IMMUNIZATION PROGRAMME IN SELECTED STATES-AN ANALYTICAL STUDY

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Title
IMMUNIZATION PROGRAMME IN SELECTED STATES-AN ANALYTICAL STUDY
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In this issue
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Immunization programme
States—an analytical study

Asadha-Sravana
Saka 1915

July 1993
Vol. XXXVII, No. 7

in

selected

Dr Badri. N. Saxena, Dr R.fc Gupta;
Dr (Sint.) Kuhu Maitra, Dr A.K. Govila,
Dr A.R. Chaurasia & Dr L. Ramach andran

Private medical practitioners an
zation programme

OBJECTIVES

161

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IMMUNIZATION PROGRAMME
IN SELECTED STATES
—An Analytical Study
Dr Badri n. Saxena
Dr r.n. Gupta
Dr (Smt.) Kuhu Maitra

The Indian Council
of Medical Research
(ICMR) undertook two
diagnostic studies in
selected States to under­
stand the lacunae .and
bottlenecks of the im­
munization programme
before devising alterna­
tive strategies. One study
looked mainly into the
organizational and func­
tional aspects of the pro­
gramme, and the other
into the qualitative cove­
rage of immunization, its
effects and perceptions of
the community about im­
munization. This report
deals with the ‘Analytical
study of existing Immuni­
zation Programme in
Selected States’ conduc­
ted between November
1987 and June 1988.
JULY 1993

DR A.K. GOVILA
Dr A.R. Chaurasia &
DR L. RAMACHANDRAN

N the overall efforts to reduce
infant and child mortality and
also maternal mortality, high
priority has been given by the
Government of India to the
immunization
programme
of
children and pregnant mothers
and this has been emphasised ade­
quately in the recent national
health policy.

I

While an expanded programme
of immunization (EPI) had been
introduced almost a decade ago
aiming at optimum coverage of
immunization among all children
below five years of age against T.B.,
Poliomyelitis, Diphtheria, Pertussis
and Tetanus, it has been envisaged
that a universal programme of
immunization (UIP) should re­
place the EPI in a phased manner
with a focus on complete and total
coverage of all infants with the,
recommended schedule of im­
munizations against six diseases
(T.B., D.P.T., Polio ‘2nd Measles)
and also complete immunization
of all pregnant mothers with T.T.
Since, the progress of the pro­
gramme of immunization on the
v/hole (EPI or UIP) was not found
satisfactory in some States, the
situation was reviewed by a group
of experts in April 1987 at the
Indian
Council
of Medical

Research (ICMR) Headquarters
and it was considered necessary to
conceptualise and test out alternate
strategies to improve the coverage
and logistics, etc. However, it was
felt by the representatives of the
Ministry of Health and Family
Welfare in the meeting that some
diagnostic studies if undertaken
immediately would be helpful to
understand the lacunae and bot­
tlenecks of the programme before
deliberating and planning for alter­
nate strategies.
Therefore, the ICMR undertook
.two diagnostic studies' in Selected
States. • ’-One .study® looked"mainly
into the * organisational "and
functional aspects of / the pro­
gramme and the other into the
quantitative coverage of immuni‘ .zation, the effect of immunization
and the perceptions of the com­
munity about immunization.

The first study was entitled as
“Analytical study of existing
immunization programme in selec­
ted States”, and the other study
entitled as “Assessment of coverage
and knowledge, attitude, practice of
the immunization programme in
different States of the country”.

161

This report deals with the
analytical
study of existing
immunization
programme
in
selected States between November
1987 to June 1988.

OBJECTIVE
The overall objective of the study
was to ascertain and investigate the
processes of planning, implemen­
tation 'and monitoring of the
immunization programme in in­
dividual States with a systemic
approach.
METHODOLOGY
Eight States were selected by ran­
dom sampling for conducting the
survey. The States selected were
Bihar,
Rajasthan,
Madhya
Pradesh, Uttar Pradesh, Maha­
rashtra. Kerala, Meghalaya and
Himachal Pradesh. In these States,
two districts each were selected ran­
domly one with UIP and the other
without UIP and from each district
two PHCs, and two sub-cenfres of
the these PHCs were randomly
selected.
The methods used were inter­
views with officials and health
functionaries, and the observation
of the working arrangements
(equipment, supply, records, etc.) at
different levels. An attempt was
also made to ascertain the aware­
ness in the community regarding
the immunization programme.
Semi-structured schedules were
used for the interviews and check
lists were used for observation.
This study was done by a team of
public health and social science
experts.

RESULTS
The salient findings for each
State are presented here under
these heads: 1. Planning and staff­
ing, 2. Training, 3. Implementa­
tion, 4. Cold Chain Maintenance,
and 5. Records and Registers.
1. Planning and Staffing
The policy followed in all the
eight States is fully in line with the
policy of the Government of India.
The guidelines provided by the

162

Name of State

Name of District

Rajasthan

—

Bihar

—

Maharashtra

—

Kerala

—

Uttar Pradesh

—

Himachal Pradesh

—

Madhya Pradesh

—

Meghalaya

—

Government of India are being
followed in all the States.
Uttar Pradesh: There is no
separate immunization officer
either at the State level or at the dis­
trict level in U.P. The Additional
Director for MCH & FP is incharge of the immunization pro­
gramme at the State level. The
overall planning is done by the
Additional Director. At the dis­
trict level the CMO is in-charge of
the programme assisted by the
Deputy CMO (health) and is res­
ponsible for programme plan­
ning. The Deputy CMO (Health)
monitors and supervises the pro­
gramme. At the PHC level there
is no specific planning.

Madhya Pradesh: In Madhya
Pradesh the State immunization
officer (of the rank of Joint Direc­
tor) is in-charge of the program­
me. The post of district im­
munization officer, is vacant in
many districts, due to procedural
delays. District Health Officers
are in-charge of the programme at
District levels were the posts of dis­
trict immunization officers are
vacant Only the Block Medical
Officers are responsible for the pro­
gramme implementation. How­
ever, the other Medical officers
(Sector M.O.s) at the PHCs are not
fully involved.

Sikar
Jaipur
Bhagalpur
Moonger
Poona
Ahmednagar
Trivandrum
Quilon
Sultanpur
Pratapgarh
Shimla
Solan
Sagar
Raisen
East Khasi
West Khasi

Meghalaya: In Meghalaya plan­
ning is done by the Director of
Health Services with the assistance
of one Administrative officer.
However, there is no proper plan­
ning for systematic coverage.
Clear cut instructions and guide­
lines for the planning at peripheral
level are not issued from the State
level. There is no separate
immunization officer ’at this
level. At the District level the
posts of immunization officers are
vacant District Medical Officer
(Health) (DMOH) is in-charge of
the programme at the District level
(there is so much shortage of
officers that one officer is looking
after six posts). Supervisory visits
by the District official are not ade­
quate. At the PHC there is a shor­
tage of Medical Officers and Lady
Health
Visitors. Mostly
the
L.H.V.s meet the ANMS only on
the days of review meetings.
Himachal Pradesh : In Himachal
Pradesh the overall planning for
the programme is done by the
Assistant Director who is in-charge
of the immunization program­
me. He issues necessary guide­
lines regarding the strategy,
techniques, monitoring, cold chain
maintenance and allots targets on
the basis of population data avail­
able from the census figures
without any consultation with the

SWASTH HIND

lower officials. There is no
separate immunization officer at
the State level. Many posts are
vacant at the district and PHC
levels. At the District level the
District health Officer (DHO) is
in-charge of the programme. In
some districts, District Family
Planning
Medical
Officer
(DFPMO) is in-charge who is not
oriented in community Health.

Rajasthan: In Rajasthan the
political support to the programme
is limited. At the State level the
Director of Health Services is incharge of the programme assisted
by the Deputy Director MCH.
There is no immunization officer.
At the district level the Deputy
Chief Medical and Health Officer
is in-charge of the programme. At
PHC level the senior most Medical
Officer is in-charge.
Maharashtra: In
Maharashtra
political support for the pro­
gramme is visible. Additional
Director of health Service is the
overall in-charge of the immuniza­
tion programme. The implemen­
tation part of the programme is
looked after by the Deputy Director
of Health Services. At the district
level the District Health Officer
(DHO) is directly responsible
for
supervision
and
moni­
toring. DHO with the assistance
of AD HO and Public health Nurse
(PHN) supervises the program­
me. At the PHC level the senior
most Medical Officer is in-charge
of the immunization activities.
There is no delay in releasing
funds.

Kerala: In Kerala the political
support is encouraging. Funds
are being released without any
delay. At the State level the DHS
is incharge and Deputy Director
MCH is executive in-charge of the
programme. Besides, a Cold
Chain Officer and a Technical
Officer have been posted. At the
district level Immunization Officer
is assisted by the District MCH
officer and District Public Health
Nurse in supervision of the im­
munization programme at the

July 1993

PHC level. The Senior Medical
Officer is in-charge for the immu­
nization programme at the PHC
level.
Bihar: In Bihar the Director
Health Services (DHS) is the
overall in-charge of the programme
assisted by the Deputy Director
Immunization. Many posts crea­
ted under UIP are lying vacant
The Chief Medical Health Officer
is directly responsible for the pro­
gramme at the District level.
There is no system of supervision at
this level by the state autho­
rities. The senior most Medical
Officer is in-charge of the pro­
gramme at the PHC level.
2.

Training

Uttar Pradesh : In U.P. some of the
CMOs and the PHC staff to some
extent, have been trained. The
training given to the PHC staff was
not adequate. Due to improper
and lack of effective training, the
PHC staff were not able to main­
tain the cold chain system pro­
perly. They were also not able to
prepare the syringes satisfactorily.
Madhya Pradesh: In Madhya
Pradesh except for B.C.G. workers
all other workers were trained in
immunization. Few
District
Officers and Block Medical
Officers have been trained. The
sector Medical Officers have not
been trained at all for want of
funds.

Meghalaya : In Meghalaya no for­
mal training has been given
specifically for this program­
me. Training of the district and
PHC staff, was about to com­
mence.
Himachal Pradesh : In Himachal
Pradesh train ing of all the staff has
been completed. However, ref­
resher training is required for
improving sterilisation of equip­
ments, cold chain maintenance
and also for improvement in
recording and monitoring system.

Rajasthan: In Rajasthan Train­
ing of the staff involved in the

immunization services at the State
level is more or less satisfac­
tory. Though the status of train­
ing is good at district level there is
no system of reorientation train­
ing. Training of the PHC staff has
been given only in UIP districts
and hot for EPI and PHC staff. It
has been presumed that as and
when the districts come under UIP
the training will be given.

Maharashtra: In
Maharashtra
key staff upto district level has been
trained. Only 50% of the PHC incharge Medical Officers and
Paramedical Staff have been
trained. Training at the district
level is satisfactory.
Kerala: In Kerala Training has
been given to a satisfactory level to
all the concerned staff at the state,
district and PHC levels.
Bihar: In Bihar training is very
poor at all levels. Even the
Deputy Director in-charge of the
immunization programme had not
been trained. The PHC staff had
not been trained at all and only the
Medical Officer in-charge has been
trained. At the district level only
the Chief Medical and Health
Officers had been trained.
3.

Implementation

Uttar Pradesh : In U.P. implemen­
tation gets considerably delayed
due
to
bureaucratic
pro­
cedures. At PHC level there is no
idea about actual coverage for any
programme based on house to
house survey. Immunization is
given only in sub-centres, and not
in villages. The review, at the dis­
trict level as well as at the PHC is
done only with reference to the
targets, set at the State Level based
on the census figures.
Madhya Pradesh : In Madhya Pra­
desh, area is divided into intensive
area and non-intensive area.
AN Ms are responsible for intensive
area and male health workers for
non-intensive area. ANMs are
advised to fix either clinic days or
market days for immunization at
the sub-centre location. There is

163

very much adhocism in this stra­
tegy. Eligible couple (E.C.) Regis­
ters or Birth Registers are not used
at the time of immunization for
ensuring complete coverage.

Vaccine is not supplied to sub­
centre. I.E.C. activities are quite
satisfactory. Medical colleges are
being involved but not to an effec­
tive level.

Meghalaya: In Meghalaya there is
no clear guideline about the stra­
tegy to be adopted at the peripheral
level for complete coverage of
population for immunization. The
house visits by the workers are very
irregular. Registration of births
and antenatal mothers arc poor.
There is no planned programme
for mass communication.

Kerala: In Kerala the programme
is being extended to district after
district steadily and perfectly
according to the schedule. Im­
munization work is carried out
through camp approach on fixed
days. Medical Officer and L.H.Vs
take part in the immunization pro­
gramme. Educational materials
like posters are supplied and used
in the PHCs. Immunization pro­
gramme in towns is not satis­
factory.

Himachal Pradesh: More impor­
tance is given to Family Planning
than immunization in Himachal
Pradesh. There is no definite
approach for giving immunization.
Tn some centres it is given during
sub-centre clinics and in some
places it is only during home visits
and at other places by mixture of
both the approaches. Both Medi­
cal Officer and staff have no idea of
the birth rate and expected number
of children. Card system has been
introduced but not followed uni­
formly.
Rajasthan: In Rajasthan team
approach (also called camp app­
roach) has been adopted. Infor­
mation, Education and Communi­
cation (I.E.C.) activities are very
poor at all levels. The M.E.Os and
Media Officers have not been
involved. At the time of-immuni­
zation of the child, the workers did
not give the detailed information
about the immunization. There is
no field staff in towns for giving
immunization. To a certain ex­
tent Medical Colleges are involved
in the programme.

Maharashtra: In
Maharashtra
implementation in urban areas is
not satisfactory, since there is no
specific infrastructure for this pur­
pose. Immunization is given
through camp approach in villages
as well as in PHCs. Drums of
autoclaved syringes and needles
are taken by the health supervisors
from PHC to immunization site.

164

Bihar: In Bihar, funds are not
released in time. There is no
specific
strategy to
provide
immunization. Immunization is
done through camps as well as
through static clinics. Involve­
ment of Medical College is not
satisfactory. I.E.C. activities are
very poor. Media Officers are not
being involved. I.E.C. materials
are dumped in stores. There is no
system of indenting and supply of
vaccine. The children who are
aged more than one year are being
immunized. Proper attention is
not given to sterilisation of syringes
and needles. In general the pro­
gramme implementation is ‘in
poor shape.
4.

Cold Chain Maintenance

Uttar Pradesh : In U.P. Cold Chain
Maintenance at the state level is
satisfactory and there is a system of
keeping stocks on regional basis
where walk-in-coolers have been
provided. However,
arrange­
ments for Cold Chain Main­
tenance at district level are not
satisfactory. At the PHC level
preservation of vaccine was not
according
to
the
instruc­
tions. Many of the refrigerators
supplied to the PHC are not out of
order. There was shortage of vac­
cine carriers.

Madhya Pradesh : In Madhya Pra­
desh Cold Chain Maintenance was
fairly adequate. A mechanic is

posted at the district level who has
not been trained. Generally Cold
Chain arrangements at district
level and PHC level are good.
Enough vaccine carriers are avail­
able but there is not enough provi­
sion for ice.
Meghalaya: In Meghalaya Cold
Chain facilities are adequate as far
as refrigerators are concerned but
there is no adequate provision for
ice to be given with the vaccine
carriers.

Himachal Pradesh : In Himachal
Pradesh there is no technically
trained person to look after the cold
chain system. Refrigerators are
not adequately supplied and those
already supplied are also not work­
ing satisfactorily. In general cold
chain maintenance is not satis­
factory.
Rajasthan: In Rajasthan Cold
Chain facilities at different levels
are not adequate.
Maharashtra: In
Maharashtra
Cold Chain facilities at the State
level are sufficient and being main­
tained well. Ice lined refrigerators
have been supplied to PHCs. 80%
of the ice lined refrigerators are out
of order in the State. Vaccine car­
riers, ice packs have been received
by the State as per allotment Fre­
quent checks are being carried out
to find out the potency of the vac­
cine. Cold Chain Maintenance at
District and PHC levels is satis­
factory.
Kerala: In Kerala Cold Chain
facilities at all levels are satisfac­
tory. There is .a cold chain officer
to supervise the cold chain sys­
tem. Vaccine is supplied from the
state level to districts under proper
cold chain system.
Bihar: In Bihar Cold Chain sys­
tem is extremely poor throughout
the State. Generators have not
been provided. Recording of tem­
perature is not practised. At the
state level walk-in-coolers is far
away from the Public Health
Institute which is vested with the
responsibility of storing and sup­
plying vaccine to various dis­
tricts. In the observation it was
SWASTH HIND

found that vaccine was supplied
in thermocol without ice packs.
Equipments supplied for Cold
Chain system are lying idle..

2. Delay in sanctioning and re­
leasing of funds from State level in
many of the States has affected the
programme. Since the fund is

There is no system for the repair of

from the Government of India

the cold chain equipments.

specially earmarked for this pro­
gramme, there is no further need
for processing it at the State level; it
has to be released as soon as it is
received from the centre. Accord­
ing to every official interviewed the
budget allocation is satisfactory.

5.

Records and Registers

Except in Kerala, the main­
tenance'of records in all other
States is very poor. Neither the
E.C. registers nor Birth registers are
maintained upto date. A one time
a year enumeration of children
below one year of age is done for
immunisations coverage. This adhoc listing of children has various
defects in it A high percentage of
babies (6 months onwards in age)
are listed and given immunisation
at a later stage. Children missing
from the village at the time of
enumeration are not covered.
Children who have come tem­
porarily from other places receive
incomplete doses because they get
back to their own villages before
the 2nd and 3rd dosages are due.
In the reports submitted only the
number of dosages of immuniza­
tion is given and information on
the number of children due for
immunization is always not'avai­
lable.

DISCUSSION AND
MENDATIONS

RECOM­

1. Despite the sanction for immu­
nization officers at State and Dis­
trict levels, these posts are not filled
up in many States due to bureau­
cratic procedures. However, the
absence of a separate officer does
not in any way affect the imple­
mentation of the programme.
What has to be ensured is to vest
the responsibility of the immu­
nization programme with the
MCH Officers or those dealing
with community health having
public health background. It is
not at all advisable to run it as a
vertical programme. It should be
an integral part of the MCH
programme.

JULY 1993

3. Targets are allocated on the
basis of estimated population or
figures available from the previous
census. The monitoring and re­
view of the programme in almost
all the States is carried out only
with reference to the targets allotted
to the workers, at PHC’s and at Dis­
trict levels. The review is not
based on any community based
survey and registers. A major
lacuna in the programme in almost
all the States is that the targets are
fixed from the top level without
consulting the personnel in the
field. There is no grassroot plan­
ning to access the exact number of
children due for immunisation.
The general practice in all the
States is to have a team approach in
the field and to do a one point of
time enumeration to list out the
children below one year and to
carry out the immunization. This
is a very faulty practice because a
large percentage of the babies are
not immunised at the appropriate
age; and a number of children who
were not in the village at the time of
enumeration are missed; children
from other places who have been
listed in the enumeration will get
only incomplete doses. The cor­
rect practice would be to update the
E.C. register and Birth registers and
to keep a watch on the age of the
baby and give it the immunisation
at the proper time according to the
reommended schedule. If this is
done, the workers will have the
realistic targets and will also be

sure that all infants in the area are
covered for immunisation at the
appropriate time. The practice of
giving immunisation very late for
the babies should be strongly dis­
couraged. It is not a question of
fulfilling the targets but ensuring
the immunization of every baby
within the time limit of its age.
The same applies to Tetanus Toxoide for pregnant mothers. It is
the antenatal register which has to
be maintained upto date and to be
used as the base for planning and
monitoring the immunization.
The review of the programme, at
the PHC or district level should be
done according to the total number
of children (new boms) covered for
immunization and according to the
number who have been completely
immunized, instead of basing it on
the total number of doses given.
4. One of the reasons attributed in
one State for not giving training to
Medical Officers was that there was
no fund to pay TA & DA In
States where such problems exist
the training can be organised at the
PHC level instead of getting them
to district level.
5. In many of the urban areas
there is no information for MCH
and immunization programme.
Required- number of Field Staff
should be sanctioned and posted
for this purpose.

6. To enable the workers to
understand the purpose of the pro­
gramme more meaningfully they
should be encouraged to register
fresh cases of immunizable dis­
eases in their area during periodi­
cal visits and maintain data on the
incidence of these diseases. It will
also enable the authorities to judge
the effectiveness of the pro­
gramme.
(ContcL on Page 179)

165

PRIVATE MEDICAL
PRACTITIONERS AND
IMMUNIZATION
PROGRAMME
Dr R.N. Basu

The private medical practitioners can be considered as active partners in the
delivery of immunization services in urban areas. People, on their own
choice, select their own physicians and pay for their services. Expanded Pro­
gramme of Immunization (E.P.I.) should not disturb this system, rather sup­
port the immunization activities of the medical practitioners, says the
author.
RIVATE medical practitioners.
mainly
paediatricians
in
metropolitan towns, have realized
the importance of preventive
health services especially immuni­
zation and nutrition for develop­
ment and survival of children.
They used to administer DPT and
polio vaccine to children as a part
of private practise, before introduc­
tion of national Expanded Pro­
gramme of Immunization (EPI) in
1978. At that time, in addition to
medical practitioners, selected
non-governmental organizations
(NGO) and medical college hos­
pitals were the main sources of vac­
cination in the urban areas.

P

Though the immunization ser­
vices are now available in all health
facilities throughout the country
free of cost, the role of medical
practitioners still remains impor­
tant. In metropolitan towns, a

166

substantial number of vaccinations
are provided by private medical
practitioners in their cham­
bers. Various vaccination co­
verage surveys have revealed the
important role of private prac­
titioners in providing immuniza­
tion services to the clients.

The practitioners can be con­
sidered as .active partners of
immunization service delivery in
the towns. There are many areas
where the relationship between
government, NGO and private sec­
tor can be strengthened to achieve
the common goal, that is, protec­
tion of children against vaccine
preventable- diseases. The exper­
tise and-goodwill of private medical
community can be favourably used
for EPI.
Service Delivery

In towns, several clinics, drug
shops, nursing homes, publicize

about the availability of some
immunization services with them.
Some practitioners have included
vaccination along with child health
or ante-natal care. There is a
private system in which vaccines
are procured and sold. Except
B.C.G. vaccine, all other vaccines,
indigenous or imported, are avail­
able in chemist’s shop. The prac­
titioners prefer single or small dose
vial and store at their cham­
bers. In some cases clients are
asked to purchase it Many of
them use disposable syringes and
needles. They follow their own
immunization schedule and note
the date of vaccination in the pres­
cription paper or cards provided by
pharmaceutical concerns. They
charge fee for vaccines and services
from the clients.

Some concern is expressed by
EPI project on the this system,
regarding the quality of services.

SWASTH HIND

These may be classified under
four categories.

(a) Immunization Schedule: EPI
project desires that every one,
including private doctors, follows
the national immunization sche­
dule, which has been prepared con­
sidering the epidemiological situ­
ation in the country. Practitioners
serving in elite group of met­
ropolitan city advocate M.M.R
(Measles Mumps Rubella) vaccine
and five doses of oral polio
vaccine.
(b) Vaccine Handling: The po­
tency of vaccine administered may
be doubtful, because of possible
breaks in cold chain require­
ments. The cold chain main­
tenance for vaccine quality has
been found to be the weakest
link.

(c) Use of Vial: Vaccine vial* once
opened, should be used up on the
same day. In case of reconstituted
vaccine, like measles, has to be
used within six hours. Due to
small attendance and large size of
the vial, the tendency exists to reuse
opened/reconstituted vial.

(d) Sterilization of Syringes and
Needles: A sterilized syringe and a
sterilized needle has to be used for
each injection. Disposable sy­
ringe should never be re-used.
Boiling for 20 minutes or steam
sterilization is prescribed by the
E.P.I.
(e) Maintenance of Record: No
record is maintained in private
clinics.
People, on their own choice,
select their physicians and pay for
the services. E.P.I should not dis­
turb this system, rather support the
immunization activities by medical
practitioners. . Technical orienta­
tion can be arranged for those who
offer immunization services. Cer­
tain facilities can be provided to
them to encourage to participate in

JULY 1993

this programme. One such faci­
lity is availability of vaccines free of
cost to the practitioners, on certain
conditions, which may be
(a)

follow national technical
guidelines
on
vaccine
administration, dosage, and
storage.

(b) submit a report on number
of vaccinations performed
during collection of vac­
cines (on a prescribed
form).

(c)

Charging clients only for
service and not for vac­
cine.

Government officials may visit
the private centers to assist in
quality maintenance, E.P.I project
may give recognition to these
practitioners.

Reporting of Diseases
The disease reduction target of
E.P.I has now been quan­
tified. The goal is to reduce
measles incidence by 90% from the
base-line level, and eliminate
neonatal tetanus by 1995. Polio­
myelitis is planned to be eradicated
by the year 2000. This requires
strengthening of disease sur­
veillance, with emphasis on routine
reporting system. Medical prac­
titioners can be important and reli­
able source of information on
vaccine preventable diseases. If a
simple system of reporting these
diseases from medical practitioners
to the programme implementation
authority can be arranged, this will
help in identifying high risk group
and taking appropriate action.

Advocacy for Vaccination

Medical personnel are con­
sidered as the best educators and
most appropriate time for educa­
tion
is
during
their
ser­
vices. There are many practi­
tioners, who may not be involved in
vaccine administration, but as-a
family physician may enquire the
vaccination status of the •children
and women under their care. All
personnel, irrespective of his
specialty and place of work, should
enquire if the newborn (children
under one) and women (especially
pregnant women) have received
vaccination. This informal en­
quiry will act as an advice to the
clients, and will be of great value in
motivating the families. His ad­
vice is generally listened to.

To take advantage of a large
number of physicians in the coun­
try and to use them as advisors to
general public, E.P.I Project has to
inform
them
the
services
available, and the place and time of
availability. Referral service by
the medical practitioners have to be
encouraged.

Organizational Activities

There are several professional
societies namely, private Medical
practitioners' Association, Medical
Association, paediatricians Associ­
ation, etc. Each organisation can
decide the role they like to play to
•promote national immunization
programme. On the basis of
experiences in different States, few
options may be considered.
(a) The organization may collect
vaccines from the State E.P.I
Officer and distribute to their mem­
bers for use. They will submit the
report on performance every
month and get re-supply. The
organization takes responsibility
for following the standard pro­
cedures by each member and
ensuring quality service. In Goa,
B.C.G vaccine, which is not avail­
able in shops, is supplied to prac­
titioners through Indian Medical
Association (LMA).

167

(b) The organization may par­
ticipate in special programmes
with government or other N.G.Os
like Rotary/Lion Clubs. This may
be in the form of organizing vac­
cination campaign on selected days
(holidays) on pre-determined Area/
site. The I.M.A played a vital role
in implementation of Patna urban
immunization drive, which could
mobilize vast political, administra­
tive, professional and media sup­
port. the services of which has led
to similar efforts in other urban
areas. A significant feature of
Patna experiment was the success­
ful networking of around 700
private practitioners under the ban­
ner of I.M.A and creation of 37 per­
manent immunization centres at

the rate of one
municipal ward.

each

per

In the country’s first national
immunization campaign in 1990,
100,000 members of Rotary club
worked alongwith members of
I.M.A and Indian government
officials during three designated
“Sishu Suraksha Diwas” (Baby
Protection Days) in October,
November
and
Decem­
ber. Rotarian
doctors
took
leadership and demonstrated that
they could work in slums. Their
volunteers brought in slum
children and women and got them
registered in the immunization
session.
(c) The organization may request
their members to find out some

time from their busy schedule in
sending data on vaccine prevent­
able diseases collected from among
those who come for advice from
them. These will not be reflected
in any statistics unless the prac­
titioners report these cases. In­
dian Academy of paediatrics has
taken leadership in disease surveil­
lance.

(d) The professional societies can
provide information to their mem­
bers on the latest developments in
the immunization programme and
offer special workshops and orien­
tation courses. They can en­
courage publication of articles on
appropriate subjects in their

journals.

A Cure for Breathlessness
Breathlessness among the not-so-young can be countered by a
device that strengthens the respiratory muscles within six weeks.

Dr Adison McConnell from the department of human sciences at
Loughborough University of Technology in the English Midlands
says she is “very optimistic” that her new respiratory muscle, traitor
can reduce what is not a product of old age but simply a result of
reduced activity.
The small device is put in the mouth and has the effect of providing
resistance to breathing in. In this way it is possible to strengthen
the respiratory muscles.

Tests have shown that six weeks of such muscle training, three times
a day for 10 minutes, is sufficient to reduce breathlessness. Among
the most breathless, improvements of up to 80 per cent have
been observed.

Already two medical equipment manufacturers and a sports com­
pany have shown interest and Dr. McConnell believes the muscle
trainer could be commercially available within the next two
years.
—Medical News from Britain

168

Swaste Hind

BLEEDING
NOSE
DR DHARAM PAUL

leeding

from

nose

is

a

emergency attended
Bthecommon
Hospital Casualty. Though

in
isolated cases with bleeding nose
are encountered in all seasons, it is
a common occurrence in sum­
mer. This common condition
affects all age groups.

Parents and patients
tend to exaggerate the
loss of blood but when it
is severe, it m.ay require
blood transfusion. Such
severe cases of bleeding
nose may turn serious
and should be treated in
a hospital.

JULY 1993
2— 6DGHS/93

There are so many causes of
bleeding nose. Children are in
the habit of putting fingers in nose
which results in profuse blee­
ding. Sometimes children put
some foreign bodies in the nose
which lead to formation of stone in
nose or causes infection resulting
in Sinusitis. This may be an
unsuspected cause of bleeding
from the nose.

Infectious diseases like measles,
chickenpox,
influenza,
nasal
diphtheria,
whooping
cough,
scarlet fever, rheumatic fever,
pneumonia, dengue fever, mala­
ria, typhoid, leech as parasite in
nose, anaemia and bleeding disor­
ders are some of the other causes of
bleeding nose.
An old man having recurrent
bleeding nose should have his

blood pressure checked up. In old
age due to thickening of the wall of
blood vessels the blood pressure is
increased. Epistaxis in old age
can be due to cancer of the nose,
sinuses, heart diseases and kid­
ney ailments.
A blow on the nose may cause
some bleeding. This is transient
but may be severe especially if the
blow results in fracture of the
nose.
At high altitudes, nose bleeding
is common due to extreme climatic
conditions and reduced atmos­
pheric pressure.-

There is an apparent relation­
ship between bleeding nose and the
menstrual cycle in women. Nose
bleeding is found to occur more fre­
quently during any period of dec­
reased hormonal secretion.
Inhaled caustic substances, irri­
tant vapours, Vit C and Vit K
deficiency are other conditions
incriminated in no.se bleeding.
Very serious bleeding can occur in
angiofibroma of nasopharynx.

169

In general, parents and patients
tend to exaggerate the loss of blood
but when it is severe, it may require
blood transfusion. Such severe
cases of bleeding nose may turn
serious and should be treated in
a hospital.

bleeding disorders and also give a
rough idea of how much blood loss
has occurred.

Important tips to avoid and/or check
bleeding nose

Everyone has had a nose bleed at
sometime or the other and most of
us on several occasions, but in only
a few cases it is necessary to ask for
medical aid. Sometimes bleeding
from the nose stops by a natural
process of blood clotting.

Children should be discouraged
from putting fingers in the nose
and advised to avoid nose
picking.

As first aid measure to control
bleeding nose, make the patient
comfortable in sitting position and
ask him to pinch the nose for 5
minutes. The attendent should
rub the ice on forehead and cheeks
of the patient. In most of the
cases, bleeding stops with this pro­
cedure. The cases which don’t
respond, needs meticulus personal
and family history, and detailed
investigations of blood. Blood
tests may reveal cancer of blood or

Moderate bleeding is beneficial
to a patient of high blood pressure
but constant*record of blood pre­
ssure is quite imperative.

Hospital Admission
If there is profuse bleeding, pre­
ssure is easily applied by putting
ribbon gauze soaked in vaseline
mixed with antibiotics in the nose.
This procedure is called Anterior
packing. The pack is left in nose
for 48 hours. On removal, if the
bleeding continues it is repacked.
Now a days various thin rubber
bags (inflatable bags) have been
devised to apply pressure as an
alternative to‘avoid packing. The

deflated rubber tampon is easily
inserted in the nose and about 10
c.c. of ’air is injected for exerting
pressure but they are less effec­
tive.
The other method is to clean the
nose, determine exact site of bleed­
ing and cauterise the bleeding
point either by chemical or by elec­
trical method.

Whatever method is adopted,
these patients are best admitted to a
hospital and kept under sedation
sufficient to make them drow­
sy. Relatives should not be
allowed to visit and overcrowd the
patients surroundings.
The above measures will control
the great majority of epistaxis but a
few cases will continue to bleed,
which may require bloqd trans­
fusion.

In convalescent period, the
patient should be given a course of
iron therapy until the haemoglobin
level is acceptable.

ANNOUNCEMENT

HEART CARE FOUNDATION OF INDIA

HEART CARE FESTIVAL-93—DEC. 9-19, 1993
World Congress on Clinical Cardiology WORLDCON-93 and ECHOVISION ’93
Official Congress of International Society for Cardiovascular Ultrasound.

December 9-11,1993 at Siri Fort Auditorium.
Fee.
Delhi.

Eminent Faculty.

No registration

PERFECT HEALTH MELA ’93, Dec. 11-19, 1993 Talkatora Garden, New

Mass awareness programme.

and Public.

Unique Medical Exhibition for Doctors

For details contact: Dr K.K. Agarwal, Vice President, B-95, Defence

Colony, New Delhi. Phone: 4631398 Ph/Fax 6839603.

170

SWASTH HIND

FORTY-SIXTH
WORLD HEALTH
ASSEMBLY CLOSES
US $1.8 Billion Budget Adopted
The Forty-sixth World Health Assembly was held from 3-14 May, 1993 in
Geneva at the Palais des Nations. Over 1400 delegates from 172 countries
attended the Assembly—the governing body of the World Health
Organization. The Assembly re-elected Dr Hiroshi Nakajima as DirectorGeneral of the W.H.O. During its proceedings, the Assembly adopted a
number of resolutions on major issues of public health and on the structure
and working practices of W.H.O. We publish here a brief report on the pro­
ceedings of the Assembly and its recommendations.
HE
Forty-Sixth
World
Health
Assembly
held
from 3-14 May, 1993 at the Palais
des Nations in Geneva adopted by
consensus a USS 1.8 billion budget
for the global work of the‘World
Health Organization in the next
two years.
The regular budget for 1994-95
amounts to USS 822,101,000, made
up of assessed contributions from
WHO’s 186 Member States. In
addition, those States and other
contributors
will
provide
extrabudgetary
funding,
esti­
mated to amount to almost USS
one billion, for the same period.
The main components of the
regular budget are health system
infrastructure (USS 272.2 million)
programme support (USS 202.8
million), health promotion and
care (USS 145.2 million) and dis­
ease prevention and control (USS
103.9 million).

T

MorC than 1400 delegates from
172
countries
attended
the
Assembly—the governing body of

JULY 1993

the World Health Organization—
held under the Presidency of Mr
Claes Ortendahl, Director-General
of the National Board of Health
and Welfare of Sweden.
On 5 May, the Assembly re­
elected Dr Hiroshi Nakajima as
Director-General of the Organi­
zation. Dr Nakajima had been
nominated for a second five-year
term of office by the WHO Execu­
tive Board in January 1993.
The Assembly then went on to
debate and adopt a number of
resolutions on major issues of
public health and on the structure
and working practices of WHO.
These included the following :

Nations including the United
Nations Development Programme,
UNICEF, the UN Population
Fund, UNESCO and the World
Bank. The resolution identifies
four areas for particular atten­
tion. These are the anticipated
growth and consequences of the
pandemic over the next two
decades; the likely level of resour­
ces available for actions in relation
to FHV/AIDS over the next decade;
the practical arrangements for
establishing such a programme,
including management systems
and structures; and the need to
have global leadership for a coor­
dinated international response to
the pandemic.

AIDS

Eradication of Poliomyelitis

A resolution co-sponsored by
over 40 countries calls on the
Director-General to undertake a
study on the feasibility and prac­
ticability of a United Nations Pro­
gramme on JHV/AIDS. This
would be a co-sponsored pro­
gramme involving other United

According to this resolution, the
goal of global eradication of
poliomyelitis .by the year 2000 is
achievable, but only if there is a
continuing acceleration of national
immunization programmes as
planned. It confirms WHO’s
commitment to the eradication of

171

poliomyelitis as one of its highest
priorities for global health work.
The basic WHO strategy is to
improve
disease
surveillance.
strengthen laboratory services and
increase immunization coverage of
children all over the world.
Tuberculosis
Tuberculosis remains one of the
most important causes .c.* death
and the already serious tuber­
culosis situation is rapidly worsen­
ing in both developed and
developing countries. This re­
solution urges Member States to
take rapid action to strengthen
their national programmes against
the disease and urges the inter­
national community to continue its
support for improved TB program­
mes at national, regional and
global levels.
Control of Malaria
The Assembly recalled that
malaria threatens 2200 million
people—about 40% of the world
population—-causing often severe
clinical illness in over 100 million
people, and that more than one
million die of it annually, hamper­
ing socioeconomic development
and severely affecting the overall
health status of populations.
It endorsed the World declaration
on the Control of Malaria, made at
the Ministerial Conference on
Malaria, held in Amsterdam last
October, which promulgated a
global control strategy for country­
specific action founded on a realis­
tic appreciation of needs and
means. The Assembly’s resolu­
tion requests the Director-General
to reinforce WHO leadership-in
malaria control, and to pursue
efforts in the progressive improve­
ment and strengthening of local
and national capabilities for
malaria control and research
through the health infrastructure.
Dengue Prevention and
Control
Aware that epidemic dengue
is an increasingly serious prdblem,
with a dramatic rise in cases and a
high risk of rapid and serious out­
breaks. the Assembly urged Mem­
ber States to strengthen national
and local programmes for the pre­
vention .and control of dengue,
dengue haemorrhagic fever and
dengue shock syndrome. The

172

resolution requests the DirectorGeneral to establish, in consulta­
tion with affected Member States,
strategies to contain the spread and
increasing incidence of this
disease.
Emergency and Humanitarian Relief
Operations
The alarming increase in disas­
ters, both natural and man-made,
and their effects on health and
health services, led the Assembly to
reaffirm WHO’s coordinating role
within the United Nations for
health and related aspects of
humanitarian assistance, and to
request WHO to prepare for and
provide relief and rehabilitation in
emergencies. Member States are
called on to increase the allocation
of resources in their health budgets
for emergencies. The resolution
also calls on the international com­
munity to respond to consolidated
appeals launched by the United
Nations system in response to
emergencies by giving greater con­
sideration to the provision of funds
for health services and reha­
bilitation.
Health Assistance to Specific
Countries
The Assembly expressed its
appreciation to the DirectqrGeneral for his continuous efforts
to strengthen the Organization’s
capacity to respond promptly and
efficiently
to
country-specific
emergencies. A separate resolu­
tion referred to the consequences of
the recent disaster caused by the
“Storm of the Century” in Cuba
earlier this year, which severely
affected the population, agricul­
tural and industrial activities, and
in particular health services. The
Assembly requested WHO to
extend the necessary assistance to
the Republic of Cuba in order to
help overcome its present crisis in
the health care sector. It called
upon, all Member States to con­
tribute towards this objective.
Increased Support Under the Pro­
gramme of Intensified Cooperation
with Countries in Greatest Need, in
particular -for the African Countries

The Assembly recognized that
many developing countries, par­
ticularly in Africa, are struggling
under the strain of structural
adjustment programmes, the debt

burden, falling prices of com­
modities, the depreciating value’of
their currencies, the rapid deterio­
ration of their health care infras­
tructure, as well as the burden of
disease and the rising cost of health
care. It therefore adopted a
resolution appealing to all Member
States, bilateral and multilateral
development agencies, other or­
ganizations of the United Nations
system and nongovernmental
organizations to continue and to
intensify their support for develop­
ing countries, particularly in
Africa, in the implementation of
their health-for-all strategies. The
resolution also requests the
Director-General to focus efforts
on the health priorities of African
countries and to mobilize the
necessary resources to support their
efforts to attain health for all.
WHO Global Strategy for Health
and Environment
This resolution warns that sus­
tainable development is possible
only when special attention is given
to health and environment-related
matters. It calls on Member
States not only to collaborate
closely with WHO for the attain­
ment of environmentally-sound
and sustainable development, but
also to establish, where these are
lacking, coordinating mechanisms
to ensure collaboration, among all
sectors with responsibilities for
health and environment, including
non-governmental organizations.
WHO is asked to carry out prospec­
tive studies on potential environ­
mental hazards to human health,
and to establish alliances with
financial and other organizations
to ensure that health goals are
incorporated into their program­
mes on environment and develop­
ment WHO, in collaboration
with the United Nations Environ­
ment Programme (UNEP) and the
International Labour office (ILO),
is invited to proceed with the
organization of an intergovern­
mental meeting on chemical risk
assessment and management
Maternal and Child Health and
Family Planning for Health
A resolution on this subject, sub­
mitted by a group of African.coun­
tries and Lebanon, was adopted,
highlighting the importance of
eliminating harmful traditional

SWASTH HIND

practices and other social and
behaviourally obstacles affecting
the health of women, children and
adolescents. The resolution calls
for the elimination of practices
such as child marriage, dietary
limitations during pregnancy and
female genital mutilation, all of
which restrict the attainment of the
goals of health, development and
human rights for all members of
society.
International Conference on Nutri­
tion : Follow-up Action
The Assembly adopted a resolu­
tion endorsing the World Dec­
laration and Plan of Action for
Nutrition that emerged from this
conference, held in Rome last
December, and requesting the
Director-General “to reinforce
WHO’s capacity in all relevant pro­
grammes”. The Director-General
is also requested to “give priority to
least developed, low income, and
drought-affected countries, and to
provide support to Members States
in establishing national program­
mes, especially those concerned
with nutritional well-being of
vulnerable populations, including
women and children, refugees and
displaced persons”.
Non-proprictary Names for Phar­
maceutical Substances
Acknowledging with satisfaction
the increasing contribution of
generic products to national drug
markets in both developed and
developing countries and aware of
the increasing use of pharmaceuti­
cal brand names that are very
similar to international non­
prop rietary names, the Assembly
adopted a resolution requesting
Member States to ensure that inter­
national non-proprietary names
used in the labelling and advertiz­
ing of pharmaceutical products are
always displayed prominently. It
also called on the Director-General
to intensify his consultations with
governments and representatives of
the pharmaceutical industry on
ways of reducing to a minimum the
problems arising from drug
nomenclatures that may create
confusion and jeopardize the safety
of patients.
WHO Response to Global change
This report by a WHO Executive
Board Working Group, due to be
debated by the Board next week, is

July 1993

a major initial step in a process of
reform within WHO. It contains
ideas and draft recommendations
on WHO’s mission and gover­
nance. the role and operation of
headquarters, regional and country
WHO offices, coordination with
other organizations in the United
Nations system, budgetary and
financial considerations, technical
expertise
and
research. The
Assembly resolution expresses con­
fidence “that the implementation
of the action proposed in the report
will improve the effectiveness of the
Organization’s operations”. The
Director-General will report on
progress to the Forty-seventh
Assembly.
Health and Environmental Effects of
Nuclear Weapons

Noting “the continued threat to
health and the environment from
nuclear weapons” and “mindful of
the role of WHO as defined in its
constitution to act as the directing
and coordinating authority on
international health work (...) and
to take all necessary action to attain
the objectives of the Organization”,
the World Health Assembly
decided by a vote of 73 to 40, to
“request the International Court of
Justice to give an advisory opinion
on the following question”: “In
view of the health and environmen­
tal effects, would the use of nuclear
weapons by a State in war or other
armed conflict be a breach of its
obligations under international law
including the WHO Constitu­
tion?” The Assembly requested
the Director-General to transmit
this resolution to the International
Court of Justice “accompanied by
all documents likely to throw light
upon the question”.
Referring to the Principles of
Medical Ethics relevant to the role
of health personnel, particularly
physicians, in the protection of
prisoners and detainees against tor­
ture and other cruel, inhuman or
degrading treatment or punish­
ment, the Assembly expressed deep
concern over alleged systematic
breaches in these principles by
some medical personnel. It adop­
ted a resolution urging parties to
armed conflicts to refrain from all
acts that prevent or obstruct the
provision or delivery of medical

assistance and services. The re­
solution also requests the DirectorGeneral to advocate strongly the
protection of medical establish­
ments and units to all parties con­
cerned and to liaise closely in this
regar with the United Nations
Secretary-General and his UnderSecretary-General for Humani­
tarian Affairs, the Office of the
High Commissioner for Refugees
(UNHCR), the United Nations
Children’s Fund (UNICEF), the
International Committee of the
Red Cross (ICRC), the Inter­
national Federation of Red Cross
and Red Crescent Societies (IFRC)
and with competent organizations
of the United Nations system, and
other International and non­
governmental organizations con­
cerned.

Natural

Disaster Becoming

More Destructive
The goal of the Decade for Natural
Disaster Reduction was to establish
on effective partnership between
the United Nations and the inter­
national community, SecretaryGeneral Boutros Boutros-Ghali
told the opening of the Second Ses­
sion of the Special High-level
Council of the International
Decade on 25 January.
Natural disasters were becoming
more destructive and more costly,
he noted. In 1991 alone, the
economic cost of disasters was
estimated at some S 44 billion, with
more than 160,000 people losing
their lives, he. said.
—UN Newsletter

173

AIDS
WHO ESTIMATES OF HIV INFECTION TOPS 14
MILLION
atest estimates released on 21

Health
L May 1993 by the World
ethal an

Organisation
reveal
estimated 14 million people have
been infected by HIV, the human
immunodeficiency virus which
causes AIDS- By the year 2000,
WHO estimates that between 30
and 40 million people will have
been infected by the virus.
The worst affected area is subSaharan Africa where WHO
estimates that over eight million
people have been infected. Of
this total, about half to two thirds
were in east and central Africa, an
area which accounts for only
about one sixth of the total popu­
lation of the sub-Saharan region.
The cities of central and east
Africa have so far borne the
greatest burden, with as many as
one out of every three adults infec­
ted, but the virus is increasingly
following roads and rivers into the
countryside, and spreading to
southern and western Africa.
Reports from Nigeria, a country
with almost one fifth of subSaharan Africa’s population, indi­
cate that HIV has begun to spread
throughout
the
country. For
example, HIV prevalence rates of
up to 15-20 percent were found
among groups of female sex
workers.
As HIV continues to spread, the
numbers of AIDS cases in Africa
are
increasing. Already,
an
estimated one and three quarter
million men. women and children
in sub-Saharan Africa have
developed AIDS, two-thirds of the
global figure. The cumulative
total of AIDS cases in Africa is
expected to exceed five million by
the end of this century.

But the most alarming trends of
HIV infection are in South and

174

South East Asia, where the
epidemic is spreading in some
areas as fast as it was a decade ago
in sub-Saharan Africa. WHO
estimates that over one and a half
million HIV infections have
occurred in adults in the South and
South-East Asia regions.- While
the majority of reported infections
appeared in two countries—India
and Thailand—high rates of HIV
spread into specific populations
have been seen elsewhere in the
region.
“While Africa suffers the explo­
sion of AIDS cases as a result of
infections ten years ago it is in
South and South-East Asia that we
are seeing an explosion of infection
today,” says Dr Michael Merson,
Director of the WHO Global Pro­
gramme on AIDS. “We can soon
expect more new infections in Asia
than in Africa. And as the second
epidemic—the epidemic of AIDS—
takes hold in Asia as it has in
Africa, we can anticipate that
individuals, families and com­
munities will be affected in the
same tragic way we are already see­
ing in parts of Africa.”
There is mounting concern for
other newly infected areas. Latest
estimates show that over one and a
half million adult HIV infections
have occurred in Latin America
and the Caribbean since the
epidemic
began. The
future
course of the epidemic in the region
depends very much on how fast
and how far the virus spreads in
Brazil, which already has more
AIDS cases than any country out­
side Africa apart from the
United States.

The epidemic has taken hold in
the Middle East and North Africa
where WHO estimates that more

than 75,000 infections have so far
occurred. These figures are of
particular
concern
because
although only limited information
is available for this region, reports
suggest the presence of other sex­
ually transmitted diseases and
injecting drug use—factors which
expose people to the risk of HIV
infection.

Current developments in Eastern
Europe and Central Asia may also
spur the rate of transmission in the
region. At the moment it is
estimated that 50,000 adults have
been
infected
with
HIV.
However, economic crisis, rising
unemployment,
ethnic
and
religious conflict, the displacement
of civilian population and the dis­
ruption of families encourage the
kinds of behaviour that spreads
HIV. Of equal concern, drug use
and prostitution are on the rise.

In East Asia and* the Pacific,
WHO estimates that by late 1992
over 25,000 infections in adults had
occurred. The limited data avail­
able indicate that the 663 cumula­
tive AIDS cases reported by
January 1993 represent reasonably
accurately the current status of the
epidemic in most of East Asia and
the Pacific.
“Parts of the world face a catas­
trophe because of AIDS,” says Dr
Merson. “Fortunately a decade of
experience has taught us how we
can prevent people becoming
infected with HIV, we know we can
avoid thousands, even millions of
deaths in adults at the prime of
their lives; we can prevent the need­
less and appalling tragedy of AIDS
babies and AIDS orphans. But,
we must have financial and politi­
cal commitment on a massive scale
if we are to slow .down this
epidemic.
yy pj q

Swasth Hind

INTERNATIONAL DAY AGAINST
DRUG ABUSE & ILLICIT TRAFFICKING
26 JUNE

PRESIDENT
REPUBLIC OF INDIA

PRIME MINISTER
REPUBLIC OF INDIA

MESSAGE

MESSAGE

The scourge of drug abuse and illicit
trafficking in narcotics poses an extremely grave
threat to the health and well-being of all human­
kind. The nexus between drug abuse and
various illegal activities which can undermine
the very existence of civilized society is equally a
matter of growing concern. The government
and non-govemment agencies who are working
in this field have, therefore, to pursue a wellcoordinated approach to tackle this serious
problem.
On the occasion of the International Day
Against Drug Abuse and Illicit Trafficking, let us
resolve to substantially intensify our efforts to
combat and eliminate this menace to the
progress and prosperity of humanity. I wish
every success to the endeavours of all those who
are engaged in this important task.

In the contemporary world, the illicit
trafficking and abuse of drugs has emerged as
one of the major threats to the quality of human
life. Its proliferation is particularly ominous for
developing countries which are still struggling to
overcome their basic problems of poverty,
hunger and disease. There is now a global
awareness that the problem has to be tackled
through concerted measures to curb the supply of
dependence producing drugs and reduce their
demand.
I am happy that on the International Day
Against Drug Abuse and Illicit Trafficking, the
Ministry of Welfare has launched a nation-wide
campaign to inform the people about the illeffects of drug abuse on the individual, the family
and the society at large.
I wish every success to all those engaged in
this humanitarian task, zx

June 3, 1993 (SHANKER DAYAL SHARMA)

June 18, 1993

CAUSES OF DRUG ABUSE
Most of the addicts start taking drugs out of curiosity
to have some pleasure, often under the influence of
their friends and peer group. Others take them to
overcome boredom, fatigue, depression or frus­
tration. Lack of affection or love from and
understanding with near and dear ones might also
force a person to take to drugs. Their easy
availability, no doubt, results in largescale drug
abuse.

*

Keep yourself interested in your child’s activities
and friends.

*

Share problems at home. Talk about your child’s
problems, teach them to handle them.

*

Do not abuse alcohol and drugs yourself.
an example.

*

Keep track of prescribed drugs in your home.

*

Learn as much as you can about drugs—be
forearmed.

HOW TO PREVENT DRUG ABUSE
Communicate openly with your child.
patient listener.

JULY 1993

Set

AS A TEACHER

AS A PARENT
*

(P.V NARASIMHA RAO)

Be a

* Talk to your students informally and openly.

♦

Discuss with them dangers of drug abuse.

175

Secretary-General
United Nations

MESSAGE

In the post cold war era, the international community faces a number of new and difficult challenges
to peace and security. None is more insidious, or more far-reaching, than illicit drug production, traf­
ficking and consumption. Hardly a country, ethnic group, or community has been spared its
effect.

Energetic, coordinated international action is needed to tackle this global menace. New approaches
are needed. Until recently, international efforts concentrated mainly on supply reduction. While
there must be no lessening of efforts for the other areas of drug control, the emphasis must now shift to
demand reduction.

Demand reduction should be part of comprehensive, balanced, preventive approach. Just as in the
field of international peace and security, the value of preventive diplomacy in averting conflict is now
generally recognised, so preventive action must become a crucial element in the long-range goal of
eliminating drug abuse.

This International Day — whose theme is “Prevention of Drug Abuse through Education”, is inten­
ded to increase international awareness of the menace of drug abuse. Drug abuse prevention must
become a worldwide activity aimed at reaching every nation, society, community, family, school and
business. Everyone has a role to play in the fight against illicit drugs and their misuse.

In the view of the United Nations, substance abuse education should now be taught in all schools. It
should be fully integrated into public and private, religious or secular school curricula, with the
emphasis on health and overall personal well-being. Educational programmes play-a critical role in
the overall fight against drug abuse. For those who have started to use drugs, appropriate educational
treatment can provide a pathway to successful intervention and treatment It can increase the misusers’
awareness of the dangers of drug abuse and help them to make the choice to stop. Awareness-raising is
also critical in helping parents and educators to understand the nature of particular situations, and how
to respond. The response will, of course, vary according to the cultural values expressed by each
society.
The United Nations has laid the foundations for a more effective and truly global strategy in drug
abuse control. The United Nations International Drug Control Programme is the vanguard and coor­
dinator of drug control activities in the UN system, and the focal point for the UN Decade against Drug
Abuse (1991-2000). One of the main responsibilities of the Programme is to ensure that the emphasis
on prevention is part of a balanced approach.

The scourge of drug abuse challenges the ability of the international community to work effectively
together; it can be tackled only by international cooperation. A clear strategy is in place. But it will
succeed only if the efforts of every national, regional and international body are combined. I therefore
call on all Governments, international organizations, and the civil society at large to move vigorously
into concerted action.

BOUTROS BOUTROS-GHALI
Keep yourself interested in your students’ interests
and activities.
* Encourage them to. volunteer information of any
incident of drug abuse.
* Talk about the problems of adolescence. Guide
your students on how to handle them..
* Help them examine career options, set goals.
* Learn as much as you can about drugs—be
forearmed.

*

AS A CITIZEN
*
*

Remain alert to requests to keep/carry
narcotic drugs.
If you notice poppy or other cannabis plants/crops
inform the nearest law enforcement authority.

176

*

If you come across anything suspicious, inform the
police, even anonymously.

♦

Advise addicts to seek treatment from Govt, hos­
pitals or counselling/de-addiction centres funded
by the Ministry of Welfare, Government of
India.

Say ‘yes’ to life,
say ‘no’ to drugs!
SWASTH HIND

THE FIGHT AGAINST DRUGS
THE CHALLENGE
* The number of registered
addicts in our country has
reached a staggering figure of
9.34 lakhs. If unregistered
addicts are also added, the
figure will be truly alarming.
*

Drug addiction leads to: ruin of
the individual, break-up of the
family, increase in crime and
affects the fabric of society.

♦ This is probably the major
threat facing young people in
our cities. Drug taking is also
a contributory cause of AIDS.

PLAN OF
ACTIVITIES OF
WELFARE MINISTRY
*

Community based action for
identification.

*

Drug Abuse awareness and
education.

*

Motivation, Counselling, Treat­
ment, Follow-up.

*

Training for volunteers.

♦

Assistance to non-governmen­
tal organisations.

THE APPROACH
*

Prevention and reduction.
(Ministry of Welfare)

*

Control of Supply.
(Narcotic Control Bureau)

♦

Suppression of Illicit Traffic­
king.
(Narcotic Control Bureau)

♦ Treatment and Rehabilitation.
(Ministry of Welfare)

NON­
GOVERNMENTAL
ORGANISATIONS
*

NGOs which are close to the
potential and actual abusers of
drugs are the best agencies for
drug awareness, prevention and
rehabilitation programmes.

ACHIEVEMENTS
♦

Mass awareness through print,
outdoor, electronic and tradi­
tional media.

*

Government of India has assis­
ted 167 NGOs for setting up 142
counselling centres, • 97 De­
addiction centres and 15 After­
care centres.

* Till now 2,67,921 addicts have
been de-toxified.
*

Budgetary support has been
•increased three fold by the
Government for drug abuse
prevention and rehabilitation
programmes from Rs. 4.6 crore
in 1990-91 to Rs. 13.8 crore in
1993-94.

*

Preparation of a Drug Control
Master Plan for a 7-year span
(1994-2000) has been entrusted
to a multi-disciplinary task
force.

Drug Abuse,
Life Abuse!

JULY 1993

177

WORLD NO-TOBACCO DAY OBSERVED

MAKING SOCIETY TOBACCO-FREE
HE Central Health Education
Bureau in collaboration with
the Govt of National Capital
Territory of Delhi observed the
World No-Tobacco Day on 31st
May 1993. The venue was Nehru
Homoeopathic Medical College
and Hospital, New Delhi. Emi­
nent people from the World Health
Organization, Govt, of India and
representatives from voluntary
organizations participated. The
theme of the symposium. was
“Health Services: our window to a
tobacco-free world.”

T

Inaugurating the symposium. Dr
D.B. Bisht, Director, Programme
Management SEARO, WHO said
that tobacco “is an intoxic drug
which leads to cancer and other
respiratory diseases. It is hazar­
dous to consume tobacco through
pan and pan masala, particularly by
the young people. Mortality and
morbidity rate in the country is very
high due to the use of tobacco
and smoking.”
Dr Bisht stated that “65 per cent
cases of cancer are avoidable and
preventable if use of tobacco is
given up.” The theme for the next
year of the World No-Tobacco Day
would be “The media against
tobacco” which would enforce total
ban on the use of tobacco in the
U.N. buildings and buildings fun­
ded by UNO, he added.
Dr Bisht said that legislation
alone was not sufficient to stop peo­
ple from smoking or consume
tobacco. Indeed, the “enactment
should come from within by the
people and not from without,” he
added.

178

Dr Bisht said that the “know­
ledge of the art of communication
is essential to convince people to
quit smoking. Each health pro­
fessional should also become a
communicator to make the society
tobacco free,” he said.
Death from smoking rising
Dr V.P. Varshney, Director,
Health Services, stated that smok­
ing was killing 2 million people a
year — three times as many as is
the 1960’s — and the death toll was
rising steadily. Of these, 1.5
million people died in India every
year, he said.

Dr Varshney said that there were
about 30 brands ofpan masala now
on sale in the country.' They con­
tain tobacco which was extremely
harmful especially for children and
pregnant women. e

Delhi Administration has ban­
ned smoking in hospital premises
and workplaces that fall under its
jurisdiction. Similar action should
be taken by the Central Govt and
other deptts., he said.
Dr Varshney emphasised the
need of health education of the
people to persuade them to quit
smoking.

Indicators
Dr Narendra Bihari, OSD,
DGHS, said the ICMR study has
indicated that the “prevalence rate
of smoking among males above 15
years of age is 90 per cent in a rural
community in Meerut district of
UP.” According to another study
undertaken in 1981-82 in an urban
situation, the prevalence of smok­
ing was found to be 59.5 per cent

among males of above 15 years of
age. These indicators show the pre­
valent situation in the country.
Smoking is responsible for
deaths due to cancer, cardiovas­
cular diseases, respiratory diseases,
peptic ulcers, pregnancy-related
complications
while
passive
smokers, with ill-health conditions
like asthma, bronchitis, cold and
other allergies are prone to more
serious reactions of Environmental
Tobacco Smoke (ETS).
The ETS causes sudden, infant
death syndrome/ Irritant effects
on eyes, nose and throat, res­
piratory tract infections had in­
creased the risk of death from lung
cancer and coronary heart diseases
by 20 per cent. Such revelations
make it imperative for the health
profession to strive for making
non-smoking a social norm which
would eventually lead to the goal of
a tobacco-free society, he said.
Dr Narendra Behari exhorted
the health personnel, particularly
medical doctors to set an example
and abstain from smoking in order
to protect their patients and their
colleagues from the risks of
passive smoking.
Non-communicable diseases rising'
Dr I.C. Tiwari, Adviser (Health)
Planning Commission, said that
India has made many achieve­
ments in the field of health. The
life expectancy has gone up from 31
years in 1947 to 58 years today.
Many communicable diseases
have either been eradicated or con­
trolled. Smallpox and plague are
non-existent Malaria is under
control. Leprosy is to be con­
trolled by 2000 AD, he said.
SWASTH HIND

But. non-communicable dis­
eases. he said, arc causing a great
alarm. As we control communic­
able diseases we have to fight
against the non-communicable dis­
eases right from the time a mother
is carrying a baby in the womb.
For, passive smoking of tobacco
among women carries the risk of
cancer of the cervix. Besides, oral
cancer closely follows it, Dr Tiwari
said.

Beedi smokers, he said, carried 6
to 8 times higher risk of tobacco
related diseases compared to
cigarette smoking, he said.

The practitioners of the Indian
Systems of Medicine who being
closer to community, especially in
rural areas, could help a great deal
in health education of the people
by presuading them against smok­
ing, lie said.
Parallel programmes

Dr Suraj Varma, a surgeon rep­
resenting Cancer Society of India

(Con id. from Page 165)

7. In states like Himachal Pra­
desh workers show interest but they
are not given adequate guidance in
the maintenance of cold chain and
maintenance of proper regis­
ters. Supervision at all levels
should be strengthened. In some
States, State officials seem to be
satisfied with the programme with­
out having, made any field visits.
The Medical Officers and Health
Visitors rarely visit the field in
some States.

JULY 1993

SWASTH HIND
1993, devoted the theme of the World
No-Tobacco Day — 31 May, 1993 Health Services — Our
window to a tobacco-free world was released by Dr Narendra
Bihari, O.S.D., DGHS,New Delhi. The issue was hailed by
all with a thunderous applause. It has been “brought out
very well” and it carries “informative and thought-provoking
articles” was the opinion of a cross section of the VIPs, pro­
fessionals and others who were present during the sym­
posium on the theme that was organised at the Nehru
Homoeopathic Medical College and Hospital, New Delhi on
31 May, 1993.
wasth Hind, May

S

said that the non-governmental
organizations were running the
parallel programmes with the Govt
in this field.
Screening in the north-east part
of the country has revealed that 15
per cent of cancer is contributed by
the lifestyles adopted. Beedi smok­
ing is responsible for 4 per cent
deaths.

8. In some States mechanics are
posted to maintain the cold chain
at district level but they are not
effective partly due to their indif­
ference partly due to the bureauc­
ratic delays. Such delays can be
overcome by getting the equipment
repaired by private companies on
contractual basis.

9. Sterilization of needle and
syringes at the sub-centre level and
in the field are not satisfactory. It
is recommended that the steriliza­
tion should be done at the PHC

Awareness

Dr V.P. Mehta, Delhi branch,
Indian Cancer Society emphasized
the need to create awareness among
people to stop smoking. Diseases
like lung and oral cancer were
caused due to the ‘mad’ use of
tobacco.
Dr Mehta emphasised on eating
fibrous foods for good health.
Dr V.S. Wadhwa,
Director,
CHEB, proposed a vote of thanks.
—M.L. MEHTA

level by autoclaving and the
syringes and needles should be
taken to the field in sterilised
kits.
10. The awareness in the com­
munity about the need for immuni­
zation is fairly adequate. But the
details of immunization schedule
are known only in small percen­
tage. People are more keen about
the polio immunizations than
other immunizations. I.E.C. acti­
vities have to be strengthened to
give complete information about
all immunizable diseases, immuni­
zation dosages and the timings of
immunization.

179

INTERNATIONAL CONFERENCE ON NUTRITION

WORLD DECLARATION AND
PLAN OF ACTION TO ATTACK
HUNGER AND MALNUTRITION
HE International Conference
on Nutrition, bringing together
ministers of agriculture and health
in a “World Nutrition Summit,”
was held in Rome from 5-11
December 1992. It concluded
after adopting a World Declaration
expressing determination to eli­
minate huhger and reduce all
forms of malnutrition.
The sjx-day conference of over
160 governments and around 160
international and non-govemmental
organizations—jointly
sponsored by the UN Food and
Agriculture Organization (FAO)
and the World Health Organiza­
tion (WHO)—also called on the
United Nations to consider urgen­
tly the issue of declaring an Inter­
national Decade of Food and
Nutrition to help achieve the objec­
tives of the Declaration.
“Hunger and malnutrition »afe
unacceptable in a world that has
both the knowledge and the resour­
ces to end this human catastrophe”,
the
Declaration
states. “We
recognize that. globally there. Is
enough foo'd for all; inequitable
access is the main problem.... We
pledge to act in solidarity to ensure
that freedom from hunger becomes
a reality”
The ICN was hailed by the
Director-General of FAO, Mr.
Edouard
Saouma,
and
the
Director-General of WHO, Dr
Hiroshi Nakajima, as a land­
mark conference.
In a closing statement, Mr
Saouma said the Conference
“opened a new area for dialogue
and concerted action on a crucial
problem for the future of
mankind.”

T

180

“At a moment when the
spotlights of the entire world are
focussed on the drama of. hunger
provoked in both Africa and
Europe by nature and the folly of
man, this Conference allowed us to
take a new look at the fundamental
issues of food and nutrition.”

However, he added, “the answers
could only be found through pro­
found reflection and unfailing
determination.”
Referring to the adoption by con­
sensus of the World Declaration
and the accompanying Plan of
Action for Nutrition, Mr. Saouma
said they “constitute an irreplace­
able reference for the conception
and elaboration of stragies, policies
and national programmes” related
to food ,and nutrition.
Dr Nakajima said: “Together,
as partners in a planetary pact, we
can achieve our objectives. Each
one of us has a role to play, whether
we are representatives of govenments or of international, bilateral
or nongovernmental organiza­
tions. tach has his or her own
expertise to contribute. This goes
hand • in hand with intensified
endeavours to mobilize resour­
ces
from
the
international
community.”

“Rome was not built in a
day. Our alliance to achieve nut­
ritional wellbeing will take time to
bear fruit Yet with this Declara­
tion and Plan of Action we are the
architects of a new world nutrition
order.. With this blueprint in
hand, we have a unique oppor­
tunity which we must not lose. We
must fulfil our responsibility,
indeed our moral obligation, to lift

the burden of malnutrition, in all
its hideous forms, from the new­
born infant, our young children,
our mothers, our elderly—from
all humanity.”

On food aid, the Declaration
says it may be used to assist in
emergencies and provide relief to
refugees and displaced persons, to
support household food security
and community and economic
development. According to the
Declaration, countries receiving
emergency food aids should be pro­
vided with sufficient resources to
enable them to cope with
future emergencies, but care must
be taken to avoid creating
dependency.
“We reaffirm our obligations as
nations and as an international
community to protect and respect
the needs for nutritionally ade­
quate food and medical supplies
for civilian populations situated in
zones of conflict We affirm in the
context of international humani­
tarian law that food must riot be
used as a. tool for political pre­
ssure. Food aid must riot be
denied because of political affilia­
tion; geographic location, gender,
age, ethnic, tribal or religious
identity.”

The Declaration states : “We all
view with the deepest concern the
unacceptable fact that about 780
million people in developing
countries—20 per cent of their
population—still do not have
access to enough food to meet their
basic daily needs for nutritional
well-being.
“We are especially distressed by
the high prevalence and increasing
SWASTH HIND

numbers of malnourished children
under five years in parts of Africa,
Asia and Latin America. More­
over, more than 2000 million peo­
ple, mostly women and children,
are deficient in one or more mic­
ronutrients; babies continue to be
bom mentally retarded as a result
of iodine deficiency; children go
blind and die of vitamin A
deficiency; and enormous numbers
of women and children are adver­
sely affected by iron deficiency.”
“Hundreds of millions of people
also suffer from communicable
and non-communicable diseases
caused by contaminated food and
water. At the same time, chronic
nonrcommunicable diseases re­
lated to excessive or unbalanced
dietary intakes often lead to prema­
ture deaths in both developed and
developing countries.”
According to the Declaration,
poverty and lack of education are
the primary causes of hunger* and
undemutrition. Slow progress in
solving nutrition problems reflects
the lack of human and financial
resources, institutional capacity
and policy commitment in many
countries needed to assess nutrition
problems and to implement pro­
grammes to overcome them, it
says.
The Declaration calls for basic
and applied scientific research and
food and nutrition surveillance sys­
tems to identify factors that con­
tribute to the problems of
malnutrition, and to identify how
to eliminate these problems, par­
ticularly for women, children and
aged persons.

“In addition nutritional well­
being is hindered by the continua­
tion of social, economic and gender
disparities; discriminatory prac­
tices and laws; floods, drought,
desertification and other natural
calamities; and many countries'
inadequate budgetary allocations
for agriculture, health, education
and other social services,” the
Declaration further states.

“Wars, occupation, civil distur­
bances. natural disasters, as well as

JULY 1993

human rights violation and inap­
propriate socio-economic policies,
have led to tens of millions of
refugees, displaced persons, waraffected non-combatant • civilian
populations, and migrants who are
among the. most nutritionally
vulnerable groups. Resources for
rehabilitating and caring for these
groups are often extremely inade­
quate and nutritional deficiencies
are common.”
“All responsible parties should
cooperate to ensure the safe and
timely passage and distribution of
appropriate food and medical sup­
plies to those in need, in accor­
dance with the Charter of the
United Nations.”
The Declaration says that nut­
ritional well-being of all people is a
pre-condition for the development
of societies and should be a key
objective of progress and human
development. It must be at the
centre of socio-economic plans and
strategies.
Policies and programmes must
be targeted towards those most in
need. The Declaration went on
“We must support and promote
initiatives by people and com­
munities, and ensure that the poor
participate in decisions that affect
their lives.”
The right of women and adoles­
cent girls to adequate nutrition was
considered crucial and their health
and education must be improved,
the Declaration stresses. Women
should be given the opportunity to
participate in the decision-making
process and to have increased
access to,
and control
of,
resources.
The
Declaration
seeks
to
promote active cooperation among
governments^ multilateral, bilateral
and non-governmental organi­
zations, the private sector, com­
munities and individuals, “to
eliminate progressively the causes
that lead to the scandal of hunger
and all forms of malnutrition in the
midst of abundance.”
While recognizing that each
government has the prime respon­
sibility to protect and promote food
security and nutritional well-being

of its people, the Declaration
stressed that low-income countries
should be supporter by the inter­
national community, including an
increase in official development
assistance in order to reach the
accepted United Nations target of
0.7 percent of GNP of developed
countries as reiterated at the United
Nations Conference on Environ­
ment and Development
In addition to the Declaration, a
Plan of Action was also adopted at
the Conference. It contains a
wide range of detailed strategies
and is a basis for national plans of
actions which individual countries
aim to revise or prepare before the
end of 1994.
Based on world-wide con­
sultations in preparation for the
Conference, actions to be con­
sidered by governments in their
efforts to improve nutrition are :
incorporating nutritional objec­
tives, considerations and com­
ponents into development policies
and
programmes; improving
household food security; protecting
consumers through improved food
quality and safety, caring for the
socio-economically deprived and
nutritionally vulnerable; and pro­
moting breast-feeding.
The Conference was attended by
almost 1400 delegates from oyer
160 countries and was addressed on
its opening day, on 5 December, by
His Holiness Pope John Paul II,
who stressed the effects of what he
described' as “the paradox of
plenty” in which so many millions
suffered'and died from hunger and
malnutrition in a world which pro­
duced enough food for all.
The chairperson of the Con­
ference, Madame Simone Veil,
member of the European Parlia­
ment and its former President and
former Minister of Health of
France, told the closing session of
the Conference:
“I wish that the message of hope
expressed* here will be heard out­
side this forum and will find a res­
ponse during the coming decade
for the concrete realization of the
commitments We have all made
here.” She hoped that as a result
of progress stemming from the
Conference, hunger and malnutri­
tion could be eliminated in a peace­
ful world.

181

LATHYRUS SATIVUS
AND LATHYRISM
—An Update
Ramesh V. Bhat & M. Kaladhar
HE disease Lathyrism had
attracted
attention
since
ancient times. Sleeman in 1833
provided the first authentic record
of outbreak of lathyrism in
India. -Since then about-40 out­
breaks have been described in
India. During the last three
decades, outbreaks of lathyrism
have been recorded not only in the
Indian States of Maharashtra and
Madhya Pradesh but also in other
developing
countries
like
Bangladesh, Nepal and Ethiopia.

T

The disease has been attributed
to consumption of the pulse
Lathyrus sativus. An unusual
aminoacid,
0-N-oxalyl Amino
Alanine (BOAA) has been isolated
from Lathyrus sativus seed, charac­
terized, synthesized and proved to
be
responsible
for
causing
neurological manifestations in a
variety of experimental animals
including primates. Lathyrism is
the first human neurodegenerative
disorder linked to an exogenous
excitatory aminoacid, BOAA.
There has been a resurgence of
interest in lathyrism all over the
world as exemplified by the
organization of three International
Symposia on the subject at Pau
France (1985), London (1989) and
Dacca (1992). An International
Network for the improvement of
Lathyrus sativus and the eradica­
tion of lathyrism has been
established.

182

Agricultural aspects

In India, lathyrus is mainly
cultivated in Madhya Pradesh.
However, it is also cultivated in
Uttar Pradesh, Bihar, West Bengal,
Maharashtra, Gujarat, Karnataka
and Andhra Pradesh. While the
production of lathyrus in Madhya
Pradesh during 1970s was about
300,000 tonnes, it had declined to
about 150,000 tonnes during late
1980s. Besides India, it is also
cultivated in Bangladesh, Peoples’
Republic of China, Nepal, Pakis­
tan, Ethiopia,
Canada
and
France.
Work on genetic impovement of
Lathyrus sativus by evolving a
variety with low BOAA content has
been progressing in several coun­
tries. A low toxin variety P24 was
identified in India and released in
1973-74. A variety which has as
low as 0.01% BOAA has been iden­
tified in Bangladesh. The Cana­
dian germplasm LS 8246 has a
BOAA content of 0.03%. Work is
in progress in Indian Agricultural
Research Institute, New Delhi on
genetic manipulation of Lathyrus
sativus plant to produce a toxin
free variety.

Social arid economic aspects
Lathyrus was traditionally con­
sidered as poor man’s crop, being
cultivated in drought-prone areas
as an ‘insurance crop’. It used to

be given to landless agricultural
labourers by the landlords in lieu
of wages. The prices of lathyrus
were, much lower than other
foodgrains. However,
during
recent years, the scenario has
changed considerably. A KAP
study undertaken by the Marketing
and Business Associates.on behalf
of the Government of Madhya
Pradesh in 1989 indicated that the
consumption of lathyrus in rural
areas of Madhya Pradesh is con­
tinuing though, at a reduced level
compared to 10-15 years ago. The
reasons for continued consump­
tion cited were, its comparatively
less cost, better taste and satiety
value.
In States like Andhra Pradesh,
Karnataka
and
Maharashtra,
lathyrus is cultivated and utilized
locally in the preparation of‘dal’ or
for preparing certain savouries.
In a study in Bhandara district
(Maharashtra), the surveys conduc­
ted by the National Nutrition Mon­
itoring Bureau had revealed that
among the 108 households sur­
veyed, 11 households were consum­
ing lathyrus as ‘dal’. The con­
sumption was 52 gm/CU/day on an
average and the maximum con­
sumption in a family was 113 gm/
CU/day. The price of lathyrus is
generally about 50% more than that
of wheat and about 40% less than
that of chickpea. During recent

Swasth Hind

years, the increase in prices of
pulses is generally more than other
foodgrains and there is a lucrative

trade of adulteration of chickpea
flour with lathyrus flour in various
parts of the country.
Chemistry and biosynthesis of
Lathyrus sativus Neurotoxin(s)

The major toxin from Lathyrus
•sativus seeds, implicated in human
neurolathyrism
is
p-N-oxalyl
aminoalanine
(BOAA). The
toxin, also referred to as ODAP
(Oxyalyldiaminoprop ionic acid)
was first isolated in 1963. The
content of BOAA in Lathyrus
sativus seed, varies from 0.2 to 1.0
gm per cent.
The biosynthetic pathway of the
toxin and the enzyme involved is
still obscure.
The enzymatic
oxalylation of p-L-diaminopropionic acid (DAPRO) to BOAA
has been demonstrated, although
DAPRO itself could not be detec­
ted in Lathyrus sativus. Recent
experiments utilizing 0-acetyl(1314C) serine (OAS) revealed
significant incorporation of the
label into isoxazoline derivatives
(BIA) and BOAA. The identifica­
tion of the particular enzyme
involved in opening the isox­
azoline ring of Bl A leading to for­
mation of DAPRO is crucial since,
development of toxin-free strain of
Lathyrus sativus is not possible
without interfering with the specific
gene transcription for this par­
ticular enzyme.
Neurotoxicity of BOAA-A.
mental studies

Experi­

BOAA was observed to be a
potent neuroexcitant and found to
be toxic to a variety of animal
species, viz., immature rat, mice and
chicks, ducklings, baby pigeons,
young guinea pigs, pups, monkeys,
horses, sheep and goats. Early
studies of acute neurotoxicity in
chicks, rodents, ducklings and

JULY 1993

baby pigeons revealed that adult
animals do not develop toxicity due
to BOAA while the young ones dis­
play neurological symptoms.

Recently, by feeding diet con­
taining Lathyrus stivus, or alcoholic
extracts of Lathyrus sativus pulse
supplemented with BOAA or diets
supplemented with BOAA alone at
higher levels,
symptoms
of
neurolathyrism were successfully
induced in cyanomalgous mon­
key. Affected monkeys showed a
variable combination of fine
tremor, periodic myoclonus—like
jerks, mild to moderate increase in
muscle tone of leg muscles, and
striking hind limb extensor pos­
turing. The motor-neuron disease
of lathyrism type was also deve­
loped in horses, sheep and goats by
prolonged feeding of Lathyrus
sativus.
The dose of BOAA
required to cause neurological
symptoms in experimental animals
varies from species to species.
While in susceptible species like
horse and sheep 0.04 to 0.1 gm of
BOAA per kg. body weight is
needed, for animals like monkeys
1.1 gm per kg/body weight is
needed.
Mechanism of action of BOAA
BOAA is an excitotoxin which is
capable of over stimulating and
destroying nervous cells. In the

convulsing young rat, depletion of
glycogen
and
high
energy
phosphate levels and an increase in
inorganic phosphate and lactate
levels could be observed along with
enhanced protein degradation and
ammonia production. The trans­
port of excitatory amino acid
glutamate, into synaptosomal pre­
parations .were found to be
inhibited by BOAA. It was
speculated that the neuroexcitatory
actions of BOAA are mediated-by
increasing the effective glutamate
levels in the synaptic junctions or
alternatively BOAA could bind to
glutamate receptor and mimick the
effects of glutamate. It has also

been demonstrated in mice that
BOAA administration causes de­
generative changes in retina,
hypothalamus and the arcuate
nucleus, similar if not identical, to
glutamate induced pathology.
Studies conducted at NIN in
Wistar rats, revealed that when
BOAA is administered during ges­
tational period, a significant altera­
tion in the neurotransmitter amino
acids viz., glutamate, GABA and
glycine concentrations occurs in
the early post-natal period. These
observations are indicative of
transport of BOAA from the
mother to the foetus, which was
also supported by detection of
radioactivity in the brain of
foetuses from mother rats who were
administered 14C-labelled BOAA
Interestingly, the brain dopamine
levels of the young ones were dec­
reased due to BOAA treat­
ment. This observation becomes
significant, since in adult rat brain,
BOAA has no effect on brain
dopaminergic system, while its
analogue BMAA (P-aminomethyl)
is a potent neurotoxin of
dopaminergic neurons. Thus the
neurotoxic effects of BOAA on the
developing brain, need to be
further examined.
Isomeric forms of BOAA in rela­
tion to neurotoxicity
BOAA occurs predominantly
(95%) as the p-form in Lathyrus
sativus. Under certain conditions,

it has been shown to spontaneously
isomerize to the cc-fonn, a reaction
that might also occur during the
prepartion of ‘dal’ from Lathyrus
sativus. Investigations
revealed
that oc-BOAA is neither acutely nor
chronically toxic. It was sugges­
ted that differences in the mode of
cooking and hence in the extent to
which
such
isomerization
occurs, may contribute to the
known variability of Lathyrus
sativus seed toxicity in different
geographical
locations. The

183

observations on the isomerization
of fl-form on cooking need to be
confirmed by other studies.
Metabolism of BOAA : Informa­
tion on absorption and metabolic
fate of BOAA in the body is scan­
ty. It was reported that in squirrel.
monkey. BOAA was found to be
metabolically inert and does not
undergo any tran formation. It
was also observed that in adult raL
chick and rhesus monkey, no
metabolite of BOAA could be
detected either in tissues or in
urine. However,
from
recent
studies carried out on humans, it is
suspected that BOAA is meta­
bolized in the body.
Detoxification : It has been obser­
ved that under laboratory con­
ditions by parboiling the seeds or
by the hot water treatment and dis­
carding the excess water, it is possi­
ble to remove most of the toxins
from Lathyrus sativus. However,
such detoxification procedures
were not found to be practical by
the rural population subsisting on
lathyrus. Establishing commer­
cial facilities for detoxification of
lathyrus was not successful.
Human studies on neurolathyrism
Two forms of lathyrism viz., the
latent and established have been
described in humans. The fully
established cases were clinically
characterized by spasticity and
varying degrees of paraparesis.
The latent form of the disease
observed in apparently normal
people can be identified only by
careful neurological examination.
The signs include exaggerated knee
and ankle jerks, ankle clonus and
extensor plantar reflexes. Spas­
modic muscular contraction of calf
muscles is the earliest recorded
symptom in affected individuals.
Other symptoms include weakness,
heaviness and stiffness of the
limbs, muscle cfamps, tremors.
coarse involuntary movement of
upper extremity, etc.. Minimally

184

affected individuals could run with
knock-knees or walk slightly
altered gait. The more severely
affected have typical scissors gait.

Lathyrism is an irreversible form
of upper-motor neuron disease
involving pyramidal tract. Unfor­
tunately, detailed histopathological
information is still scanty in
humans. A study carried out in
Unnao district (U.P.) in 1976 by
ITRC, Lucknow, revealed subclinical lathyrism. A follow-up study
indicated that those who could not
avoid eating lathyrus. subsequently
developed full blown lathyrism.
Similarly, during the outbreak of
lathyrism in Bhandara district
(Maharashtra) in 1975, it was
observed that in patients with
lathyrism cessation of consump­
tion, particularly in the early stages
of disease, resulted in distinct
improvement
of
the
con­
dition. These observations em­
phasize the need for those who are
already at risk for totally refraining
from consumption of lathyrus.
A recent visit to Medak district in
Andhra Pradesh and Bidar district
in
Karnataka
revealed
that
lathyrus is cultivated all along the
banks of the river Manjira. A few
typical cases of neurolathyrism
were detected in the villages
Pulkurti and Vallur of Medak dis­
trict. This confirms the earlier
observations
that
whenever
lathyrus is cultivated and con­
sumed. cases of lathyrism do
occur.

Legislations
In 1671, Grand Duke of Wurtemberg issued an edict prohibiting the
use of lathyrus in bread. It was
prohibited in France in 1829 and in
Algeria in 1881. In India, in May
1870, the Government prohibited
the cultivation of lathyrus in
Allahabad district, but the order
was withdrawn in August 1874.
Legal suits claiming damages for

the occurrence of crippling disease
in humans and animals due to con­
sumption of Lathyrus sativus were
settled in France, England and
India during 19th century.
The various State Governments
of the Indian Union (except the
Stale of Bihar. Madhya Pradesh,
West Bengal) are implementing the
provisions of the PFA Act pertain­
ing to prohibition of sale of
Lathyrus sativus. Such a provision
was first made by the Central
Government in 1961.
The
Nepalese Government in 1992
banned the import and export of
Lathyrus sativus ‘dal’ and flour
under
the
Import-Export
(Control) Act

The Madhya Pradesh Govern­
ment in a notification issued on
15th December, 1983, imposed a
ban on giving Lathyrus sativus Mai*
to* farm labourers in the form of
wages. The Supreme Court while
disposing a Writ Petition No.,153 of
1982 (Jyoti Prakash vs State of
Madhya Pradesh) directed the
Planning Commission to make an
investigation on the problem of
lathyrism. The report prepared at
that time agreed with the assump­
tion that regular consumption- of
lathyrus ‘dal* in whatever form
results in lathyrism and the cultiva­
tion of Lathyrus sativus be banned
and “should not be used for
consumption ”.

Risk assessment
It is now unequivocally estab­
lished that the pulse Lathyrus
sativus
contains a potent
neurotoxin capable of causing
toxicity to humans and a variety of
experimental animals. It is also
beyond any doubt that consump­
tion of the pulse in ‘comparatively
large quantities' for as short as 15
days to 1 month by human leads to
spastic paraplegia. Active sur­
veillance of the disease to detect
cases of either subclinical/latent or
active stage of neurolathyrism in

Swasth Hind

most of the states in India is not
being pursued since it is yet to be
classified as a. reportable disease.
Data generated from such an active
surveillance coupled with data on
intake of Lathyrus sativus are essen­
tial to arrive at appropriate conclu­
sion on the safety of Lathyrus saltvus
as is consumed by population
groups. If small amounts of
lathyrus are consumed for pro­
longed periods by humans would it
pose any risk to human health ?
What is the safe level of BOAA in
Lathyrus which will not cause toxic
effect with either prolonged con­
sumption or with higher consump­
tion level for over a short period ?
To what extent differences in the
methods of cooking modify the
seed toxicity of Lathyrus sativus ?

Epidemiological
evidences
hitherto gathered, specially during
outbreaks that have occurred m the
past, do not throw much light bn
these aspects: On the other, hand,
we do not have unequivocal
evidences either in experimental
animals or humans to indicate that

consumption of ‘small quantities’
of lathyrus (as dal) is safe and
would not result in any neurologi­
cal damage.
Even after considering the
soicio-economic compulsions, it
would be reasonable to suggest the
continuation of the ban on sale of
lathyrus
for
the
following
reasons?
(1) It would be feasible to
cultivate alternative crops such as
bcngal gram and lentils in areas
endemic to lathyrism.
(2) Efforts are underway to
evolve varieties of lathyrus low in
toxin content. Such a variety
could be popularized for culti­
vation.

(3) The price of the lathyrus
often fluctuates according to the
price of the other puises, and if the
ban . on sale is lifted, the price of
lathyrus is bound to increase.
(4) In the Medak district of
Andhra Pradesh and Bidar district
of Karnataka, as a consequence to
the ban on the sale of Lathyrus

sativus, the culliation of this pulse
on the banks of river Manjira has
reduced, consumption by humans
has decreased, and frank cases of
lathyrism minimised.
(5) There is an isolated report of
a child in the district of Bilaspur,
developing lathyrism during early
1990s as a result of eating lathyrus
as ‘dal’.

(6) It would not be possible to
suggest logistic mechanisms to
ensure consumption of only detox­
ified ‘dal’ or only in small quan­
tities exclusively for the prepara­
tion of ‘dal’.

Conclusion
Since it is now well established
that BOAA is a powerful neurotoxi­
cant and exicitotoxin, it would be
undesirable to expose population
groups to this toxin even at very low
concentrations. Under'these cir­
cumstances, it is suggested that the
provisions of PFA Act pertaining to
Lathyrus sativus should be fully
implemented in all the states of the
.Indian Union.
—Nutrition News,
April 1993

Success for Ovarian Cancer Screening
A new method of screening women for ovarian cancer is claimed to be able to
detect the disease some 18 months before the symptoms show.
Until 10 years ago’, screening was ineffective but it has since been found
that over 80 per cent,of women with clinically‘diagnosed ovarian cancer have
increased'levels of what is known as the CA125.tumour marker substance in their
blood. And .ultrasound, has been successfully used; to measure;.the. size of
the ovaries.
-h’-y
Now, an investigation of these two developments by Dr lah Jacobs, a
gynaecologist at Adenbrooke’s Hospital in Cambridge, eastern England, has
concluded that a combination of CA 125 and ultrasound has produced a useful
two-stage method of screening.
To date, 22,000 volunteers, all over 45 and post-menopausal, have been
screened in this way. Of these, 340 had raised levels of CA 125 and 41 of them
had an abnormal ultrasound scan. When operated on, 11 of the 41 were found to
have ovarian cancer while most of the remainder had benign disorders or can­
cers of other organs.
Dr Jacobs and other researchers in Britain and the US are now working to
develop new tumour makers that can increase the sensitivity of the present test
■from 50 per cent to nearer 80 per cent.
—Medical News from Britain

JULY 1993

185

HE Vice-President, Shri K.R.
Narayanan, gave away awards
to individuals and institutions in
recognition of their work on popu­
lation control at a brief function
held on 26th March 1993 at Hotel
Ashok, New Delhi.

T

Of the 14 entries selected for the
awards for promotion of family
welfare for 1992, eight were bagged
by the electronic media, three by
the organised sector and three by
voluntary
organisations. The
awards have been instituted by the
Department of Family Welfare to
give an impetus and bring forward
the best promotive work in popu­
lation ‘control.
Addressing the gathering Shri
Narayanan said the population
problem was progressively becom­
ing uncontrollable and complicat­
ing every other problem faced by
mankind. “We have to resort to
scientific, technical, social and
economic methods to control the
staggering growth rate and make all
facilities available and acceptable
to the masses”, he observed.

Media and men have proved to
be the main stumbling block in
the country’s population drive,
according
to
Vice-President
ICR. Narayanan.
Psychological resistance to the
use of family planning methods*
was only from the men folks, hesaid.
He regretted that the media too
had not given adequate attention to
this crucial issue. This was clear
from the fact that there were not
enough entries from the print

186

Awards on Family
Welfare Presented
medium and the first prizes had to
be withheld in the categories of fea­
ture films, short video films, radio
jingles, radio features and songs,
since “no entry was found up to the
desired standards”.

Underlining the importance of
family planning, Shri Narayanan
said it was but appropriate that the
present generation of Indians was a
“condomed generation”. The use
of condoms was essential both for
preventing unwanted baby births
and also for fighting AIDS. The
Governments at the Centre and in
the States, the voluntary bodies and
all concerned must use condodi to
this dual purpose with success.
While the desirability of the
family planning methods was
being propagated, not enough was
being said about their accep­
tability,
the
Vice
President
noted. He pointed out that
ancient scriptures were replete with
references about various methods
used in the past to contain the baby
boom. The present population
was the proof of their not being suc­
cessful, and now it was time to
utilise technology and social and
economic measures to meet the
challenge.

Also speaking on the occasion,
the Union Health & Family
Welfare Minister, Shri B. Shankaranand, emphasised on the. need
for greater determined effort to

bring down the birth rate.
According to him, deep rooted cus­
toms, traditions and socio-cultural
beliefs were the root cause for large
family'size and increasing popula­
tion which were Creating not only
environmental hazards but eco­
logical crises as well.
Shri Shankaranand called for a
national consensus in support of
family welfare programmes with
willing participation of all sections
of the society. “Provision of con­
traceptives and other services alone
would
not
suffice. It
was
necessary to improve infonhation,
education, inter-personal com­
munication” he added.

Also present on the occa­
sion were the Deputy Minister
for Health & Family Welfare
Shri Paban Singh Ghatowar and
the Labour Minister, Shri P.A.
Sangma. Shri Sangma in his brief
address said rather than stressing
on one-child family norm, the need
was to ensure good quality of
citizenship.

The Awards and the Awardees

First prize was not given in
several categories to set a precedent
for high quality of work. Follow­
ing are the lists of prize winners in
different categories:

SWASTH HIND

RADIO Jingles (30 Seconds)

FEATURE FILMS
1st Prize:
Rs. 1 lakh

No entry was found
desired standard.

Ilnd Prize:
Rs. 50,000

Awarded to film DHURI
Producer & Director:.
MS. KUCKOO MATHUR

Synopsis:

DHURI - revolves round two charac­
ters, Bimla and Angoori. The film
portrays the problems of early
marriage, frequent births and the pop­
ulation issues illustrated by compar­
ing the life style of the two
characters.

SHORT VIDEO
mentary)

FILMS

(Half an

upto

the

No entry was found
desired standard.

Ilnd Prize:
Rs. 20,000

To be shared by:
MUNNA YA' MUNNI
By Dr. Abha Mishra and
HAATH MEIN JEEVAN BIMA
By Sh. Sardari Lal Babbar

Synopsis:

Munna Ya Munni conveys family
welfare messages with distinct appeal
as a composite piece of music.

No entry was found upto the desired
standard.

Ilnd Prize:
Rs. 50,000

Awarded to film WARIS
Producer: NANDINI TYAGI
Director: BRU BHUSAN
WARIS highlights the obsessions with
the male child preference. It revolves
around the theme that girls can also
carry the family name.

Synopsis

Awarded to DO GULAB
Producer: RAMESH G. NAWANI

The film depicts the theme that it is
futile to go on having too many
children in the vain hope of a male
issue. A limited number of children
make life happy, gender of child
not withstanding.

SPECIAL MENTION BY JURY (For short video.
films)
PRERNA

Producer: Confederation of Indian
Industry (CII).
Director: Puneeta Roy.
Synopsis:

JULY 1993

Depitcs the laudable work done by
various business houses seeking to
improve the quality of life of its
employees by emphasising small
family ^nd doing service in internalis­
ing family limitation message.

the

RADIO FEATURE (15 Minutes)
1st Prize:
Rs. 1 lakh

No entry was found
desired standard.

Ilnd Prize:
Rs. 35,000

To be shared by:
YEH. BHI KHOOB RAHI AND
JAGRITI By Shri Vinod Rawal and
Shri Kishan Bhutani

The Feature

Yeh Bhi Khoob Rahi has an absorb­
ing format with a participative poten­
tial centering round the theme of
family welfare.

The. Feature

Jagriti endeavours to bring about
awakening towards present day socio­
economic realities.

SPECIAL JURY AWARD (for short video films)

Rs. 15,000

upto

Haath Mein Jeevan Bima presents
family welfare message through the
medium of aesthetically pleasing
musical composition.

hour Docu­

1st Prize:
Rs. 1 lakh

Synopsis:

1st Prize:
Rs. 50,000

upto

the

SONGS (3 MINUTES)
1st Prize:
Rs. 60,000

No entry was found
desired standard.

Ilnd Prize:
Rs. 35,000

GORI TERA PAON BHAARI
By Rakesh Pandit

The Song:

Gori Tera Paon Bhaari—an ima­
ginatively rendered composition in
lilting tune focussing on care
during pregnancy.

SPECIAL
JURY
PRIZE

BETA HO YA BETI
(Rs. 10,000)
By Shri Satish Babbar

The Song:

Beta ho ya Beti revolves round the
theme that a daughter is as worthy as a
son through the format of a
touching melody.

upto

the

187

VOLUNTARY ORGANISATIONS

ORGANISED SECTOR

1st Prize:
Rs. 1.5 lakhs

TRI B HAWAN
DAS
FOUNDA­
TION, ANAND (GUJARAT)
For their excellent* contribution for
providing MCH and immunisation
services and for their noteworthy
initiatives in generation of awareness
on population issues including
environment
through
electronic
media
in
Kheda
district of
Gujarat. The
Foundation
con­
tributed significantly towards provid­
ing family planning services, holding
meetings/seminars/workshops
and
organising press coverages on popu­
lation issues.

1st Prize:
Rs. 1.5 lakhs

TATA IRON AND STEEL CO.
(TISCO), Jamshedpur.
For outstanding work in providing
MCH, Immunisation and family
planning services in Jamshedpur and
surrounding areas. Was instrumen­
tal in generating large scale awareness
on population issues through cam­
paigns and harnessing electronic and
print media. Their song on popula­
tion, “Aao Milker Gayen, Aage
Kadam Badhayen”, broadcast over
AIR and Doordarshan proved im­
mensely popular. “Parvati”, the
video film on the status of girl child
adds another dimension to their
initiatives.

Ilnd Prize:
Rs. 1 lakh

MAHARASHTRA
AROGYA
MANDAL, PUNE
For best contribution in providing
family
planning,
MCH
and
immunisation services. The Mandal
provided new thrusts in awareness
generation, logistics support and gain­
ing access in remote rural areas and
slums in and around Pune and in
motivational work.

Ilnd Prize:
Rs. 1 lakh

STEEL AUTHORITY OF INDIA
(SAIL), New Delhi
For doing commendable promo­
tional work in family welfare, MCH
and immunisation services through
their innovative campaign appro­
ach. Were instrumental in wide
press coverage and also organised
Essay Competitions etc. in SAIL’s
various steel plants at Bhillai, Bokaro,
Rourkela, Durgapur, Salem etc.

Hird' Prize:
Rs. 50,000

JYOTHI SANGH, AHMEDABAD
For their significant contribution in
services delivery’in family planning,
MCH and immunisation. The sangh
undertook training schemes for
motivating and energising workers,
besides themselves working in slum
areas of Ahmedabad.. .

Hird Prize
Ps. 50,000

NORTHERN COAL FIELDS LTD.
SINGRAULI (Madhya Pradesh).
For best work in providing family
planning sendees and organising
family planning camps, made com­
mendable contribution in other
spheres especially electronic and print
media and providing MCH and
immunisation sendees in Singrauli
Goal Fields.(MP).

Tokyo : World’s Largest City
Tokyo , has replaced Mexico City as the
world’s largest city, according to United
Nations estimates.

The top 10 cities are Tokyo with 25 rtiillion
population, Sao Paulo with 19.2 million. New
York with 16.2 million, Mexico City with 15.3
million, Shanghai with 14.1 million, Bombay
with 13.3 million, Los Angeles with 11.9
million, Buenos Aires with 11.8 million, Seoul
with 11.6 million and Beijing with 11.4
million. This ranking is based on estimates
and projections from the United Nations
Population Division.
188

World
Urbanization
Prospects,
1992,
published both as a wall-chart and statistical
volume, contains estimates and projections of
the urban population of each country, as well
as city data.
Readers wishing to obtain a copy of one of
these publications may write to the Sales Sec­
tion, United Nations. New York, NY 10017,
United States.
—Population Headliners,
April 1993

SWASTH HIND

Hopes for mental illness
sufferers
T least 52 million people in the
world suffer from severe men­
tal disease such as schizophrenia
or severe depression. In addition,
some 155 million are estimated to
suffer from neuroses, about 120
million from mental retardation,
and 100 million from affective dis­
orders. Epilepsy is estimated to
affect some 50 million others, and
dementias to affect about 15
million. These figures provided by
WHO (Division of Epidemiologi­
cal Surveillance and Health Situa­
tion and Trend Assessment) show
that countries are facing, an impe­
rative need to help the mentally ill
and their families, which means
providing care to at least an
estimated 300 million people.

A

New insight into mental •illness
and prospects of better treatment
are emerging from two WHO
research projects, the biggest, of
their kind ever mounted. One pro­
ject, supported by the Laureate Psy­
chiatric Research Centre in Tulsa,
Oklahoma, USA, as well as centres
in ten countries, is a study of the
long-term course and outcome of
schizophrenia. A sequel to the
WHO International Study of Schi­
zophrenia which began in 1968, it
will provide information about the
course and outcome of illness in
some 3000 people who were given
the diagnosis of schizophrenia 1525 years ago.

JULY 1993

Schizophrenic illnesses are ubi­
quitous, appearing with, similar
incidence in different cultures, and
have clinical features that are more
remarkable by their similarity
across cultures than by their dif­
ferences. They are influenced by
genetic, developmental, and envi­
ronmental factors whose exact
nature, interaction and relative
importance have yet to be iden­
tified. The existing evidence sug­
gests that treatment needs to be
directed at both the social and
biological aspects of mental illness.
Patients in developing countries
seem to have on the whole a more
favourable course and outcome
than their counterparts in the
developed world. One of the aims
of the study is to help explain the
reasons for this difference.
The second major WHO study,
which is now nearing completion,
is investigating the types and fre­
quency of psychological problems
seen in primary health care in 14'
countries. It began in 1989, and by
1992 some 25,000 patients aged 18
to 65 had been screened in general
health services to identify people
with symptoms of mental disor­
ders. The patients were classified
in different categories according to
the symptoms, ‘and, after being
interviewed and diagnosed they are

being followed up over a period of
one year. It is expected that the
results obtained in the study will
lead to action programmes for the
extension of mental health care
into general health care in several
countries, and provide the neces­
sary knowledge and helpful techni­
ques that are applicable world­
wide.
WHO’s mental health pro­
gramme includes many other
research activities and has a much
wider focus—ranging from psycho­
social aspects of health care in
general to rehabilitation of people
with chronic mental and neurologi­
cal disorders—in recognition of the
fact that mental health activities
are able to improve greatly the
health of populations. It has been
formulated through a process of
consultation within WHO, with
other United Nations bodies, with
governments, the scientific com­
munity • and
various
non­
governmental organizations.
It
relies for its implementation on a
network of collaborating centres in
more than 60 countries, expert
advisory panels, nongovernmental
organizations and various govern­
mental agencies in WHO’s Mem­
ber States.

—World Health

189

World Environment Day
Focusses on Poverty
HE relationship between po­
verty and the environment was
highlighted by the United Nations
Environ Programme (UNEP) in
connection with the observance of
the World Environment Day (5
June). The Day—celebrated inter­
nationally each year on the anni­
versary of the opening day of the
United Nations Conference on the
Human Environment which was
held in Stockholm in 1972. (See
Secretary-General’s message on
next page).

ment than the rich”. Wastefulness,
over-consumption remains the
“single most powerful threat to the
world’s environment”.

According to UNEP information
on the Day, nearly one fourth of
humanity lives in absolute poverty,
with 400 million people obtaining
only four fifth of the food they
need. Half of all people in develop­
ing countries do not have safe water
to drink and 25,000 people die from
waterborne diseases every day.

The worldwide observance of the
Day included special school pro­
grammes, public marches, com­
munity clean-up campaigns, tree
plantings, a volunteer collections of
recyclable paper, as well as other
workplace, community and politi­
cal action to promote environmen­
tal awareness.

Setting forth the rationale of the
day’s theme, UNEP Executive
Director Elizabeth’ Dowdeswell
states that “the poor use fewer
resources, create less waste and do
less harm to the global environ­

This year, the main international
celebrations were held in Beijing
where a special ceremony re­
cognized the outstanding con­
tributions of a number of indi­
viduals and organizations to the
protection of the environment

T

There is a threshold of poverty,
however, below which the poor,
too, become disproportionately
destructive, she explains. “There
comes a point when present sur­
vival means destroying resources
which could have nurtured poor for
years. The most vivid image of this
is the farmer eating his next year’s
seed grain.”

They included urban activists,
scientists, journalists, architects,
business leaders and small farmers,
who received UNEP’s Global 500
Roll of Honour award for 1993.
This year the Roll of Honour
included a new special award for
youth to be presented to nine young
people.between the ages of 6 and 2.

The UNEP encourages indivi­
duals to take part in World
Environment Day by buying
wisely, consuming less, using water
sparingly and using environment­
friendly products.

“The world has the ability to end
absolute poverty” according to Ms.
Dowdeswell. “We must find the
will and mobilize the necessary
means match our abilities or else
this poverty and degradation will
continue to affect us all.”' Not until
the poor are given the means and
opportunity to break out of the
vicious circle in which poverty
holds them, will teal development
become a possibility, she states.
It was at the Stockholm Con­
ference in 1972 that the decision,
was taken to form UNEP, to be a
catalyst for improved environmen­
tal policies throughout the inter­
national community and to coordi­
nate those policies within the
United Nations system.
World
Environment Day has been celeb­
rated in past years in all regions, of
the world, including a com­
memorative event held during the
United Nations Conference on
Environment and Development in
Rio de Janeiro last year.

—UN Newsletter

ANNOUNCEMENT
INDIAN SOCIETY OF HYPERTENSION
1.

15th Scientific Meeting of the International
Society of Hypertension, Melbourne (Australia),
March 1-9-26, 1994.

Contact: Dr. Shailendra Vajpayee, President,
Indian Society of Hypertension, Govt, Medical
College, Surat-395 001, Gujarat. Phone: Off. 46130,
(Res.) 41371, Fax : 91-261-652338.

190

2.

“HYPERTENSION AND HEART RESEARCH
IN DEVELOPING COUNTRIES” (A Satellite
symposium of ISH 1994 Melbourne Meeting)
BOMBAY, March 14-15, 1994.

Contact: Dr. K.t G. Nair, President, Organising
Committee, 206, Doctor House, Redder Road,
Bombay-400 026, Phone: 3865008, Fax: 91-22467.780.

Swasth Hind

Grim WHO
Report on
World’s Health
Tropical
diseases,
acquired
immunodeficiency
syndrome
(AIDS) and diabetes were growing
problems which left no room for
complacency, the World Health
Organisation (WHO) said in its
report on the State of the World’s.
Health for 1985 to. 1990. Cholera
had spread to the Americas for the
first time this century,- pulmonary
tuberculosis was increasing—sti­
mulated by the human immuno­
deficiency virus (HIV) — and there
were more cancer cases in the
developing world than in •deve­
loped countries.
At the same time, childhood dis­
eases such as measles and polio­
myelitis had decreased due - to
better immunization programmes,
and cardiovascular disease had
waned in developed countries
because of health education. The
overall death rate was decreasing
globally, while life expectancy was
increasing, the report said. How­
ever, gains had been Over­
shadowed
by
epidemics
of
diseases such as cancer, heart dis­
ease, stroke and diabetes in the
poorest countries. Those diseases
had previously afflicted mainly the
industrialized countries.
Meanwhile, the World Health
Assembly in Geneva had called for
an end to such harmful traditional
practices as child marriage, dietary
limitations during pregnancy and
female genital mutilation. Those
practices prejudiced the health,
development and human rights of
all members of society, it said.

JULY 1993

SECRETARY-GENERAL’S MESSAGE
ON WORLD ENVIRONMENT DAY
OLLOWING is the text of the message of Secretary-General Boutros
Boutros-Ghali, on the occasion of World Environment Day, 5
June:

F

“Last June in Rio de Janeiro, the
largest ever gathering of world
leaders explicity acknowledged
that protection of our common
environment is an urgent require­
ment, and that continued destruc­
tion of our environment* can no
longer be tolerated.
“After years of environmental
neglect, the crisis facing us has now
been recognized. There is a new
awareness of the peril in which we
have already placed ourselves, and
of the danger, towards which we are
rapidly heading. If we are to suc­
ceed in preserving a viable planet
for
future
generations,
co­
operation and commitment must
now characterize our efforts.

“The challenges that confront us
are increasingly being measured in
global rather than ipi. 'national
terms. Environmental destruction
or harm in one country—depletion
of the ozone layer, destruction of
the world’s forests, the spread of
dangerous toxins and conta­
minants—affects the health of the
entire planet.

“At Rio, in a consensus unique in
the history of international rela­
tions, the world’s leaders agreed on
the steps that now must be taken.

The Assembly also marked the
fifth anniversary of the WHO’s
declaration to eradicate polio­
myelitis by the year 2000. Some 81
per cent of the world’s infants were
being vaccinated against the dis­
ease, and not a single case resulting
from the wild polio virus had been

"Agenda 21’ outlines a plan and a
concrete approach to creating
environmentally sound and sus­
tainable development

“In concrete and practical terms,
sustainable development means a 1
commitment to finding and using I
resources that are renewable, and a
more careful management of those
resources that are non-renewable. It means choosing products
and .production processes that
avoid an adverse impact on the
environment It means a greater
willingness by business tq take
environmental
factors
into
account, It means respecting
biological diversity in. agriculture,
and avoiding the excessive use of
harmful, energy-intensive che­
micals.
It means eliminating
public, subsidies that encourage
the liquidation of our natural
environmental heritage. It means
addressing the acute poverty that
leads parents to wish for ever more
children as a buffer against the
insecurities of old age. It means
using preventive diplomacy to
avoid the destruction of war and
the waste engendered in the pre­
paration for war.
—UN Newsletter

detected in the western hemisphere
in the last year. However, Bangla­
desh, China, India, and Pakistan
accounted for.71 per cent of repor­
ted cases of poliomyelitis in 1991
and reporting in much of Africa
was considered unreliable.
—UN Newsletter

191

EFFECTIVE PREVENTION COULD HALVE
NEW HIV INFECTIONS
— Says World Health Organization
HE World Health Organization
(WHO) says that effective HIV
prevention in developing countries
could reduce the number of new
adult HIV infections during the rest
of this decade by 9.5 million —
halving the number of new adult
infections. This would mean over
four million fewer infections in
Africa, over four million less in
Asia and a reduction of about a
million
infections
in
Latin
America.
Speaking in Berlin at the open­
ing of the IXth International Con­
ference on AIDS, on 6 June 1993 Dr
Michael Merson, Director of the
WHO Global Programme on
AIDS, said such a reduction in new
infections could be achieved if all
developing countries implemented
a basic HIV prevention package
now:

T

“We must waste no time in scal­
ing up those interventions that
work. This means implementing,
worldwide, a prevention package
which should include the promo­
tion and distribution of condoms;
the treatment of conventional
STD’s because of. their role in
fat d-.''tnv transmission;
AID?
'■
in schools and
throug
ss media: promo­
tion-5of <
. ji use byqprostitutes
and their *•* *nts; maintenance of a
safe blc
supply and needle
exchange
grammes for injecting
drug useK But, let me emphasize
that WHO fa not advocating a stan­
dard
blueprint
for
preven­
tion. The best mix of inter­
ventions must be adapted for the
local context and adjusted to
local constraints.**
Based on an analysis of the cost
of existing programmes WHO has

192

calculated that comprehensive pre­
vention in the developing world
would cost between $ 1.5 and $2.9
billion a year (1990 US dollars).
The sum is not unreasonable: S 2.5
billion is a fraction of the cost of
Operation Desert Storm and would
hardly buy one can of Coke for
every person in the world.

Dr Merson says that an annual
S 2.5 biliion price tag for HIV pre­
vention should not be regarded as
current spending but as an invest
ment for the future:

“It is an investment on which the
returns’ would be huge. WHO
calculates that investing this
amount from now to the year 2000
would save close to 90 billion
dollars in direct and indirect costs
from AIDS by the turn of the cen­
tury. The main impact of preven­
tion will be seen later, well into the
21st century — both in financial
terms and in the incalculable yield
of diminished human suffering.”
WHO estimates conservatively
that 13 million adults and around 1
million children have been infec­
ted by.H.iy since the start of the,
pandemic--^ At 'present*. WHO
estimates that about'half of all HIV
infections sq far have occurred in
young people 15—24 years old.
This means since the start of the
pandemic at least 6 million
youngsters have been infected with
HIV through unprotected inter­
course or needle sharing. And
there is enormous potential for
further spread among youth, par­
ticularly since 800 million live in^

developing countries, where the
pandemic is expanding the
fastest
At the same time, more and more
people infected 5—10- years ago
with HIV are developing AIDS.
Since the last International Con­
ference in Amsterdam, AIDS cases
have increased by half a mil­
lion. The cumulative world total
of AIDS cases is now more than 2.5
million — 20% higher than in
1992. Today the majority of the
AIDS cases are concentrated in
Africa, Europe and the USA, where'
the pandemic is oldest Five to ten
years from now, AIDS will be
claiming far more lives in Latin
America and Asia. Faced with
such an alarming situation, it is
time to act now, says Dr Merson:

“AIDS is a grim reality, not a
myth. It’s time to do what works,
not just in pilot projects but coun­
trywide, worldwide”, says Dr Mer­
son. “To respond to AIDS in the
developed world, we must commit
ourselves to realistic prevention
programmes and a true partnership
with people living with HIV and
£jpS. Jb;9pmJ?ato’the pandemic
in ihe •develdping' World,, will take
exactly the same commitment’and
an annual investment of $ 2.5
billion. I appeal to world leaders
to help mobilize these resources —
from national budgets, non­
governmental organizations, the
private sector. We can afford
AIDS
prevention. We
cannot
afford to neglect it’’

—W.H.O.

Swasth Hind

BOOK REVIEW

SURGERY AND ANAESTHESIA
AT THE DISTRICT HOSPITAL
A series of three handbooks that can help doctors acquire
safe, standardized—and life-saving—surgical skills

General Surgery at the District
Hospital

Surgcry at ths District Hos­
pital: Obstetrics.
Gynaecology.
Orthopaedics, and Traumatology

This second handbook provides
a guide to general surgical pro­
cedures suitable for use in small
hospitals. The book describes
and illustrates standard procedures
for essential operations, including
• abscess drainage
• skin grafting
• suturing
• tracheostomy
• laparotomy
• appendicectomy
• resection- of
the
small
intestine
• colostomy
• sigmoidoscopy
• anal fissure and abscess
“....full of extremely valuable infor­
treatment
mation and advice....clear, precise, and
• herniorrhaphy
easy to read....many young doctors
• bladder catheterization
working in difficult circumstances in
• hydrocoele
the district hospitals of developing
• circumcision
countries, will
be
immensely
• vasectomy
helped....”
• intussusception.
—British Journal of Anaesthesiology
Paediatric surgery is covered in a
separate section.
“....superb....beautifully clear, con­
cise, informative and understan­
“....an invaluable practical guidefor
doctors working in remote areas....each
dable.... The author and publishers
have done the ‘Second World of
procedure is described in a clear, con­
cise and easy to follow format....ex­
Anaesthesia* a great service by produc­
ing this book.... ”
cellent
diagrams....well
worth
buying....
”
—Anaesthesia and Intensive Care 2

The final handbook covers
essential surgical procedures for
treating the major complications of
pregnancy and childbirth and for
managing
traumatic
injuries,
including fractures and bums.
Gynaecological procedures com­
monly required in small hospitals
are also covered.
The book opens with six chapters
describing essential procedures for
treating the major complications of
pregnancy and childbirth and for
preventing maternal deaths. Life­
threatening emergencies, such as
obstructed labour and ruptured
ectopic pregnancy, are covered
together with more general obstet­
ric procedures commonly needed
during or after delivery.

Anaesthesia at the District Hospital

This first handbook was produced
to assist doctors who lack formal
training in anaesthesia and yet find
themselves called upon to provide
anaesthesia, particularly in the
emergency care of the critically ill.
To this end, the book concentrates
on a selection of tried and tested
techniques, procedures, and equip­
ment capable of producing good
anaesthesia despite the .primitive
conditions often found in small
hospitals. Particular attention is
given to the use of draw-over anaes­
thesia as the technique of first
choice for inducing general anaes­
thesia in small hospitals.

1988, 143 pages (English
French)

and

Sw.fr. 20-/US $ 18.00
In developing countries: Sw.fr. 14.-.

—British Journal of Clinical Practice

Gynaecological operations form
the focus of four chapters, which
describe general gynaecological
procedures, techniques for female
sterilization and IUD insertion,
and procedures for obtaining
biopsy or cytological samples from
the endometrium, cervix, and
vulva. The remaining 14 chapters
describe essential techniques in
•orthopaedics and traumatology.
1991, 207 pages (English; French
in prepartion)

1988, 230 pages (English and
French)
Sw.fr. 30.-/US $ 27.00
In developing countries: Sw. fr. 21.-

Sw. fr. 25./US S 22.50
In developing countries: Sw.fr.
17.50

Authors of the Month
Dr Badri N. Saxena
Sr. Dy. Director General
Dr R. N. Gupta
Asstt. Director General

and
Dr (Smt) Kuhu Maitra
Sr. Research Officer
Indian Council of Medical Research
Ring Road, Ansari Nagar
NEW DELHI-110 029

Dr A. K. Govila
Dean

and

Dr A. R. Chaurasia
Research Officer
G. R. Medical College
GWALIOR (M.P.)
Dr L. Ramachandran
“SHOBANA”
Sri Ramar Colony
DINDIGU1.-624 009
(Tamil Nadu)

Dr R. N. Basu
A-73 Yojana Vihar
DELHI-110 092
Dr Dharam Paul
Sr Specialist & Head
ENT Department
ESI Hospital
NEW DELHI-110 015
Ramesh V. Bhat
and
M. Kaladbar
C/o National Institute of-Nutrition
Tam aka. Hyderabad, 500 007

ISSUED BY THE CENTRAL HEALTH EDUCATION BUREAU (DIRECTORATE GENERAL OF HEALTH SERVICES). KOTLA MARG
NEW DELHI-110 002 AND PRINTED BY THE MANAGER, GOVERNMENT OF INDIA PRESS. COIMBATORE641 019.

SWASTH HIND
Media
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