
production of iodised salt compared to the need of the
country which literally ‘ forced” the affected popula
tion to consume non-iodised salt from the neighbour
ing areas. Unsatisfactory and long storage of iodatcd salt resulted in a substantial loss of iodine from the
salt.
There are other important' reasons as well.
The Strategy for IDD Control
The Government of India after realizing this unsatis
factory situation and considering the various lapses,
both administrative and technical, has decided to
adopt universal iodation of salt in the country. Ac
cordingly, entire common salt in the country used
for human consumption will be iodized by 1990. The
estimated total need of iodised salt at that time will
be to the extent of 40 lakh metric tonnes.
This is
undoubtedly a heroic decision of the Government, but
this challenge has to be faced to overcome numerous
administrative and logistic dimcultis encountered in
programme for targetted coverage and when both iodi
sed and not iodised salt are available in the market.
Operational research in various aspects of IDD
and it’s control is urgently needed in the country not
only for better understanding of the epidemiology of
the problem and the mechanism of it’s affect on human
beings but also for more effective control mechanism.
Some of the priority areas of research may be
1. Role of goitrogenic food in causation of IDD.
What has India done for IDD Control?
India is the first country in the South-East Asia
region to start the Naitional Goitre Control Programme
(NGCP) during 1962.
Under the NGCP, iodine com
pound was added to common salt through a techno
logical process in several iodation centres in .the coun
try.
At the moment, 12 iodation plants in three
different centres in India Kharagoda (Gujarat), Sambhar Lake (Rajasthan) and Howrah (West Bengal)
are producing almost two lakh metric tonnes of iodised
salt for distribution to the affected parts. Pottasium
iodate is used for fortifying salt with iodine since the
compound is stable and as such the iodated salt will
retain it’s iodine contents for a fairly long period. Un
fortunately, recent exploratory studies to assess the im
pact of this programme in the affected areas have de
monstrated that the reduction in the prevalance of
goitre! has been very marginal in most cases, and none
in some cases. Careful studies conducted by the
Ministry of Health & Family Welfare and other Re
search Institutions have shown that many operational
October 1986
2. Technical, operational, financial and administra?
five feasibility of oral administration of iodised
oil in prevention of IDD.
3. Bioavailability and stability of iodine in lodated
salt under different geo-climatic conditions.
4. Interrelationship between geo-chemical proper
ties of soil and causation of IDD.
5. Profile of salt consumption in different regions
of the country.
6. Knowledge, attitude and practices in commu
nity regarding epidemiology of IDD.
7. Interrelationship between IDD and Protein
energy malnutrition and its impact on growth
and development of children under five years
of age.
8. Development of simple analytical methods for
detection of Iodine in salt and Biological
fluids. O
235
M ALNUTRITION: THE KILLER
Prabha Arora
The malnourished infants are less likely to catch up in growth later in life, and the
overall growth of children who suffer from malnutrition early in life is poorer. A definite
co-relation has been noted between socio-economic status and pre-natal mortality.
distress’ (due to sub-normal deve
means imperfect Most common deficiencies
lopment of the foetus during gesta
or faulty nutrition, defined as
In the present situation, and from tion period) are all usually due to
an acute stage of imbalance between
Incidence
requirement of the body for a certain past experience, it seems that defi maternal malnutrition.
nutrient and its intake.
There ciencies of total dietary calories, of SFD babies in developing coun
vitamins, iron, calcium tries is five times greater than in
could be two types of malnutrition. proteins,
iodine are the most common in developed ones. In India, it ranges
In one, the demand is not fully and
our country. One nutrient, an ex from 27—33 per cent as compared
met, and in the other, the nutrient
cess
is common in isolated to 6.7 per cent in Canada and 10.6
is consumed in excess. These con partsofofwhich
the
country,
is fluoride. per cent in the USA.
ditions are defined under-nutrition Some nutritional disorders
are caus
and over-nutrition respectively.
ed by ingestion of poisonous subs
It has been found that 15—20
tances found in some articles and
per
cent babies bom to impoveri
Malnutrition has today emerged cause conditions like lathyrism,
as a major “health problem” in our afla-toxicosis, epidemic dropsy and shed mothers show severe growth
retardation with birth-weight less
country.
In India, under-nutrition veno-occlusive disease of liver.
than 2 Kg., body length less than
is more prevalent and over-nutrition
45 cm, and head circumference less
exists rarely.
In general usage,
Malnutrition tends to affect some
the terms malnutrition and under sections of our society predominan than 30 cm. The mean birth-weight
in different parts of the country
nutrition have become almost syno tly.
Malnutrition being a reflec
The
nymous. Apart from diseases direc tion of unfulfilled dietary demands, was found to be 2.8 Kg.
tly attributable to malnutrition, the it is most likely to occur during the same for Western countries is 3.2
The incidence of low-birth
contributory role of malnutrition in three most demanding periods in Kg.
weight babies in poor families was
increasing the susceptibility to in human life:
(1) growing age, (2)
fections of various kinds, and in pregnancy, and (3) lactation. There more than twice of that in wellIt was also observed
aggravating the course of such in fore, the worst impact of malnutri to-do ones.
that
birth-weight
decreased with
fection after they set in, has now tion is on people falling within
the lowering of economic conditions
been elucidated.
these three groups. Due to restric of families.
tions of diet suffered by poorer sec
In India, deaths of children of tions of society, malnutrition is more
Supplementation with proteins,
0—5 years account for nearly 50 prevalent among them, and the
per cent of total number of deaths worst sufferers are infants and child calories, folic acid, etc. of the diet
of poor pregnant women even late
as against 2—4 percent in affluent ren, pregnant and nursing women.
in pregnancy significantly increase
countries.
The major underlying
x
the birth-weights of their infants.
factor responsible for such a high
SFD babies arc more prone to con
child mortality is malnutrition. ‘SFD’ Babies
genital malformation and chromo
Malnutrition is also responsible for
'Small for date’ pregnancy (SFD) somal anomalies, poor thermoregu
high mortality of mothers in our
hypocalce
country.
One out of every 50 is a full-term baby whose weight lation, hypoglycemia,
hypomagnesemia, metabolic
women in the reproductive age- at birth is less than 2,500 gm. Low- mia,
group die during pregnancy and birth-weight, intrauterine growth re acidosis and low levels of immuno
15—20 per cent of such deaths are tardation, ‘Foetal malnutrition’, globulins, resulting in a high mor
attributed to anaemia.
‘dysmaturity’ and ‘chronic foetol tality rate.
M
326
alnutrition
Swasth Hind
Intra-uterine growth retardation
is due to reduced transfer of nutri
ents, either due to placental abnor
mality or on account of factors like
low maternal reserves, maternal dis
eases and malnutrition. The second
group of factors, of which anaemia
and hypoproteinemia are most com
mon and most important, leads to
poor placental blood supply, resul
ting in inadequate transfer of even
available nutrients.
There is a great demand for all
nutrients during infancy and child
hood.
The infants and children of
the under-privileged sections of
society fall easy prey to malnutri
tion.
These nutrient deficiencies
directly affect the growth of infant.
Infant Mortality’s importance
Infant mortality rate has been
identified as an index of general
state of public health of a commu
nity.
Though a considerable dec
line has been recorded in the last
20 years, even now our infant mor
tality rates are high, being 81—87
per 1000 live births as compared
to 14.2 in Sweden, 19.1 in Australia
and 24.8 in the U.S.A.
Besides
higher rates of pre-natal deaths and
infant mortality, malnutrition leads
to increased toddler mortality.
It
has been suggested that mortality of
children between 1—4 years of age
is the best index of the seriousness
of protein-calorie malnutrition. In
the Western countries, toddler mor
tality rate is one per 1000 live
births.
In India, it was 33 per
1,000 in 1951 which fell in 1970 to
12 per 1000.
However, overall
pre-school child mortality in our
country is 18.7 per cent of all deaths.
Milk and milk products are the primary protein foods and
contain all the necessary aminoacids required for the health
of human beings. The Seventh Plan seeks to achieve an
annual production of 51 million tonnes of milk against the
base level production of 38.80 million tonnes in 1983—84.
[Photo :
Taking
South-East Asia as a
whole, 45 per cent of deaths occur
before 5 years of age whereas the
same percentage of deaths in the
U.S.A, occur after the age of 60.
Almost 25 per cent of all children
born, die before reaching the age of
five years according to a recent
study in India.
Thus, almost a
quarter of our infants fail to be
come adults.
Although deficiency diseases have
been estimated to be directly res
ponsible for only I—2 per cent
deaths, presence of malnutrition
aggravates the course of other in
fectious diseases and is indirectly
responsible for a much high toll.
Some of the causes of infant morta
lity have been estimated as follows:
Infant mortality is caused by
premature births and low-birth
weight due to maternal malnutrition.
Premature births 33 per cent,
respiratory diseases 18.2 per cent,
alimentary diseases 11 per cent,
fever 4.1 per cent, infections 1.8
October 1986
WHO]
per cent, deficiency diseases 1.2 per
cent, genito-urinary diseases 0.6
per cent, cardiovascular diseases
0.5 per cent, wounds and accidents
0.2 per cent and venereal causes 0.1
per cent.
A definite co-relation
has been noted between socio-eco
nomic status and pre-natal morta
lity.
More than half the cases of
infant mortality can directly or in
directly be attributed to malnutri
tion.
In many situations, delayed
weaning is due to poverty as the
mother tries to compensate the lack
237
of solids by breast milk.
Then, indicates that unchanging conditions
the nutritional demands of the grow of malnutrition during gestation, in
ing infant remains unsatisfied and fancy and childhood would lead to
malnutrition results in high infant a smaller age-for-age population.
mortality.
A survey in rural Andhra Pradesh
showed that 20 per cent of pre
school children were shorter in sta
Malnourished Infants
ture, 40—50 per cent were lighter in
These malnourished infants are weight, 25 per cent had smaller
less likely to catch up in growth mid-arm circumference, 9 per cent
later in life and overall growth of had smaller heads and 30 per cent
children who suffered from malnu had thinner skin fold (fat content)
trition early in life was poorer. The as compared to normal Indian child
Delayed erruption of teeth
availability of these essential nutri ren.
ents to poor sections of our society was noted and 40 per cent had hae
is nowhere near the requirements. moglobin value less than 10.8 gms.
The age-for-age height of children (Normal 12-13 gms.).
from such families was 2--4 cm.
less than the Indian Council of
Medical Research (ICMR) stand In urban areas
ards.
The problem is very severe in
Though it is not easy to predict large cities, too.
The study con
long-term effects, present evidence ducted in Bombay on children up
to the age of 12 including those
from urban slums proved that this
is an urban problem, too.
Of the
total number studied, 84 per cent
were from families with a monthly
per capita income of less than Rs.
40.
Their height was 2-4 ems
less than the ICMR standards.
Over 54 per cent had haemoglobin
values less than 11 gms (Normal
12-13 gms).
Fortunately, several nutritional
problems of our country can be
mitigated today, if not entirely sol
ved, through
currently available
technological tools even under the
prevailing
socio-economic condi
tions.
The health sector plays a
major role in the implementation of
these programmes, which can make
an important contribution to the
nutritional uplift of poor communi
ties under the present circumstances. O
NATURE COMPENSATES FOR DIETARY DEFICIENCIES
It has been long known that
'‘eating
for
two**
daring
pregnancy is unnecessary, but expectant mothers do need more
food to help them produce healthy babies and to equip
their bodies for breastfeeding. But a new study has shown
that pregnant women have remarkable ways of naturally
compensating for dietary deficiencies.
The U.K. Medical
Research Council’s Dunn Nutrition
Unit, based at Cambridge, has been investigating the nutri
tional needs of pregnant women at its field station at Keneba
In the Gambia. It has found that in practice few women
increase their food intake by the recommended 15 per cent
during pregnancy but nevertheless few babies suffer as a
result.
There are said to be three main reasons for this. First,
expectant mothers spend more time resting. Dr Roger Whitehead, the Dunn Unit’s Director, Says cutting down on acti
vity during pregnancy is one of the most important ways of
ensuring that a woman will have a healthy baby.
Secondly, women experience natural metabolic changes
during pregnancy, but the resting metabolic rate does not in
crease by anything like as much as experts assumed would
be necessary to support the increasing size of the baby and
supporting reproductive tissues.
238
Thirdly, researchers have found that when food really is
short, a pregnant woman lays down less fat, although this
can lead to greater stress after delivery when she needs the
stored energy for breastfeeding her baby.
Dr Whitehead is anxious to stress there is a limit to these
natural mechanisms.
“While scientists such as myself can
marvel at the ways nature has devised to protect a baby still
in the womb, once a woman has passed the threshold of
these accommodating factors, the size of
the baby does
suffer.”
The Gambia study has shown that during the wet season,
when food fo very short, 30 per cent of babies are born
weighing less than 2JS kilos. Babies born too small are
more prone to fall victim to Infection. Small birthweight can
also affect long-term physical and mental development. By
giving mothers a dietary supplement in the form of a
groundnut biscuit during the last six month? of pregnancy,
scientists have managed to reduce the Incidence of low birth
weight babies to only five per cent.
“It Is particularly
encouraging to note that this advantage stays with those babies
throughout Infancy. They grown better and are now able to
ward off Infection,” says Dr Whitehead.—Spectrum
Swasth Hind
STORY
THE PARTY-KAVITA
WILL NEVER FORGET
Dr R. L, Bijlani
The schools had just
reopened after the summer vacation. Rahul dis
tributed toffees to the classmates for his birthday. He
had also invited to his home those class-mates who
had stayed close to him for a party in the evening.
“My birthday was, in fact, on 2nd July. But I post
poned the party by 6 days so that I could invite you
all. Please do come,” Rahul told them. Kavita was
among those invited.
t all happened last summer.
I
It was a great party, indeed. There were games,
and there was a lot to eat.
To top it all, there was
fruit cream. Reena was unlucky for she was having
a bad throat, and therefore did not take fruit-cream.
Dabboo, the fat boy, was always looking for an ex
cuse to eat more. He gallantly came forward to help
Reena out by accepting her share of fruit-cream, too.
All good things must come to an end, however, and
so did the party. Everyone said goodbye to Rahul
and started going home.
of vomiting and passing loose motions. Therefore, it
was good that he had been taking nimboo-pani; in
fact, that was the easiest and safest way to return to
the body what he had lost. But in the hospital, they
were going to use the surest and fastes way to re
place the losses. They were going to inject water and
salts directly into his blood. Words like injection and
blood terrified Dabboo to no end, but the gentle be
haviour of the doctor was a great comfort. Finally
arrived the nurse with a smile on her face and a neat
little bottle in her hands. She hung the bottle on the
stand, and connected some plastic tubes to it. Then
she used a needle to send the ‘water’ from the bottle
into Dabboo’s blood. The prick of the needle was not
half as bad as he had imagined. The doctor also
asked Dabboo’s parents if they had brought a sample
of the stool or vomitus with them, but they hadn’t. If
they had, he could have examined the sample to try
and find out the type of germs which had made Dab
boo sick.
Enters Kavita
Soon after reaching home, Dabboo felt uneasy. As
time passed, the uneasiness grew. He became restless.
His parents were worried, and were thinking of what
to do, when he vomited. He was put to bed, but
could not stay there long; for, he soon felt like going
to the toilet. He had a large, watery motion. This.
continued, and within the span of half, an hour, he
had vomited twice and passed five loose stools. His
parents knew that clean boiled water with salt, sugar
and lemon juice should be given to a child who is
vomiting and having loose motions to make up for what
the body is losing. They boiled and cooled some water,
and made nimboo-pani out of it, and gave it to Dab
boo to drink. In the meantime, they got ready to go
to the hospital. In the Casualty, the doctor was told
how Dabboo had gone for a birthday party, and soon
after returning home, had vomited thrice and passed
seven loose stools within two hours. The doctor felt
that probably something that he ate at the party was
not right. He told the parents not to worry, and asked
the nurse to set up an i.v. drip. He told Dabboo that
the most essential thing to do was to send back into
his body the water and salts he had lost in the process
October 1986
The doctor had hardly taken care of Dabboo when
Kavita and her parents walked in Kavita had also
been sick. She had vomited once and passed four
loose stools in the last two hours. It did not take the
doctor long to find out that both the children had been
to the same party. Fortunately, Kavita’s parents had
brought a few samples of her stools. Kavita did not
look as sick as Dabboo. So the doctor asked her
parents to continue with the nimboo-pani which they
had already started at home. However, he took the
samples they had brought and sent them for examina
tion. He also told Kavita’s parents to find out what
had happened to the other children who had gone to
the party. They discovered that Reena and Savita were
all right, but all the other children, including Rahul
himself, were sick—some just a little bit, and others
quite so, but none was as sick as Dabboo. On further
questioning by the doctor about who had what at the
party, they found that it all fell into a pat
tern. Daboo had double his share of fruit
cream, and he had suffered the most. Reena did not
(Contd. on page 244)
239
MESSAGE AND MEDIA
IN NEO-NATAL CARE
Paras Nath Garg
Neo-natal care starts even before conception or premarital age through postponement
of first pregnancy until the mother herself has reached full physical maturity and
through spacing of births. It continues from conception, through suitable care during
pregnancy, child-birth and childhood. Communication campaigns can be planned and
implemented in neo-natal care to initiate new behaviour, reinforce behaviour which
may not be stable or change behaviour which is undesirable.
H
ealth communication is a process by which health
idea is transferred from a source (such as primary
health centre) to a receiver (community) with the in
tent to change the latter’s behaviour. Further in desig
ning communication programmes and campaigns, it is
essential to consider media factors such as media dis
tribution; reach and accessibility to the target group;
audience factors as audience comprehension and under
standability of messages, and audience selective expo
sure to selective perception of and selective utilization
of media and messages; message factors as thematic
content and treatment of messages, language level, in
formation content and density of messages.
Neonatal care starts even before conception or pre
marital age through postponement of first pregnancy
until the mother herself has reached full physical matu
rity and through spacing of births. It continues from
conception, through suitable care during pregnancy,
child birth and childhood.
Target Group (Receiver) in Neonatal Care
* Parents, grandmothers* Traditional birth attendants, Traditional health prac
titioners, trained dais.
* Village health guides, multi-purpose workers, Balbadi, Anganwadi workers.
* Mahila mandals and community influential leaders.
The terms media, medium and channel are synonyms
and most frequently used in communication literature.
Generally, the term media refers to mass media. As
a matter of fact, there are other media in addition to
mass media. These include: (a) mass media, (b) Inter
personal communication, (c) traditional/indigenous
folk media.
(a) Mass media
Mass media have been classified as impersonal de
vices that multiply a message many times in trans
240
mitting the message from a source to the audience.
They spread messages with words, sound and pictures.
Mass media not only carry programme-information to
a large number of people, but can also reach all of
them with the same message at the same time.
In the natal care (premarital age to child-birth), mass
media are used for creating or sustaining a favourable
climate, supporting the channels of face-to-face com
munication and creating mass awareness for the pro
grammes and related activities. The basic role of mass
media is to:
* Create awareness and political will about ante-natal
care, pre-natal care and. neo-natal care and its goal.
* Build public opinion and enlist participation of
women, birth attendants, trained dais and traditional
health practitioners, in fostering communication for
involvement.
* Help in social encouragement and moral responsibi
lity by raising the consciousness.
* Provide support to face-to-face communication at
home and at clinic level.
* To inform decision makers about the latest deve
lopments. Press, radio, TV, printed materials, ac
cording to the educational status of the target group,
could be used much more advantageously to pro
mote neonatal care services and to encourage grea
ter utilization of the existing health care at different
levels.
(b) Interpersonal media
This media refers to face-to-face communication and
discussion in individual and group situations. Personal
communication which takes place continuously bet
ween relatives, friends, neighbours and others has been
found to be a major factor in promoting adoption of
new ideas, including those of family planning. One
should never entrust his message t'o a single medium,
but make a judicious use of different media. A multi
media approach has been widely accepted and this
Swasth Hind
should be adopted in educational activities for mater
nal and child health care. Interpersonal media gene
rally involve the following target groups in neonatal
care:
* Parents, grandmothers, pregnant and nursing mothers.
* Influential and opinion leaders.
* Trained and untrained dais, village health guides,
traditional health practitioners (THPs).
* Balwadi, Anganwadi, Multipurpose workers.
Trained birth attendants
help build public opinion
and enlist women’s
participation.
Interpersonal communication, which is suitably re
gulated by local social structure, promotes local parti
cipation in health and famliy welfare programme.
Interpersonal media promote greater flexibility in
communication. For example, if the communicator
faces problems in the course of discussion, he or she
can change the message so as to suit the reactions and
feelings of the audience. Thexpersonal relationship of
the involved individuals is further strengthened and
this acts as a reward as well as a motivating factor
within the situation.
Opinion leaders’, viz., (Dais and traditional health
practitioners) role in interpersonal communication is
very crucial in facilitating decision making and beha
vioural changes.
Favourable practices can be adopted by motivating
and providing scientific and systematic information to
the service group in regard to dangerous traditional
practices. Considering the educational level of women
and trained and untrained Dais (India 24.73 per 100
and Madhya Pradesh, 15.53 per 100 female literacy),
model flash card, flannel-graph, slides, tape recorder
and pictures are useful media.
(c) Traditional indigenous folk media
The traditional folk media of communication have a
good impact on the rural audience. A planned pro
gramme of preparation and use of different media
including the coordination of the message through
them is very important.
Traditional folk media transmit messages and infor
mation through songs, dance, drama, puppet show
and story-telling. Traditional media very often in
corporate the peoples* beliefs, social system and
values.
Therefore, its credibility is high.
This
makes them a very useful vehicle for promoting
health and family Welfare programmes.
Traditional and folk media include a wide range of
verbal communication, performing arts and visual aids.
Health workers can prepare and use these according
to the socio-cultural beliefs and values of the popula
tion to be given the information.
Message is Neonatal care
Message is the Heart of the communication process.
Health workers and trained birth attendants (TBAs)
are change-agents who are required to plan and implemnt persuasive communication, the purpose of which
is to initiate a new behaviour, reinforce behaviour
October 1986
which may not be stable or change behaviour which
is undesirable. Communication to be effective must
fulfil certain conditions.
To bring about the desired response the message
must gain the attention of the target group (i.e. preg
nant and puerperal mothers, grandmothers and TBAs).
It must be understood by them exactly as intended by
the communicator. It must be related to their felt
needs and thus arouse their interest. It must indicate
means of meeting these needs which are acceptable to
the society. Having ensured that message content ful
fils these conditions, the communicator must decide
upon the choice and combination of channels.
Choosing the appropriate channels depends upon
factors, such as availability of channels to the sender
and the capability of the audience or group to be ex
posed to the media to receive the message. Litetracy,
accessibility to channel and trust in the source influ
ence the capability of the receiver.
Message Contents
Communication contents or message for neonatal
care must include the following areas:
(a) Complete preparation for motherhood.—prema
rital, antenatal, natal and postnatal care, psychophysio
logical preparation for child-birth, role of grandmothers
and opinion leaders.
(b) Neonatal care : Resuscitation, cord care, breast
feeding, avoidance of infection, maintenance of body
temperature and early detection of congenital disor
ders.
(c) Positive attitude towards traditional practices.—
In these areas, motivational, emotional and fear aro
usal message is required, alongwith the scientific rea
sons. Main dangerous traditional practices are :
—Delaying the first feeding to 2-3 days after delivery
—Fasting practices after delivery.
—Annaprasan—ceremony at the age of 9-10 months.
—Cutting of umbilical cord through unhygienic and
unsterilized instrument by TBA and relative.
(Contd. on page 244)
241
Primary Health Care
In the game of life and death many people in the world
are playing against the odds:
* 1 in 2 never see a trained health worker
• 1 in 3 are without clean drinking water
© 1 in 4 have an inadequate diet
people in
Every year diarrhoea kills 5 million under-fives; malaria kills one mill0^’
an(j
Africa alone. These and other killer diseases are preventable, L)o
oC|cls is a
hospitals offer cures for some. But.what can really change the survi
package known as Primary Health Care (PHC).
FOOD
AND
NUTRITION
Around two-thirds of
under-fives in the poor
world are malnourished.
PHC means ensuring an
adequate, affordable food
supply and a balanced
diet
ESSENTIAL
DRUGS
WATER AND
SANITATION
• 80% of the world's
disease is related to lack
of safe water and
sanitation.
PHC means providing
everyone with clean
water and basic
sanitation.
X
PHC means restricting
drugs to 200 essentials.
preferably locally manu
factured. and made
available to everyone at
a cost they can afford.
• Over half a million
mothers die in
childbirth and 10%
o f babies d'e before
the,r first birthda
PHC means
immunisation against
childhood diseases
and combatting
others like malaria.
On,torin9 child health
curatne
A 000 million cases
of acute diarrhoea m
under-f>ves each V he
33% of people »
world infested wtth
hookworm.
PHC means 'ra,n‘n9.
health workers
village
and treat
“
common
injuries.
MATERNAL
AND CHILD
HEALTH
• Some 5 million
children die and another
5 million are disabled
yearly from 6 common
childhood diseases.
TRADITIONAL
CARE
Up to 50% of health
budgets are spent on
drugs.
DISEASE
CONTROL
• Traditional birth
attendants deliver 60% —
80% of babies in the
developing world.
PHC means enlisting
traditional healers.
giving additional
training and using tradi
tional medicines.
dVedses and
HEALTH
EDUCATION
• Preventing ill
health depends on
changing personal
and social habits
PHC means
educating people in
understanding the
causes of ill health
and promoting their
own health needs.
THE WINNING HAND
The eight elements of Primary Health Care give
everyone - young children and poor people
especially - the best chance of winning the fioht
for life.
a
The cost of putting PHC into practice world
wide is an extra S50 billion a year: less than twothirds of what the world spends on cigarettes
and only one-fifteenth of world military
expenditure.
FOOD & rJUTRITION
W«ki Health Organize.'
The Party Kavita Will Never Forget—Contd. from page 239
have fruit cream at all, and she was all right. All
other children had fruit cream, and, except for Savila,
were sick. The doctor said that the exceptional case
of Savfta was not very surprising. Some people, some
times, can get away with spoilt stuff. Things like that
did happen, he added. So the culprit was fruit cream.
Kavita’s parents wanted to know if one could make
sure about it. The doctor said that a sample of the
fruit cream was essential for that.
The next morning, Kavita’s father met Rahul’s
father and talked the matter over. Luckily there was
still some fruit-cream left’ over from last evening’s
party. Some fruit cream was handed over to the doc
tor for examination. He sent it for the same sort of
test for which he had sent Savita’s stool. In that test,
favourable conditions are provided for germs to mul
tiply, and an arrangement is also made to identify
them. After a few days, the report of the test was
available. The fruit-cream had the same sort of germs
that Kavitas stool had. That made it pretty sure that
the fruit cream was responsible for the children’s ill
ness. The doctor said to the children, “I am sure you
all like fruit-cream—I like it, too. But the germs like
it as well. Therefore, if cream has been lying warm
for some time, germs grow in it very easily. Other
foods on which germs thrive, and which can therefore
lead to a similar illness, are chaat, dahi-bada, sugar
cane juice, sweets, ice, and sometimes poor quality ice
cream. To avoid falling sick, never take food that has
been lying for a long time outside the refrigerator. It is
specially important to take only clean drinking water.
When eating outside, specially at large gatherings, avoid
drinking water and iced drinks, and as far as possible,
eat only items which are hot. Heat kills germs; there
fore, when you eat a hot pakora or drink a hot cup
of tea, you are sure that at least you are not taking in
any germs.' The children thanked the doctor for his
advice, and decided to follow it in future. ®
Message and Media in Neo-natal Care—Contd. from page 241
—Deliveries in dark room, ill-ventilated and cleaned
by using the cow or buffalo dung.
—Using ash and oil on cord in place of suitable anti
septic powder.
Principles of media and message selection
Audience understanding’. The individual is a part of
the society. Every individual has his own perceptions,
purposes, needs, concepts, beliefs, understanding and
culture. For the development and use of media one
should be aware of the audience for whom he is de
vising the media.
Pretesting of communication material and message:
Educational materials need to be pretested with a small
group of typical audience to assess reaction. Pretest
ing, before their large-scale production and dissemi
nation, will keep down the cost. Pretesting minimises
communication failures. The following characteristics
of a message can be pretested in view of target
groups :
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
244
Effectiveness of appeal
Readability
Clarity
Comprehensibility
Effectiveness of presentation
Acceptability
Length
Credibility
Appropriateness of layout work, colour, etc.
Agreement of audience with the message.
Emotional and motivational appeal in innovative ap
proaches: Innovative approaches in neonatal care must
involve the emotional appeal, specially in populariza
tion and adoption of breastfeeding and care of um
bilical cord.
Communication by satisfied adopter: Research stu
dies reveal that satisfied adopters play pivotal role in
behavioural and practice change. Satisfied adopter of
female sterilization and the grandmother are the best
communicators for motivating the mothers to attend
antenatal, postnatal and neonatal clinics and practising
breastfeeding.
Fear arousal message: Communication studies re
veal that fear, threat, and anxiety have powerful moti
vational components. These are applied extensively
for favourable changes in health behaviour. Fear
arousal message can be effective in neonatal and in
fant care specially in the areas of breastfeeding, timely
immunization and cutting of umbilical cord at home
level by Dais and family relatives.
Socio-economic and cultural similarity
It is true that the audience accept the message com
municated by the local leaders or health care providers
due to the same socio-economic and cultural simila
rity. Trained and untrained birth attendants, village
health guides and traditional health practitioners are
the best examples in neonatal care. These agencies
are also seen as two-way flow of communicators.
People have a tendency to pass information to their
nearer target group.
Message and media should be selected separately
for rural and urban set-ups and according to the tar
get groups. Message must be prepared in clear, sim
ple, unambiguous terms.
Swasth Hind
IS CHLORINATED WATER
SAFE TO DRINK ?
P. K. Ray
B. S. Khangarot
Chlorination of water has tremendous benefits for human beings as it improves public
health through destroying or reducing the incidence of water-borne pathogens. However,
chlorination presents possible hazards to human health and the environment, which should
be given adequate consideration so that its random use can be restricted.
has been the most widely used disin
fecting agent for drinking water and waste water
treatments in both municipal and industrial appli
cations. The chlorination of water has been of tre
mendous significance in eliminating the water borne
diseases by killing bacteria, fungi and invertebrate
hlorine
C
October 1986
animals.
The reaction of chlorine in water take
place as follows:
Cl, + H,O
HOCL + H,O
HOCL + H+ Cl—
H
+ OCL—
245
Both the hypochlorous acid and hypochlorite ions
are termed as “free chlorine”. Hypochlorous ions
react with ammonia or other organic amines that
may present in water to form toxic compounds call
ed chloramines. These secondary toxic compounds
present an environmental health hazards to man, fish
and other non-target organisms. Recent studies have
shown that these chlorinated organic compounds are
carcinogenic to man. Laboratory tests indicate that
trout,- salmon and plankton are highly susceptible to
chlorine toxicity. Experimentally, it has been shown
that 50 per cent of rainbow trouts are killed within
96 hour by a residual chlorine level of 0.014 to 0.029
ppm (parts per million). The more hazardous com
pounds formed by reaction of chlorine with organic
chemicals present in the water are a class of com
pounds known as THMs (Trihalomethanes), which
are formed of methane—a single carbon atom bound
ed to four hydrogen atoms, in which three of the
hydrogen atoms have been replaced by chlorine or
by other halogen atoms. THMs include chloroform,
bromoform and iodoform. The toxicity and public
health hazards of THMs compounds are well Imown.
These are highly reactive compounds, inhibit enzymes
activities, damage the target organs, such as, liver
and kidney and some of them even show carcinogenic
(cancer producing) activity.
Reducing after effect of chlorine
The adverse effects of chlorine can be reduced
either by reducing the amount of chlorine added to
water or by replacement of chlorination with other
methods. A number of possible alternative disinfec
tants have been suggested such as chloramines, chlo
rine dioxide, bromine, iodine, ozone, bromine chlo
ride, ultraviolet lights (UV), and irradiation.
AU
these alternative disinfectants have advantages and
disadvantages. The disadvantages include the forma
tion of harmful compounds that were not present in
untreated water. Therefore, usage of all these me
thods may depend on the risk versus benefit ratio.
compounds.
Unfortunately, chlorine dioxide has
one drawback that it produces high concentrations
of chlorates and chlorites, which are toxic to human
health and non-target aquatic organisms. Similarly
bromine and iodine, both chemically related to chlo
rine, are also strong oxidizing agent and can be used
as disinfectants. However, these are more expensive
than chlorine and have toxic properties which make
them unsuitable for several water treatment applica
tions. The other alternative methods like UV light
and irradiation are impractical from the point of
view of its utilization for disinfecting large volumes
of water.
Chlorination to continue till substitute is found
Although chlorination has been found to be res
ponsible for the production of potential carcinogen
in drinking water, its continuous use should not be
stopped until or unless adequate substitutes,
free
from harmful side effects, are available. Even then,
water disinfection with chlorine should not be re
placed until it has been shown that water treatment
process manifestation is inadequate to minimize ha
zards due to carcinogens. TMHs risk is significant,
it can be removed by modifications in chlorination
practices rather than by complete stop of chlorina
tion. Further research should be directed to remove
TMHs or the reduction of these potential carcino
gens once produced in drinking water.
Thus, chlorination of water has tremendous bene
fits for human beings by improving the water qua
lity to improve the public health through destroying
or reducing the incidences of water borne pathogens.
However, chlorination presents possible hazards to
human health and the environment which should be
given adequate consideration so that its random use
can be restricted.
FURTHER READINGS
!• Jolly, R. L. (Ed.). Water chlorination: Environmental
impact and health effects- Ann. Arbor, MI: Ann. Arbor
Science, 1978, Vol. I.
Possible alternatives such as chloramines, which
are added to water may react with ammonia or
other organic amines and produce about 70% less
total organic chlorine (TOC1) than chlorine and are
also less harmful than chlorine. However, chlora
mines have less disinfecting power than chlorine and
persist longer in the water supply system which may
have to be taken into consideration.
2.
Another alternative disinfecting agent, chlorine
dioxide produces much lower levels of THMs and
TOC1 than chlorine, and it produces no brominated
4. Brungs, W. A. (1973). Effects of residual chlorine on
aquatic life. J. Water Pollut. Control Fed. 45;
2180-2193.
Cotruvo, J. A. (1981). THMs in
Environ. Sci. Technol. 15: 268-274.
drinking water.
3- Clarke, R. M. (1981). Evaluating costs and benefits of
alternative disinfactants. J. Am. Water Works Assoc.
93: 89-93.
THE RESULT OF EDUCATION is :
an expected change in the behaviour of the student in the course of a
given period.
From : J. J. Guilbert, Educational handbook for health personnel (WHO Offset
Publication No. 35), Geneva, 1977, p. 108.
246
Swasth Hind
Epidemiological surveillance has very wide scope to cover all aspects of the disease
that are pertinent for its control. In short, epidemiological surveillance is information
for action.
PRIORITY DISEASES FOR
EPIDEMIOLOGICAL SURVEILLANCE
R. S. Sharma
of disease is the
continuing scrutiny of all aspects of occurrence
and spread of disease that are pertinent to effective
control f).
This includes systematic collection and
evaluation of data on morbidity and mortality, field
investigation of epidemics, isolation and characteri
zation of infectious agents by laboratories, relevant
aspects of vaccines, insecticides and other substances
used in control and immunological status informa
tion.
Therefore, epidemiological surveillance
has
very wide scope to cover all aspects of the disease
that are pertinent for its control. In short epidemio
logical surveillance is information for action.
pidemiological surveillance
E
However, there has not been always total agree
ment regarding the exact meaning and scope of
epidemiological surveillance.
The following work
ing definition of epidemiological
surveillance was
adopted at the consultative meeting on epidemiological
surveillance held in Colombo, Sri Lanka in Decem
ber 1985; “The dynamic close continued observa
tional study and monitoring of the health status of
October 1986
a population and trends of disease occurrence through
a systematic collection, tabulation and analysis
of
relevant health, mortality and morbidity data with
interpretations to those who need to know and are
responsible for control and prevention activities
Requirements
India is committed to attain the goal of “Health
for All by the year 2000 A.D.”, through the univer
sal provision of comprehensive primary health care
services.
Our National Health Policy 0 lays suffi
cient stress on the development of Management In
formation System. We are having health infrastruc
ture at the peripheral and higher level. Recent pilot
studies also revealed that it is feasible to develop
community/village level surveillance (*), in addition
to passive surveillance through hospitals/dispensaries,
etc. C) and sentinel surveillance 0. In order to achieve
the qualitative and quantitative goals for our health
and family welfare programmes, as given in National
Health Policy Statement (3), it is important to deve
lop epidemiological services in the country.
247
Priorities
A large number of ailments cause human suffer
ing. W.H.O. is preparing a detailed 10th revision
of International Classification of diseases, which is
likely to be ready by 1990 and operative from 1993.
It may not be possible and may not be required also,
to have surveillance for all these diseases. Priority
need to be fixed for disease surveillance at National
and regional levels. Different States in India have
their own list of notifiable diseases. Few among the
several diseases of public health importance may
have to be selected. The decisions may be difficult.
but the following parameters of the diseases are
helpful in making priorities for surveillance :
(i) morbidity quantum, (ii) mortality, (iii) illness
duration, (iv) severity of sickness, (v) destability or
residual effect of the disease,
(vi) age-group in
volved, (vii) epidemicity, (viii) diagnostic feasibility,
(ix) amenability to control, (x) financial input re
quired for control, (xi) requirements of International
Health Regulations, and (xii) impact on economic
development.
To pinpoint the prority, the weightage can be
worked out for each of the points given above. Each
disease will score the marks against each point, which
will be added up to give the total weightage.
The
disease which will get the maximum weightage by
such scoring should be the priority disease for epide
miological surveillance. In this way a priority order
for all the diseases can be prepared.
But such an
exercise require all the relevant information on the
disease in question. This is extremely difficult. So
assessment by experts taking all the relevant informa
tion available, may help in determining priority
diseases for surveillance. It may also. be necessary
to review and modify the priority order from time to
time.
among all ages. The field trial was undertaken in
five districts of five states with successful results.
More recently
Acquired Immuno Deficiency Syn
drome (AIDS) has been selected for nation-wide sur
veillance following the report of serologically detected
antibodies to the infection against HTLV-III virus
among six women from Tamil Nadu in April 1986
followed by the detection of more infected persons
in the area. National viral hepatitis surveillance pro
gramme has been developed. Rabies control pro
gramme is also’being developed. Other programmes
of non-communicable diseases focusing the attention
of the planners are dental health, mental health, can
cer and cardiovascular diseases. In other words we
have reached a stage when we will be facing the
problems of non-communicable diseases in addition
to communicable diseases.
It may be mentioned here that the most important
element of smallpox eradication was an effective sur
veillance programme. Other diseases where eradi
cation is feasible are guineaworm disease and yaws,
requiring priority in surveillance.
REFERENCES
1. Control
248
Communicable
Diseases
in Man. Ed.
2. R. Kim-Farley,
R. Aslanian and A. Sohnur. The
concept of Epidemiological Surveillance. Progress in
Development of Epidemiological servicesNational
Institute of Communicable Diseases. Delhi—May 1986
(page 13-21).
3.
Statement on National Health Policy, Govt, of India,
Ministry of Health and Family Welfare. New Delhi1982.
4.
R. S. Sharma, J. P. Gupta, R. N. Basu (1986). Assess
ment of Epidemic-prone diseases surveillance in Alwar
Programme development
Recently, the National Institute of Communicable
Diseases (NICD) formulated a programme for promo
tion of surveillance in the country. After careful con
sideration of various parameters mentioned above, the
epidemic-prone diseases selected
were : diarrhoeal
diseases, measles, poliomyelitis among the 5 years
children and viral hepatitis and Japanese encephalitis
of
Abram S- Benenson. 14th Edition—1985.
American
Public Health Association, 1015 Fifteenth Street NW
Washington DC20005. (Page 456).
district, Rajasthan (India). International Epidemiolo
gical Association, Regional Scientific Meeting, Jhansi
(India), 25-28 February 19865.
Hand Book of Health Statistics of India—1985. Central
Bureau of Health Intelligence, DGHS, New Delhi.
6.
Sentinel Surveillance—1985.
Communicable Diseases, Delhi.
National
Institute of
0
Swasth Hind
BEHAVIOURAL SCIENCES AND
COMMUNITY HEALTH PROBLEMS
Dr S. C, Gupta
Dr M. L. Chugh
People mostly contract infection in the community and not in the Hospital. They come to
hospital for treatment. So if we are really committed to curb the morbidity and mortality,
we must understand the community in depth and the different forces operating in it, which
can only be done, if we have a sufficient understanding of the subject matters of
behavioural sciences.
elations between medicine and behavioural Scien
ces have been explored intensively from both
sides of the fence in recent years. Health services
throughout the world are now confronted with new
challenges. They are no longer considered merely as a
complex of solely medical measures but as an import
ant component of socio-economic development (WHO,
1975), The enjoyment of highest attainable standard
of health is a fundamental right of every human be
ing. In providing health*for all by the year 2000 A.D.,
health by the people is one of the important approa
ches which is gaining wide acceptance as an alterna
tive approach to delivery of health care. In this, com
munities are encouraged to identify their own health
needs and objectives, order and rank them and to
develop their internal and external resources to meet
these needs through joint efforts.
R
A wide range of illness can be prevented; treated
at the community level by the community itself after
simple training and its exposure to the knowledge of
common community health problems. Today, com
munity health encompasses the entire gamut of com
munity organized efforts for maintaining, protecting
and improving the health of people. Probably as stated
by Leavell (1952) and Mahley (1983), many commu
nities, physicians and the other health workers, res
ponsible for the delivery of community health care
today, have had relatively little knowledge of beha
vioural sciences responsible for health behavioural
changes in the different communities. It is compara
tively difficult, therefore, to understand precisely the
relationship between behavioural sciences and health
October 1986
and medicine. In this article attempts have been
made to specify this relationship in a very concise
form.
Changing Structure of a Community
If we wish to help a community
improve its
health, the first principle in community health is to
start with people as they are and with the commu
nity as it is. As pointed out by various behavioural
scientists, every community has a health culture of
its own, which is closely tied up with its social
structure. In the modem era one could see that in
the process of social change, community structure is
deeply stirred by emergent forces
threatening to
over-run the flimsy beliefs created by various old
generations. Owing to the said dynamic forces, tre
mendous
structural and
functional changes are
taking place very rapidly in the contemporary urban
and rural communities. It is therefore, essential for
health functionaries to know these new emerging
forces, if they are to provide comprehensive health
services to the community through the available
health infrastructure.
To understand what caused a community to be
come sick, it is necessary to know what sort of
families it has, how the people in that community
live, what kind of clothes people wear, what food
they eat, what kind of employment they have, what
are their customs, values,
beliefs,
traditions and
habits as all these have close relevance to health of
a community. The above and many other changing
249
aspects of behavioural sciences are crucial to under
standing relationship between man and social envi
ronment.
Definition of community
Different scientists
have defined the community
in different ways. The definition of community
which is universally accepted is, “An area of social
living marked by some degree of social coherence.”
It denotes uniformity permanently shared by the
people over a region. In other words it is a group
of peop’e having common life. Every community
differs from the other community in its language,
mores, folkways,
myths, superstitions, and other
social institutions like caste, class and family pat
terns, etc. It has a specific geographical aiea and
interdependency followed by community sentiments.
In a community life, a greater emphasis is laid
upon unity, i.e., resulting due to common living and
thinking than its regional aspects. Members generally
have common interest and they are mostly in agree
ment with one another. Hence, a goal of commu
nity health is to achieve average status of health of
the individual. As documented by Berry (1953),
medical education is in transition, and increasing
emphasis has been and will be placed on the rela
tionship between the men and their socio-cultural
and economic environment in a community setting.
Forces faced by modem community
There are countless forces which are today res
ponsible for different transformations in the com
munity life. Among the more important of these are
^increasing industrialization and urbanization result
ing in a shift from relative independence to greater
interdependence. There is a tremendous shift in the
human outlook towards individualism and mate
rialism. Greater geographic mobility of the popu
lation have altered housing arrangements and is also
responsible for the creation of urban slum colonies.
Disintegration of joint family pattern has increased
the problem for older family members, widows and
sick persons. The problems of food supply as well
as other means of subsistence and rapid increase in
the population owing to greater application of pre
ventive medicine are causing greater concern in
many parts of the world. In the developing coun
tries like India, many old traditional health practices
like breastfeeding, have witnessed a big setback.
Because of wider and broader education, people
have learned the value of modern medicine in relieving
and preventing sickness. Alcoholism for example, is
coming to be regarded as a disease, not simply a
crime and bad habit, and venereal disease as an
illness, rather than just a punishment for sexual aber
ration.
250
All the above stated factors create new problems
for the medical profession itself, and for the indivi
dual, for his family as well as for the community at
large. Hence, the foundations of community life are
shaken, and many of the socio-cultural traits are no
longer effective. Some of these socio-cultural trans
formations make the community more susceptible to
sickness. So our aim of attaining positive health and
health for all by the year 2000, still appears a tanta
lising idea, difficult to demonstrate but a stimulus to
thinking. Since there is a need of a behavioural
change towards the above factors, the idea is wide
spread among the concerned scientists that the ad
vancement in behavioural sciences research field will
eventually help the members of the health team to
solve some of the major community health problems.
The changing concept of health and diseases
Different scientists have defined health in different
ways. In this era of rapid social change, the concept
with respect to the causation of disease has also
shown global changes. According to Seal (1963), the
concept of disease causation evolved by stages from
supernatural and deistic origin to the natural and
multi-factorial causations. Mahajan (1972) has also
emphasised that poor social environment is the main
factor responsible for poor health or sickness. Simi
larly, as brought out by Richardson (1945), profes
sion of medicine progressed from the disease organ
to the total personality of the patient, and is now
ready for the concept of the individual as a. member
of a family in its community setting. Keeping in view
the changing modem concepts regarding disease cau
sation, a few scientists have repeatedly pointed out
the contribution of behavioural sciences to medical
sciences.
Behavioural sciences and community health behaviour
As per Park et al (1979), the term behavioural.
sciences is applied to those disciplines committed to
the scientific
examination of human
behaviour.
Park has also elaborated that these sciences are
mainly Sociology,
Social
Psychology and Social
Anthropology. As per Barelson (1967), these three
disciplines have their own history, founding fathers,
their own focussed areas of study and perspective of
approach. Each shares, however, a common con
cern to the study of human and community health
behaviour and a scientific commitment to account for
it.
It is a corroborative fact that the health status of
a community is influenced by its cultural traits like
customs, habits, values, taboos, mores, folkways
beliefs, superstitious ceremonies etc. (Seal 1963 : 119,
Leonard 1952:15). Similarly, there are numerous so
cial factors, for instance, family and marriage pat
tern, Socio-economic status, social mobility, urbani
zation and industrialization, etc. which are also deeply
Swasth Hind
linked with the individual and community health
status. All the above stated factors determine and
modify the community health behaviour. Since some
of the above stated milieu are not static, community
health behaviour also varies from time to time to
wards any given practice or innovation.
After independence, Indian health administrators,
as brought out by Banerji (1975), directed their ap
peal particularly towards the then social scientists,
engaged in generating behavioural science knowledge
to legitimize the existing community structure and
social relations. The response was generous. Eminent
social and behavioural scientists from the west such
as Marriot (1955) and Lewis (1958); and the studies
carried out by their Indian disciples like Hasan
(1967), Dhillon
(1971) Kakar (1977) and Prasad
(1972) drew attention to the certain basic social and
cultural factors which militate against acceptance of
communtiy health practices. In general, as stated by
king (1962: 28). there is a sufficient sophistication of
theory in the behavioural sciences for its direct ap
plication to some of the problems faced by people
in the health profession. In the past few decades, as
pointed out by Dhillon (197.1 : 11), behavioural scien
ces have grown considerably, evolving a theoretical
framework pertaining to human health behaviour.
Similarly, Foster (1970:23) has stressed the point that
for avoiding disastrous decisions in the field of com
munity health, the knowledge of certain areas of
behavioural sciences serve as an accurate map which
every health professional should carefully go through,
if he is not to get lost, and which will also help him
to know his ways around the community.
Keeping in view the existing institutional and
domiciliary health care delivery facilities and the
low response from the community, the health profes
sionals are beginning to ponder why people behave
in indifferent manners than desired by the health
functionaries? What makes them more reluctant and
hostile towards the adoption of any new health inno
vation? For answering these questions, public health
workers are turning increasingly to those behavioural
sciences whose central concern is human health beha
viour and the conditions that determine it.
Observations of Leonard (1952) is testimony to the
above fact, wherein he reiterated that medicine and
public health are strongly and rapidly realizing that
the specialised knowledge and techniques of beha
vioural sciences are required for the proper study of
community health needs and their solutions. The
above fact is further strengthened by Wahi (1972)
that medicine is intrinsically and essentially a social
science and as long as this fact is not recognised, we
shall not be able to enjoy its benefits.
It is also evident as pointed out by Colfeman
(1971), that behavioural sciences can suggest to -the
OctoberH986
community health planners about what type of net
work of communication is likely to produce better
results and for which programme and among what
type of people. To them, common to community
health and social sciences is human behaviour. Many
community health problems are essentially social in
nature and thus need social solution. The focus here
is on man as unit in community and on the groups
human beings form in carrying out their activities.
In practice the field has been sub-divided into a
number of more or less overlapping with certain
fringe areas, which are mentioned below precisely.
Sociology
Sociology is the science of society which studies
situation in which human beings are in relationship
with one another. To the sociologist the community
is a constellation of social institution such as the
basic cultural
institution of family, church and
school. It also studies situations in relation with ill
ness, and the social principles in medical profession
and treatment. Broadly speaking, as cited by Park
(1979), it includes the relationship of medicine to
public and of the social factors in the etiology, pre
valence, incidence and
interpretation of diseases,
urbanization and its affect on health.
Some of its concepts like social survey, socio-eco
nomic status, social
pathology and anatomy, and
social medicine have very deeply crept into medical
terminology and are being frequently used in medical
and community health research. Sociology also stu
dies the population problems which are being inten
sively debated in many parts of the world. Excessive
increases in population in certain areas have nullified
the results of all developmental plans. Most of these
concepts are studied under medical sociology which
is a newly developing branch within the field of
sociology.
Cultural Anthropology
Cultural anthropology is more definitely a social
science, Davis (1943) remarks that if one wishes to
know what we may expect of a man, one needs to
know in what kind of culture, not' in what race, he
has been reared. Culture is the central concept around
which cultural anthropology has grown. Culture is
defined as. learned behaviour which has been so
cially acquired. Culture is the product of human
societies, and man is largely a product of his cul
tural environment. In general, culture transmit the
customs, beliefs, laws, religion moral percepts, arts
and other capabilities acquired by man as a mem
ber of a community. It is now fairly established that
cultural factors which govern the human behaviour
in every walk of its life are deeply involved in mat
ters of personal hygiene, nutrition, immunization,
seeking earlier medical care, family welfare, dis-
251
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252
Swasth Hind
posal of refuse and
health system.
excreta, in short the
whole
2.
Berelson, B. Human Behaviour, New York: Harcourt,
Brace and Wored, Inc. (1961).
3.
Berry, G, “Medical Education in Transition”, Journal
of Medical Education, Vol-28, March, 1953, pp 17-42.
4.
Colfcman, J. et al. “The Diffusion of Innovation
among Physicians’ in D.H.S. Punjab (ed), Sehat,
Dec. 1971, pp-12 (1975).
5.
Davis, A, “Racial status and Personality Development”.
Scientific monthly 17: 354-362, 1943.
6.
Dhillon, H. S. “Sociology of Health”, Sehat, D.H.S.
Punjab, Chandigarh. 1971.
7.
Foster, F. M. : The Traditional Culture and the
Impact of Technological change, New York: Harper
and Row Publishers, (1971).
8.
Gupta, S.C-. “Social-cultural Factors Affecting Child
Health”, Ph.D Thesis Approved for publication by
Punjab University, Chandigarh, 1981-
9.
Hasan, K. A., The Cultural Frontier of Health in
Village in India, Bombay: Manaktalat, 1967.
10.
King. S.A., Perception of Illness and Medical Practice,
New York: Russell Sage Foundation, 1962.
11.
Kakar, D. N. Folk and Modern Medicine, New Delhi:
New Asian Publishers, 1977.
12.
Leavell, H, “Medical Progress: Contribution of the
Social Sciences to the Solution of Health Problems”.
New England Journal of Medicine, 247:885-897,
(Dec-4), 1952.
13.
Lewis, O, Village Life in Northern India, Urbana:
University of Illinois Press, 1958.
14.
Leonard, A. S. (1952), Role of Basic Research in
Elucidating Etiology and Prevention of Major Causes
of Disability and Death, New York: Milbank Memo
rial Funds, 1952.
15.
Mahajan, B. K. Textbook of Social and Preventive
Medicine, New Delhi: Jay Pee Brothers, 1972.
16.
Mahler, H. Traditional Medicine and Health
Coverage Geneva WHO, 1983.
17.
Marriott, Mckin, Village India-. Studies in the little
Community, Chicago : The University of Chicago
Press, 1955-
18.
Park J. E. et al. Text book of Social and Preventive
Medicine, Jabalpur: Messers Banarsi Das Bhanot
Publishers, 1970.
19.
Puffer, "Industrial and Occupational Environment and
Health”, Milbank Mem. Fund Quarterly, 26:22-40,
1948.
20.
Richardson H. D., Patients Have Famililies, New York,
Commonwealth Fund, 1945-
21.
Seal, S. C., “Presidential
Address:
50th Science
Congress” in ICSSR(ed). Social Sciences in Professional
Education, 1963.
22.
Prasad, B. G. Teaching of Community Medicine to
Undergraduates in India, New Delhi : WHO(SEAR),
1972.
23.
WHO, WHO Chronicle, 1, 12—18, 1975.
Social Psychology
Puffer
(1948) states that in
combination with
psychology, sociology becomes social psychology,
which is concerned with the mental processes and
reactions of men in groups of masses. This discipline
is on understanding the basis for perception, thought,
opinion, attitude, general motivation and learning in
individuals and how these vary in human societies
and groups. In other words, it deals with the effect
of social environment on health personnels, their at
titudes and motivations. While planning any health
programme, the knowledge of community altitudes
and values is essential. Today, almost every member
of a health team has to act as a change-agent. His
primary responsibility is to bring a radical change in
the community health behaviour by discouraging
negative attitudes and promoting positive ones. The
most of the principles of health education have also
been derived from social psychology for achieving
the objectives of community health by motivating in
dividuals and groups to change patterns of behaviour
as to take such actions, including seeking of medical
care, which would enable them to achieve optimum
health.
The courtship of medicine and behavioural sciences
has begun with honourable intention on both sides.
Community health and medicine are concerned, in
their own special way, with human and community
health behaviour. The field of community health
needs the co-operation and help of behavioural
scientists in studying problems such as the social
components of health and disease, behaviour of peo
ple in illness, efficient use of medical care and the
study of medical institutions. From the above facts
it is noteworthy that the physician and other commu
nity health workers need two kinds of knowledge;
medical knowledge, and social knowledge, so that
they could more effectively serve the patient as well
as the community.
People mostly contract infection in the community
and not in the hospital. They come to hospital for
treatment. So if we are really committed to curb the
morbidity and mortality, we must understand the
community in depth and the different forces operating
in it, which can only be done, if we have a sufficient
understanding of the subject matters of behavioural
sciences. However, an actual importance of this rela
tionship is beginning to be realized.
REFERENCES
1.
Bancrji, D. Social and cultural Foundations of the
Health Services of India, New Delhi; Jawahar Lal
Nehru University (1975).
October 1986
Care
253
LABORATORY MOVES IN THE FIGHT
AGAINST MULTIPLE SCLEROSIS
Prof. Alan N. Davison
lthough the cause of multiple
nerve fibres.
That is where the to the myelin sheaths—demyelina
scar
tissue,
forms.
tion—there are the relapses and
sclerosis (MS) is not known, there
remissions of disease activity so
is a great deal of information to
Recent clinical studies with a new
suggest it may be the result of the nuclear magnetic resonance imaging characteristic of MS.
body’s own defences attacking the technique have enabled doctors to
Certain long standing infectious
central nervous system.
see that such areas are often near animal diseases, such as chronic
These canine distemper, have some featur
Defence of the body against at ventricles within the brain.
spaces
in
the
brain
contain
spinal es in common with MS.
These
tack by foreign organisms or subs
tances is controlled by the immune fluid and are particularly accessible conditions are characterised by chro
system, which produces antibodies to cells from the bloodstream, sug nic, progressive, neurological defects
to fight the invader.
However, gesting that sensitised cells may act together with some demyelination.
white blood cells—lymphocytes and locally to damage the myelin sheath. There seems to be a link between
experimental viral infection and the
macrophages—play a more direct
A small number of white cells immune reaction, for after infection
part in immunity.
causing this damage migrate through of the brains of rats with a specific
T-lymphocytes,
a
particular the tissue of the brain or spinal virus, white cells in the blood were
form of white blood cell, can aid cord and appear in the spinal fluid. found to be
sensitised to mylin
•or suppress the immune reaction Indeed, the presence of white cells antigens.
and so control the progress of the and antibodies in the spinal fluid
infection.
Sometimes the immune can be helpful in diagnosing MS. Treatment options
response can be harmful, as where
Research workers have found that
The first problem lies in assess
white cells attack the membrane some of the white cells are sensitised ing the treatment. In MS, relapses
lining of a joint in cases of rheuma to certain chemical components of and remissions cannot be predicted.
toid arthritis.
the myelin.
These components A few patients progressively be
The pro come more affected by the disease,
That disease, like MS, has periods act as latent antigens.
of relapse and remission, and cer portion of activated cells is much whereas many others experience
tain groups of people are more sus higher in the spinal fluid than in the periods—sometimes lasting years—
It seems, therefore, that when they are apparently free of
ceptible than others.
This is typi blood.
Clearly an effective
the
disease
originates in the central symptoms.
cal of an auto-immune disease.
nervous system where sensitisation drug can be discovered only as a
A key step in the auto-immune occurs.
So far, we do not know result of a trial on a large number
response is recognition of a foreign how this happens.
Perhaps a of patients when the drug’s action
substance (or antigen) that stimula mild viral infection such as influen is compared with a placebo, which
tes the lymphocytes into action and za or measles, or even stress, can is something resembling the test
makes them sensitive to it.
Acti release enough antigen to start an drug but not containing medication.
vated T-lymphocytes spearhead the auto-immune response.
Secondly, there is still the debate
defensive attack and release substan
about
whether MS is an auto-im
Animal
disease
link
ces that attract scavenging macro
mune disease and about the extent
phages to the site of the damage.
In animals, an auto-immune res
These cells consume the organisms ponse and sensitisation of cells to of the malfunction of the immune
and debris associated with the in substances in the brain can be pro system.
fection and, finally, scar-or hard, duced experimentally. This occurs
Since the cause of MS is still
sclerotic
tissue-forms at the site when we inject a special homogeni unknown, it is difficult to find out
of the damage.
sed mixture of brain and spinal whether the disease should be treat
cord into animals.
In susceptible ed by drugs to increase the immune
Nuclear magnetic imaging
animals, paralysis occurs within a response to an infective agent—
When brain samples from MS few weeks and, as in MS, inflam immunostimulants--or if immuno
patients are examined under the matory areas are found in the spinal suppression is needed to block the
microscope, they often reveal many cord and brain.
cellular auto-immune system.
white cells clustered around blood
The use of immunostimulants was
If certain strains of young animals
vessels close to areas of damage.
Some macrophages can be seen are injected with the mixture, the based on claims that the white cells
digesting the fatty insulating mate resultant disease shows many simi of MS patients were powerless in
As
As well as damage response to the measles virus.
rial, the myelin, that sheaths the larities to MS.
254
Swasth Hind
a result, an extract of normal white
cells containing a transfer factor—
the factor in the cell that makes it
react against infection—was given to
patients to stimulate immunity.
Avoiding side effects
After 18 months’ treatment it
seemed that the disease progression
may have been retarded, but only
in those with mild-to-moderate MS.
On the whole this approach has been
disappointing, but there are no re
ports of the disease worsening
following treatment with the trans
fer factor.
Immunosuppressant drugs block
the response of the white cells to
antigens, and this can be helpful
in the case of auto-immune disease
and in the transplantation of organs.
Thus immunosuppressants are used
to prevent rejection when a human
kidney is transplanted into a patient
with renal failure,
even though
every effort is made to match the
tissue types of donor and recipient.
There is hope that such treatment
may be helpful to patients with MS
following research on animals with
experimentally induced paralysis.
If immunosuppressants are given
before the paralysis is established,
the animals can be spared many of
the harmful effects of the auto-iriimune disease.
New Hope For Arthritis Patients
etter treatment for arthritis could come from a technique for
observing what happens inside affected joints.
B
The discovery, made at the Strangeways Research Laboratory in
Cambridge, is now in use at Addenbrooke’s Hospital near by, and
should make it possible to evaluate, for the first time, whether a drug
or other therapy improves an arthritic joint or, as some doctors sus
pect, only worsens it.
Dr John Dingle, Director of the laboratory, said it would be
possible also to monitor new drugs for their effect on the disease itself
and not just the symptoms.
Explaining the development, Dr Dingle said that joint cartilage
was made up of collagen fibres holding a substance called proteoglycan.
This had a strong affinity for water and, swollen by it, absorbed
stresses and strains as well as lubricating joints.
Lack of proteoglycan resulted in the wear of cartilage and bone
typical of advanced rheumatic disease. Proteoglycan, however, was
broken down by another body substance, interleukin one, known as
ILL This was a messanger molecule, widespread in the body, which
played a role in the immune reaction and in fever, and probably also
in tissue repair.
Fragments from the breakdown of proteoglycan survived for a
short while in synovial fluid, and the amount could be measured by
the technique.
In preliminary trials, 100 arthritic patients had been studied, and
all had more proteoglycan than healthy people but could be losing it
faster than it was being replaced. The amount increased six-fold from
the mildly to the severely affected, providing a sensitive scale for
comparison.—Spectrum
Nevertheless, doctors have had to
be very careful in using immunosup
pressants on their patients.
The
side effects may expose patients to
infection by impairing their bodies’
normal defence mechanisms. Ano
ther serious problem is that, because
the cause of MS is unknown, the
immunosuppressive drug treatment
may exacerbate the disease by re
moving control of a latent infection.
Luckily there are no reports of any
patients becoming distinctly worse
as a result of immunosuppressive
therapy.
The claim was made that this International effort
treatment was most helpful at an
Although the results of immuno
early stage of the disease.
Since
the effects are minimal only a few suppressive treatment are perhaps
so far, interest in
doctors, mainly in Britain, recom disappointing
mend dietary supplementation with transplant surgery has led to new
linoleic acid.
Trials with more drugs becoming available for future
powerful immunosuppressants, aza- testing.
thioprine and
cyclophosphamide,
showed a slight improvement in the
The discovery by scientists at the
annual relapse rate and progression Institute of Neurology in London
of the disease.
that activation of lymphocytes may
•occur primarily in the brain presents
Since the courses of treatment a challenge to pharmacologists to
were relatively short—only 15 design substances that will penetrate
Diet controversy
months—it could be that treatment the nervous system and so block
Although there have been a num would be more successful over a a possible key step in the disease
ber of trials of immunosuppressants, longer period.
Trails of immuno process within the brain itself.
their value is still not conclusively suppression are continuing both in
established.
Controversy followed the United States of America and
Hopefully, the concentrated rese
reports that eating more foods con Britain, but it is likely to be several arch effort in centres all over the
taining fatty substances, such as years before the place of this form world will lead to the discovery of
linoleic acid, could help slow the of treatment in the managing of drugs that will suppress the pro
MS is defined.
progress of MS.
gress of MS. A
October 1986
255
DIALOGUE ON
HEALTH FOR ALL
LEADERSHIP
Minister of Health and Family Welfare.
Shri P.V. Narasimha Rao, has urged upon the
health experts to help check deterioration of the
health systems in India and to keep alive the concept
of health for all which was once all pervasive. Shri
Rao inaugurated on 28 July, 1986, the 12-day first
“Inter-Regional Dialogue on Health for All Leader
ship Resource and Network Development” jointly
organised by the National Institute of Health and
Family Welfare and the World Health Organization.
he
T
Shri Rao recounted the role the Indian vaidya
used to play in olden times when he used to look
after the health of the villagers without accepting any
fee. His requirements in return were taken care of
by the villagers. The knowledge was passed on from
father to son. The Minister lamented that the treat
ment was available now only to those who could
afford it. It was not the case, he said, when the an
cient system was prevalent in the villages.
Top level policy makers and health administrators,
representatives of non-governmental organisations
from about a dozen countries and a few experts of
the World Health Organization participated in the
Conference. The overall objective of the ‘dialogue’
was to stimulate process for creating and strengthen
ing a network of human and institutional resources
for the pursuit of Health for All Leadership Develop
ment.
Shri Rao said that he was apprehensive that the
present medical curriculum does not instil in the
medical students the same degree of commitment
and responsibility for health of community members
as for hospital patients. He wanted more and closer
interaction between the medical colleges/universities
and Health Departments of the Central and State
Governments. A
An Announcement
First International Seminar
on Unani Medicine
The Central Council for Research in Unani Medicine, an
autonomous organization under the Ministry of Health and
Family Welfare, Government of India, is organizing an Inter
national Seminar on Unani Medicine at New Delhi, India
from February 13 to 15, 1987. The theme of the Seminar
will be “Unani Medicine and the Goal of Health for All
by the Year 2000”. The Seminar will be examining how best
Unani Medicine can be utilized in health promotion with
particular focus on the delivery of primary health care, which
is the strategy for the attainment of the World Health Orga
nization’s goal of “Health for All by the Year 2000”. The
seminar will review recent advances in Unani fundamental
and applied research, including clinical trials. It will also
examine the relationship between other systems of medicine
and Unani Medicine with regard to the provision of health
care to humanity.
The programme of the Seminar will include lectures by
distinguished scholars in the field, presentation of recent j
research papers, discussions and exhibitions.
For further information regarding the Seminar please write I
to:
Hakim Mohammed
Abdul
Razzack, Secretary
General, First International Seminar oik Unani Medi
cine, Central Council of Research on Unani Medi
cine, 5
Panchseel
Shopping
Centre, New
Delhi-110017 (India).
gramme (NLEP), the National Leprosy Eradication
Board decided at a recent meeting to extend the MDT
to 32 highly endemic districts in the country.
LEPROSY ERADICATION
PROGRAMME EXTENDED
TO 32 DISTRICTS
The Board, set up to monitor and evaluate the
high priority NLEP, decided to introduce Multi-Drug
Treatment of leprosy cases in five low endemic dis
tricts on an experimental basis involving primary
health care staff. Multi-Drug Treatment will be
extended to dapsone refractory cases in every district
under dapsone monotherapy. Laboratory services
will be strengthened by creating additional posts of
technicians in all MDT districts. In Lakshadweep,
all leprosy cases will be brought1 under Multi-Drug
Treatment to arrest disease activity by 1988-89. TheBoard also directed the Central Leprosy Training and
Research Institute, Chingleput to step up monitoring
and evaluating activity.
The leprosy prevalence rate per 1000 population
has declined from 16.2 to 4.0 in Srikakulam and from
13.1 to 3.5 in Ganjam district. Noting with satisfac
tion the perceptible fall in leprosy prevalence rate in
these districts chosen for the Multi-Drug Treatment
(MDT) under the National Leprosy Eradication Pro
The meeting was chaired by the Health Secretary,
Shri S.S. Dhanoa. Other members of the Board in
cluded Union Secretaries of Finance, Planning, Wel
fare, Rural Development and Information and Broad
casting.
------ P.LB.
256
Swasth Hind
Minimum-Needs Programme : A Qualitative
Assessment. Mulhayya, BC., Aneesuddin, M.
and Azad, GS. Journal of Rural Develop
ment 1986 Mar; 5(2): 191-240.
The minimum-needs pogramme (MNP) was initiat
ed as a separate programme in the Fifth Plan to
improve the living conditions of people in the rural
areas especially those who are below poverty line.
This study covering six villages in Nagpur and Akola
Distt. of Maharashtra, examines the type of impact
this programme has made on the conditions of living
of people. Among the eight components of MNP,
only seven, viz., Rural Roads, Housing for Rural
Landless, Rural Electrification, Elementary Educa
tion. Rural Water Supply, Rural Health, and Nutri
tion are implemented in the study. Impact factor
varies in each of the seven components of the MNP
in these villages. For instance the water facilities
provided in the study villages have created a positive
impact among the villagers. They felt happy about
its easy accessibility and contribution to improvement
in health. The assessment of the various aspects of
the health programme, viz., family planning, mother
and child care, preventive and curative medicine
revealed that these services have been successful to
some extent in fulfilling their task as evinced by rela
tively low birth and death rates in the study villages.
As for general medical facilities the position has im
proved as now they don’t have 'to depend on private
doctors who charge exhorbitant rates nor had to
travel distant places even for the treatment of ordi
nary ailment. Services of the Village Health Guide
though deemed essential are considered inadequate by
most of the respondents.
In the area of nutrition, the Balwadi Scheme for
pre-school children and the milk .scheme for the pri
mary school children, do not seem to have created
any perceivable impact on the beneficiaries. Adequate
resources and proper planning of implementation are
required to make the programme effective.
Lack of peoples’ participation was found to be
the major stumbling block in the maintenance of the
different facilities under the MNP. Some percentage
of total budget under the programme be allotted for
the maintenance, renovation and improvement of the
physical infrastructure developed through the different
schemes under the programme.—National Medical
Library
AUTHORS OF THE MONTH
Dr P. K. Ray
Director
Industrial Toxicology Research Centre
Post Box No. 80. Mahatma Gandhi Marg
LUCKNOW-226001
Uttar Pradesh
B S. Khangarot
Pool Officer
Industrial Toxicological Research Centre
Post Box No- 80, Mahatma Gandhi Marc
LUCKNOW-226001
Uttar Pradesh
Dr Umesh Kapil
Lecturer
Department of Gastroenterology and Human Nutrition
All India Institute of Medical Sciences
New Delhi-110029.
Dr R. L. Bijlani
Associate Professor of Physiology
All India Institute of Medical Sciences
New Delhi-110029Prabha Arora
Research Scholar in Anthropology
C/o Press Information Bureau
Shastri Bhavan
New Delhi-110011.
Vinod Singh
Life Scientist
D-2 Medical College
Kanpur-2
Uttar Pradesh.
Dr S. C. Gupta
Reader (Health Education & Family Welfare)
and
Dr M L. Chugh
Prof, and Head, Department of Social
and Preventive Medicine and Community
Health Christian Medical College
Ludhiana-141008
Punjab.
Paras Nath Garg
Lecturer in Health Education
(S- S. Medical College)
Qr. No. F-16,
Medical College Colony
Rewa-486001
Madhya Pradesh.
R. S. Sharma
Asstt. Director (Epidemiology)
National Institute of Communicable Diseases
22 Sham Nath Marg
Delhi-110054.
Prof. Alan N- Davison
Institute of Neurology
The National Hospital
London
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NEW DELHI
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PRINTED
BY
THE
MANAGER,
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PRESS, COIMBATORE-641019.
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Regd. No. R. N. 4504/57
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swasth hind
AROGYA SANDESH
SPECIAL NUMBERS—1985
(A Hindi illustrated monthly)
I
January
The International Youth Year
(Theme: Participation, Development and Peace)
February
Nutrition
For
March-April World Health Day
(Theme: Healthy Youth; Our Best Resource)
June
Environment and Health
July
Heart Disease
August
Health Progress
October
Behavioural Research and Health
November
Universal Children’s Day
(Theme: Community Participation)
December
Women, Health and Development
1
1
*Healthful living
*Information on health programmes
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