MEDICAL SERVICE VOL. 40 No. 3 MARCH-1983
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- Title
- MEDICAL SERVICE VOL. 40 No. 3 MARCH-1983
- extracted text
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sfS
councils for health promotion * natural family planning in developing
countries with special reference to india • radioimmunoassay • leprosy—a
—a
physical disease
isease with a mental problem • medical ethics forum—31 • chai
news and notes
40
no 3
march 1983
medical
service
official house journal
of the catholic
hospital association of India
"the love of christ
urges us" 2 cor 5 : 14
vol 40
no 3
editorial board
dr c m francis
dr ravi narayan
dr prem chandran john
dr daleep mukarji
mr augustin veliyath
fr george lobo sj
march 1983
contents
1
editorial
1
2
councils for health promotion
dr c m francis
5
natural family planning in developing countries
with special reference to india
dr m m mascarenhas
9
radioimmunoassay
dr ramdas shrirang raikar
17
leprosy—a physical disease with a mental
problem
bro paul
22
medical ethics forum—31
fr george lobo sj
25
extract from a who technical report on
chemotherapy of leprosy for control programmes
29
chai news and notes
32
3
editor
fr john vattamattom svd
4
5
cover design
6
p m isaac bangalore
7
8
published by the catholic
hospital association of India
c b c i centre, goldakkhana
new delhi-110001
printed at kalpana printing
house new delhi-110016
"Articles and statements published in this journal
do not necessarily reflect the policies and views of
the catholic hospital association of india"
EDITORIAL
How healthy our health services 1
In this issue, through an article : "Councils for Health Promotion",
Dr. C.M. Francis raised a number of issues regarding the promotion of a
He speaks the part today's life-style has to play in
healthy health service.
determining the health of the people.
He identifies five requirements for
health living, i.e. good nutrition and dieting habits; healthy environment;
[
avoidance of smoking and alcohol; good drinking water-supply and sanitation; and prevention of accidents. In order to bring about this he speaks of
establishing health promotion councils at various levels, by which the people
need to be made aware of various measures to improve health.
He ends
his article with a question, in the form of a challenge for us : "Will Catholic
Hospital Association of India give the lead in establishing the Health promo
tion Council ?"
It is here we need to have a hard look at our health services and see if
they really promote health or only to a great extent keep up a certain system
of practice in delivering cure for the diseases and that too, in many cases, to
those who come to our health care institutions.
follow the easy course.
It is a human tendency to
We all like to follow the beaten track.
But we are
told in no uncertain terms about the need for leaving the beaten track and
following a new track.
I am referring here particularly to two documents,
namely the new National Health Policy and the document by the Pontifical
Council Cor Unum :
The New Orientation of Health Services with respect
to Primary Health Care work.
Copies of the new National Health Policy
was made available to all concerned together with the December '82 issue
I
of our journal 'Medical Service' with a request to study it and see how we
can implement it through our existing health care institutions. I had also
made reference to the document by Pontifical Coucil Cor Unum.
Together with this issue of Medical Service we are making arrange
ments to send to you all, copies of the Cor Unum document again with
the same request to all concerned to study these two documents carefully
and in the light of these two documents to frame policies and guide our
actions in the field of health.
The study of these two documents will show what exactly should be
our attitude, policies, priorities etc. in the field of health.
For us the docu
ment by Cor Unum is an additional mandate.
Speaking about the need
for conversion of our hearts and also methods the document continues :
"The rapid development in the field of health service technology has often
meant installing expensive equipments in the hospitals, requiring a large
number of patients, while in many of the same countries in the world, up
to 80% of the population are still with out health care services.
Since
Christians are the learner, we must reach out towards the masses by
providing simple, accessible and promotional health care according to our
own possibilities, modest as they are, or in conjunction with the public
services, where this is allowed.
Let us ever be mindful of the fact that
service to the sick begins and continues to operate through the patient's
human environment.
Community Health Care is therefore part of the
comprehensive pastoral work of the Church".
The document goes on, then with the various aspects of primary health
care and Community Health.
Responsibilities in this field.
The last section speaks about Christians'
Much is also said about the responsibilities of
religious congregations in this field.
The need for having a healthy
relationship with the governments and for cooperating with them and others
who are concerned with peoples' development, is pointed out in the
document.
Now a few questions remain to be answered.
What are we going to
do with such documents and the messages in them ? What are our
priorities going to be ? What is going to be our approach ? The answers
will depend very much how convinced all of us are of the contents in these
documents and how willing we all are to leave the beaten track and take up
a new track which would involve struggles, difficulties and risks.
But we
have no other choice except taking up this challenge, if we are serious in
serving the poor as Christ did.
The question Dr. C M Francis posed and the
challenge he has put forward are worth considering.
Then let us all put our
heads together, plan together and do something to meet this challenge
before it is too late and make our own health care services more healthy.
Councils for Health Promotion
Dr. C.M. Francis
It is easy to follow the beaten track; this
is what the cattle do. Is it not the same
that we in the less affluent countries do with
respect to health (and mnay other activities)?
We pass through the same curative and
preventive path, followed earlier by the more
affluent countries, using their outmoded
technologies, importing equipments which
are about to be discarded by those countries
and whith are totally unsuited to meet our
heaith needs. An editorial in the Lancet of
January 1/8, 1983 says: "the unjust
distribution of health care among the world's
peoples is a continuing disgrace." It will
be good if the countries will share some of
their resources, but our experience so far
has been that this is unlikely to happen.
But if our target is Health and not merely
health care services, we need not wait for
the affluent countries to dole out some of
their surplus. We must cut across the
circuitous path and have innovative pro
grammes which will yield better health;
the knowledge for the same is already
available.
It is well known today that life-styles
determine to a large extent whether people
are healthy or become sick, needing costly
repairs and patchwork. Improvements in
health-giving life-styles are not costly and
such measures can help to reduce the health
gap between different classes of social and
different parts of the country.
Among the more important requirements
for healthy living are
(1)
good nutrition and dietary habits;
(2)
healthy environment;
March 1983
(3)
avoidance of smoking and alcohol;
(4)
good drinking
sanitation;
(5)
prevention of accidents.
water
supply
and
People who have been fed for a long
time by propaganda and news of cures by
medical and surgical procedures, have to be
convinced that better health can be achieved
by simple change in life style. Very often
the adverse life styles are brought about by
propaganda by vested interests. Such pro
paganda must be countered by positive
propaganda — we have to sell health. Those
interested in health of the people must make
full use of all methods and media to pro
pagate the fact that by taking a little more
care of their life-styles, they can have a
healthy life and avoid many of the diseases.
The media must be courted, news must be
created and views must be ventilated; we
have to work with the people, the health
professionals, legislators, politicians and the
leaders. We have to forge strong links with
various bodies — clubs, associations, schools
and other educational institutions, industries
and trade unions. All of them must be
informed, convinced and persuaded not only
to follow but also propagate healthy life
styles.
Newspapers, magazines, cinema,
radio, television and all other media must be
made use of in this campaign.
That propaganda, if sustained, can achieve
a lot without too much money and materials,
is shown by the successful compaign against
smoking in many of the more affluent
countries, where
cigarette consumption
(which can lead to cancer and cardiovas
5
cular diseases) is declining. Propaganda
has led to enactment of legislation to control
smoking — restricting advertisements, pro
hibiting smoking in public places like schools
and other places where young people
gather and protecting the rights of the nonsmoker. Efforts are being made to make
smoking socially unacceptable, countering
the advertisements of the mighty tobacco
firms to make smoking fashionable. Seven
years of antismoking measures in France have
produced very good results with millions
giving up smoking and youngsters not
taking up smoking, thus reaping the benefits
of freedom from many crippling and killing
diseases.
Alcohol also poses health problems; these
problems are to the drinker, his family and
the community. Both acute episodes of heavy
drinking and prolonged drinking are injurious
to health. They can lead to increased risk
of cirrhosis of liver, cardiovascular disorders,
aggravation of other physical disorders,
malnutrition, aggressiveness, accidents and
suicides.
A change in life style, with
abstention from alcohol or reduction in con
sumption, can bring about better health and
reduction in illness.
With money saved from abstention from
or reduction in drinking and smoking, the
poorer people will be in a position to buy
more and better food. This will reduce
malnutrition. Considerable extent of fertile
land is now being used for tobacco cultiva
tion. With global and national reduction
in tobacco consumption, the land could be
better used for growing food grains and oil
seeds, reducing the scarcity in food. With
greater availability and better distribution of
food, it should be possible to improve the
nutrition of the people. Even where more
food is available, it is necessary to be
knowledgeable about nutrition and cultivate
proper dietary habits so that the caloric.
6
protein, vitamin and other requirements of
the body may be met optimally. There is
need to know how to prepare the food
properly so that wastage is avoided and
the wholesomeness of the food is retained.
Water is scarce, but intelligent use of
available water will be beneficial.
Many
arid regions are making the available water
serve more and better purposes. At *the
same time, it is also necessary to explore
sufficiently in advance the possibilities of
making more water available to the people.
A little care can go a long way to make
water more safe for drinking.
It is not
enough to make more water available for
drinking and other purposes; disposal of
water is equally important. More -attention
to such disposal can reduce water-borne and
water-related diseases.
If people are conscious of their civic and
social responsibilities and conduct them
selves in such a way as to be responsible
citizens, much of the environmental degrada
tion can be reduced.
Improvement can
occur by individual and collective efforts, by
Governmental and voluntary activities, by
legislation and monitoring.
Accidents are on the increase, at home
in factories and on the roads. Greater
attention must be paid to the prevention of
accidents.
Many of them are caused by
human errors and can be prevented if the
instructions and rules are followed.
If people are to be made aware of these
measures to improve health and persuaded
to adopt them, it is necessary to make a
concerted effort. This can be done through
Health Promotion Councils.
Such Health
Promotion Councils need not cost a lot of
money, but they certainly require people who
have
a vision
and prepared to take
innovative steps.
There can be Health
Promotion Councils at each hospital or
Medical Service
health care institution, at the regional level
and an apex body at the centre. The activ
ities at each level will vary. The health care
institution can effectively participate in
health education. It is local and can relate
well to the people. The regional level
council can co-ordinate the activities of the
institutions and also provide health education
to people who do not have access to the
health care institution. They can also
mobilise public opinion. The apex body at
the centre should provide the guidance and
help to the smaller regional and local coun
cils. They should be able to get the co
operation of the media and the legislatures,
both State and Centre. It should have the
mechanism to collect information and data
from various sources and to disseminate
them to the appropriate bodies for action for
Better Health. Will Catholic Hospital As
sociation give the lead in establishing the
Health Promotion Council ?
40th National Hospital Convention
and Exhibition
Respect Life
Theme
Venue
Dates
:
St. Pius X College, Goregaon East
Bombay-400063
November 2-5, 1983
Await Details in Next Issue
March 1983
7
Natural Family Planning in Developing Countrieswith Special Reference to India
Dr. M.M. Mascarenhas
"Staying Close to Nature to Nurture our Families is our Life's Aim"
Introduction
To develop is to form into something
whole, mature and fulfilling. The people of
the developing countries were naturally
evolving and growing to a desirable adul
thood, when the technological thrust of the
overdeveloped countries was forced on
them, often we must admit with the con
trivance of its own people.
William Dyson speaking in Bangalore
recently at the Asian Conference on the Total
Health of the Family said — "The Industria
lised nations do not have the answer. We,
who come from the Western European
nations are held up as peoples who have
found the path, the one and only path, to
follow towards development. We alone, so
many believe, have the response to the
question about what is the best way to
enable us all to live well upon this planet.
I come to say to you that this is a myth. We
do not have the answer. Possibly from the
approaches to life of both your people and
mine taken together, something much better,
much more appropriate, may be found — so
that tomorrow all your children and all our
children might together share life better and
more fully."
Dyson continues to say "that the words
'developed* and 'developing' as applied to
nations today are narrow and inappropriate.
They claim too much.
Different people
have taken different roads as their cultures
have matured. One is more developed in
March 1983
one way. At best, we of the Western
nations are adolescents on the historical
scene when it comes to human wisdom.
Western health and medicine are schizo
phrenic. They speak of an aim for man's
best, yet functionally they delve into his
worst. Their primary orientation as sciences
and as practices is toward human path
ology — sickness, to failure, to human
distortion.
Our understandings and approaches to
health are out of balance and have become
distorted, that we are crippled when we
are called upon to contribute positively and
well to our own lives.
Man becomes simply matter, and is
viewed as functionally malleable.
Human
diversity and richness - personally, familially
and culturally wanes. Creativity and the
immense range of the human faculties and
spirit are more and more narrowly valued,
and focussed.
Human love, not perceived as functional
and relevant, is now downgraded leaving a
vacuum:
As persons and peoples are
devalued more and more, the road to mani
pulation has been thrown over more widely
open'*.
Dr. Dyson's remarks are remarkably
relevant to the field of contraceptive
technology.
9
Dr. Vai Beral, a colleague of mine, in a
paper published by the British Medical
Journal (15.9.82) concludes :
"The transfer from traditional to modern
methods of contraception in recent decades
has been accompanied by a transfer of deaths
from complications of pregnancy (which
modern advances in obstetrics and science
have almost totally eradicated) to deaths
from complications of the modern contracep
tive methods. In 1975, for example, it is
estimated that there were more deaths at
ages 25-44 years in England and Wales
from adverse effects of oral contraceptive
use than from all complications of pre
gnancy, delivery and the
puerperium
combined."
She noted that the excess mortality from
circulatory disease in women taking the pill
was a direct effect of the pill.
The International Family Planning Per
spectives on a ten country's study (Vol. 7
No. 3 Sept. 1981) "found that although
many cultures impose behavioural sanctions
on menstruating women, a substantial
majority of women would reject a contracetive method that induced amenorrhoea.
For whatever, their perceptions of the
drawbacks of menstruation, most women
consider it a natural, vital physiological
occurrence indicative of good health, and a
sign of continuing youth, fertility and
feminity".
menstruation and contraceptive use, and
to determine the limits of disturbance or
change in the cycle that users of contracep
tive methods will tolerate.
When one considers that in those
developing countries, whose women con
stituted the subjects in the above study,
anaemia and malnutrition are so widely
prevalent, one can see the reasons why the
U.D. and hormonal medications not only
I.
failed to find acceptance, but also led to a
higher mortality and morbidity.
Approximately 50% of all eligible women
would accept natural methods for spacing
and even limitation, as shown in both the
pioneer research studies in India, namely the
W.H.O. Multicentre Trial of the Ovulation
Method (O.M.) and the Karnataka State
Fertility Research Study.
India, in common with other developing
countries, has about 80% of its population
in rural areas. However, only 20% of the
total number of doctors practise in these
rural areas, while 80% prefer the cities.
Hence, adding to the cultural resistance to
artificial methods is the medical drawback
making the IUD and pill which need
medical supervision, unsuitable for the
majority of our population.
These observations made in a study of
the cultural constraints and attitudes with
regard to menstruation involved 5.322
parous women from 14 cultural groups in
ten nations. The study was funded by the
World Health Organisation's Special Pro
gramme in Research Development in Human
Reproduction.
'‘We may well ask ourselves the question
whether in a country like India, which has
only 23°/q of the couples of childbearing
age practising family planning and where
there are 90 million couples between 15
and 24 not using any method for any signi
ficant time, and amongst whom unfortuna
tely breastfeeding in also decreasing, we
can afford not to advocate and make
accessible on a wide scale an effective, safe
and acceptable natural method".
The purpose of the study was to develop
an understanding of the relationship between
Nearly 50 years ago Mahatma Gandhi
said "In this world there is enough for every
10
Medical Service
man's need, but not for every man's greed —
and again 'Birth control is self-control'. Non
violence and Love were his bywords to our
people.
Again we see that in spite of incentives
and free services a recent house to house
survey revealed that only 24% of the target
couples were covered by sterilisation".
{Medical Times Bombay — Nov. 1982.)
In Puerto Rico it was shown that suffici
ent data existed to demonstrate a definite
and alarming relationship betw'een contra
ception and neurosis which showed a great
increase.
(Foster J.M. Paper 'Some Psy
chological Aspects of F.P.').
The Indian Council of Medical Research
(Bulletin Dec. 1982) admitted that we have
to accept that at the moment there is no ideal
contraceptive free from side effects and
complications suitable for use in all women.'
Family Planning is meant to help families,
and to help or deepen the relationship
between husband and wife. Only Natural
Family Planning can meet this challenge, for
by its very nature it opens the lines of
communications and makes marriage a living
and loving partnership. Marriage Counsellors
need to realise this fact, and use Natural
Family Planning (NFP) as a therapeutic tool
in pathological marriages. Natural Family
Planning meets the challenge of a human
problem with a human solution, whereas
technology dehumanises the partnership.
In developing countries spacing is much
more important and contributes more
significantly to regulating births than
sterilization.
"This is because marriages
take place earlier and women under 30
account for the majority of births'*. (Centre
Calling Sept. 1981 New Delhi).
March 1983
W.H.O. Study
Research findings of the WHO Study in
India, the Phillipines and El Salvador showed
many common features shared by these three
developing countries which the family plann
ing policy makers could note. The two
developed countries were Ireland and New
Zealand.
The WHO Study included over 10,000
cycles in the most significant cross cultural
study ever undertaken in the world. The
Karnataka Study (K.S.) included over
50,000 cycles in a widely spread popula
tion typical of Indian conditions.
The following abservations were made
at the conclusion of the WHO study and
these conclusions were again amply con
firmed by the Karnataka State Study.
1.
2.
Prime Motivation: In Bangalore
the reasons given for freely choosing
the Ovulation Method were equally
divided between.
a.
Dissatisfaction
with
other
methods, either after their use
or by hearsay.
b.
Natural was good and harmless.
c.
Religious reasons given equally
by Hindus, Protestants, Muslims
and some Catholics.
Teaching : by simple women called
BAREFOOT TEACHERS led to the
best results. The only taught who
had to be withdrawn from the WHO
study was a married nurse. Some
times older and mature women make
excellent teachers.
This is teaching using simple analogies to
everyday life, e.g. a seed in the soil requires
moisture to grow into a plant. Similarly a
male egg or sperm needs the moisture and
11
nourishment of the woman’s mucus to join
the ovum and grow into a bady, or again the
example of artificial insemination when the
farmer sees the mucus at the cow's vulva
as the right time for insemination.
3.
4.
Rural and urban couples : Generally
speaking the slum or rural women had
a better acceptance, as also illiterate,
and semi—literate or less educated
women. The rural people who prefer
'natural' things, accept abstinence
more easily. In the three developing
countries the majority of couples
were from rural areas. Most of the
families lived in 'single-room dwell
ings in poverty".
Education : This made no difference.
On the contrary a quicker acceptance
by illiterates made true our motto that
FERTILITY KNOWLEDGE IS FERTI
LITY CONTROL.
For community
health workers, the concept of a "self
energised"
independent
couple
makes NFP a desirable practice. In
the WHO Study, 94% of illiterate
subjects produced an interpretable
pattern, 95% of those who had less
than 6 years of schooling and 83%
of those with a university education.
Results of the teaching phase (3
cycles) showed that ONE TEACHING
CYCLE would have been sufficient.
The illiterate women are often most
intelligent. Once given the knowledge of
their bodies they treasure this new awareness
of their fertility.
5.
Religion : In the WHO Study (268
couples) 33% were Hindus, 12%
Muslims, and Protestants, Catholics
were 36%.
The WHO Study concluded that the
profile of a successful user couple was a
'Hindu couple with three children with the
12
wife having less than 6 years of schooling
and who used the O.M. for limitation.'
In most developing countries Natural
Family Planning (NFP) has been accepted
for reasons other than religion.
The following was a documented state
ment by WHO :
IT IS OF INTEREST TO NOTE THAT THE
STUDY BEGAN AT A TIME
WHEN
LEGISLATION REGARDING COMPULSORY
STERILISATION WAS BEING ADOPTED
IN INDIA.
SOME OF THE SIGNIFICANT FEATURES
OF THE WHO STUDY :
6.
In the developing countries (India,
the Phillipines and El Salvador) the
DAYS OF BLEEDING OR MENSTRUA
TION AVERAGED 4.4 PER CYCLE,
while they averaged 5.6 per cycle in
the developed countries.
Hence women with leucorrhoea or vaginal
and cervical discharges.
7.
Vaginal Discharges .* It was note
worthy that history of, or findings of
cervical and vaginal infections did
not influence the women's ability to
learn symptom recognition. In the
WHO Study 15% of subjects gave
the history of pathological vaginal
discharge.
Hence women with leucorrhoea of
vaginal and cervical discharges could dist
inguish cervical mucus. This is an import
ant finding, since leucorrhoea is present
in approximately one-third of women in
developing countries.
8.
Attitudes of Husbands : 80% of the
husbands in the first cycle were
described as willing to co-operate
in the practice of abstaining.
Medical Service
In 10% partners were ALWAYS involved
in their wives charging, in 3% he was
indifferent.
so much better now, and we have greater
satisfaction".
11.
In 2 % he was described as un-coopera*
tive.
A further 28% were occasionally involved.
9.
Libido or sexual urge : A frequently
asked question is 'when does my wife
experience more libido T is it during
the fertile period ?"
More than 60% of women who freely
answered the question on timing of Libido,
said they experienced the urge just before
(pre menstrual) or after menstruation (post
menstrual).
These two periods correspond to the
infertile periods. 14% women experienced
libido during the fertile period. Often these
wives have a communication problem with
their husbands and need counselling.
10.
Coitol frequence of couples using
the O.M.: The most common fre
quencies as given in Bangalore, was
twice weekly, 55% of the responding
subjects said they were satisfied with
this frequency, while 16% would
have preferred a higher frequency.
It is interesting to note that there
was no decrease in coital frequency
AFTER the couple started using this
natural method requiring abstinence.
In fact there was a marginal increase
once the couples were well esta
blished (1.7 to 1.9 coital episodes
per week).
This fact together with the findings on
Libido were used to motivate reluctant husb
ands in the learning or transition period.
As one formerly reluctant husband remarked
after the first 3 months "I do not mind the
abstinence now, because my wife -responds
March 1983
The fertile phase : (Days of sticky
and slippery mucus 4* 3) averaged 8
days in the developing countries
while they averaged 10.6 days in the
developed countries.
The probability of pregnancy on days of
sticky mucus was 0.024 — 0.0500. (WHO
Study). 'In 96% of the cycles in the overall
study no friction in the couples was caused
due to abstinence in the fertile phase.'
12.
The average duration of mucus:
before the peak day was about 6
days giving adequate warning —
only 2% if the case of OM users
had one day of mucus before the
peak day, 7% had 2 days and 10%
had 3 days.
13.
In both studies the CONTINUATION
RATES WERE HIGH.
In
India
these continuatic rates were higher
than for any other method of spacing,
and were in the region of about
70%.
14.
Spacing and limitation: In both
(WHO and K.S.) Studies the majority
of couples used the method of
limitation. In the K.S. only 39.2%
used the O.M. for spacing whereas
60.8% used O.M.Iimitation.
Also in the WHO Study, "The desire for
more children did discriminate some degree
between the groups, as 51 % of those
becoming pregnant had expressed the wish
for more children, compared with 37% of
those who continued to the end of the study.
15.
The effectiveness was significantly
high in all three developing countries
(Both WHO
99%
and
89%
K.S. Effectiveness).
13
16.
It was interesting to note that many
of the couples had previously used
the rhythm method with arbitrary
variations of so called 'safe and
unsafe' days, e.g. one practised
abstinence for the first 20 days of
the cycle.
Another couple had
intercourse till the 8th day and then
abstained till 15th day, and then
recommenced coitus. Such couples
were explained in a scientific method
that of determining fertile and infer
tile days and thus got many more
days for intercourse.
Twenty-two percent of couples overall
fell into this category.
Conclusion : From the above data we
can conclude that as in the W.H.O. recom
mendation and I quote "That the O.M. is a
method worthy of more extensive trial to
determine its general applicability in India,
the Phillipines, and in San Miguel. Although
the pregnancy rate in San Miguel is relatively
high, it must be recalled that the majority of
couples in that centre had never used fertility
regulating methods previously, and would
have an anticipated pregnancy rate of 90%
or more rather than the 38% actually
observed.
March 1983
Widespread use of the O.M. in these
circumstances, if it gave rise to results similar
to those reported here, would be of sub
stantial value in reducing the overall birth
rate".
Though I have emphasised the immense
suitability of NFP for use in the developing
countries, it is by no means intended or
implied that it is unsuitable for use in the
developed countries. Not only are couples
in these countries looking for an alternative
to the methods available, but increasingly
they seek the right to control fertility by an
understanding of their own bodies and they
need to live in harmony with their partners
in an ecology free from artifice.
To the world in general is presented a
safe, inexpensive, highly effective and cultur
ally acceptable method of fertility control,
where the couple knowingly and independ
ently learn to use their sexuality as a
partnership to achieve marital satisfaction
and responsible parenthood in a mutually
fulfilling relationship.
(Those who wish to get further details,
references, information, etc., may contact:
Dr. M.M. Mascarenhas, Director, CREST,
14 High Street, Bangalore-560005 —Editor).
15
Radioimmunoassay
Dr. Ramdas Shrirang Raikar, Ph.D.
The advent of radioisotopes in the field of
diagnostic medicine marks an important mile
stone in medical history. In recent years,
radioisotope techniques have come to be used
in medicine for a wide variety of important
diagnostic procedures. These techniques
enable accurate and ready evaluation of a
variety of physiological parameters such as
functioning of important organ systems of
the body, including thyroid, liver, pancreas,
heart and kidney and metabolism of vita
mins, proteins, carbohydrates, fats, etc., in
health and disease.
The majority of these radioisotope proce
dures essentially involve administration of a
'tracer dose' of the radioisotope, either
orally or by injection to the patient. The
uptake, retention and clearance of the
radioisotope by and from the organ is deter
mined by external measurement of the
radiations from the isotope. Another intere
sting application, known as isotope scinti
graphy, enables visualization of the size and
shape of these organs and delineation of
structural lesions in them.
A major breakthrough in recent years in
the application of radiotracers in medical
diagnosis has been the development of a
wide spectrum in-vitro radioassay techniques.
The specific advantage of these techniques is
that they do not involve administration of
radioisotopes to the patient. The concentra
tion of important biologically active ingredi
ents in body fluids can be estimated by
these assays.
Among the in-vitro applications of radio
isotopes, radioimmunoassays have already
been established as versatile and unique for
March 1983
a variety of diagnostic procedures. These
assays are employed for clinical evaluation of
the concentration levels of vitally important
biological ingredients such as hormones,
vitamins, steroids, drugs and exogenous
antigens, thereby enabling early diagnosis of
various diseases and better management of
treatment.
Dr. Rosalyn Yalon along with Dr. Solomon
A. Berson—both sharing the Nobel Prize
for Medicine in 1977—discovered the tech
nique of Radioimmunoassay and nurtured
it through the early years with hard and
meticulous work to establish its usefulness
in medical science.
Techniques for the measurement of the
physiological concentrations of many bio
logically active and important substances
require the accurate and precise quantitation
of picomole (10~12 mole) or even famto
mole (10”l5mole) amounts of these com
pounds in biological fluids. Measurements
of such low concentrations of a * compound
is usually most satisfactorily accomplished
by the use of a compound in a radioactively
labelled form together with a specific
binding reagent in a saturation analysis
system such as radioimmunoassay.
Principle of Radioimmunoassay
Competition between a labelled and an
unlabelled (standard/sample) antigen for a
limited amount of antibody forms a basis of
radioimmunoassay. In radioimmunoassay, a
fixed concentration of labelled tracer antigen
is incubated with a constant dilution of
antiserum such that the concentration of
antigen binding sites on the antibody is
17
limiting—for example, only 50% of the
total tracer concentration may be bound by
antibody. If unlabelled antigen is added to
this system, there is competition between
labelled tracer and unlabelled antigen for
the limited and constant number of binding
sites on the antibody and thus the binding
of the labelled antigen to the antibody is
progressively inhibited with increasing con
centrations of unlabelled antigen present in
the incubation mixture either as a standard
or the unknown plasma sample. A calibra
tion or standard curve is set up with increas
ing concentrations of standard unlabelled
antigen and from this curve the amount of
antigen in unknown samples can be calcula
ted.
Ag
(Labelled
antigen)
4-Ab
(Anti
body)
-> *
Ag. AB (Bound
<complex)
+
Ag (Uniabelled antigen
f standard or unknown)
I
Ag. Ab (Bound complex)
There are several major assumptions in
application of the above principle.
They are: a) Physico-chemical properties
of the labelled and un
labelled antigens are identi
cal.
b) Behaviour of the standard
antigen and the antigen to
be measured in an unknown
sample is similar in respect
of displacing the radio
labelled antigen from antigen-antibody complex accor
ding to the law of mass
action.
c) Antibodies against the speci
fic antigen to be homo
genous.
18
The three basic necessities for a radio
immunoassay system are an antiserum to the
compound to be measured, the availability of
a radio-actively labelled form of the com
pound and a method whereby antibody
bound tracer can be separated from unbound
tracer.
The two main advantages of radio
immunoassays are their sensitivity and speci
ficity both of which depend predominantly
on the use of anti-bodies that possess a
higher selectivity for the material to be
assayed. Antibody is secured through
bleeding at set times over precise time
periods using an animal host (typically a
rabbit; guinea pig and sheep) which has
been periodically challenged with a given
antigen. There are various techniques for
the production of antisera. The specificity,
affinity and titre vary with immunization
procedure and hence each antiserum must be
tested carefully. The antiserum should be
specific and should not cross react with
related antigens/compounds. Affinity of the
antibody should be high because this deter
mines the sensitivity of the assay system and
moreover the attainment of equilibrium will
be faster (after antigen-antibody reaction).
Titre is a dilution of antiserum at which 50%
of the labelled tracer will be bound to anti
body in the absence of unlabelled antigen.
If the titre is high, one can include more
number of samples per unit volume of an
antiserum.
One of the essential reagents in this
system complex is the labelled antigen.
Antigens are most frequently labelled131!,
i26|, 3Hz HQ or 67QQ anc| protejn molecules
are usually labelled with isotopes of iodine
i. 131l or 126l. Radioiodination is nothing
e.
but the 'tagging* radioisotopes on the
tyrosine residues of protein molecule. There
must be a methodology for the preparation
of a highly purified antigen that can be
Medical Service
radiolabelled (tagged) without
any of its immunoreactivity.
sacrificing
The third essential thing is the separation
procedure of bound and free antigen which
involves various techniques suggesting that
no single procedure is completely satisfactory
for all purposes. The method should be
relatively simple to perform, economical and
reproducible. Among the methods used are
electrophoresis, chromatoelectrophoresis, ad
sorption to dextran coated charcoal, cellulose
powder, finely divided silica or talc; precipi
tation with salts or organic solvents of the
immune complex; bonding the antibody or
antigen to a solid phase absorbent which
facilitates the precipitation or separation of
bound and free fractions by centrifugation.
Another technique used is the double-antibody method, where a second antibody is
used to precipitate the primary antigen
antibody complex.
Advantages of Radioimmunoassay
1.
Simple procedure
2.
Extremely sensitive and specific
3.
Reproducible results
4.
No radiation exposure to patient
5.
Simple instrumentation and low ini
tial investment
6.
Widely applicable
Applications of Radioimmunoassay
(RIA)
The great potentialities of radioimmuno
assay procedures in medicine can be readily
appreciated from the following typical
applications:
1.
RIA of Insulin
Estimation of the levels of insulin present
in the blood serum under various condi
tions, including fasting and after-glucose
March 1983
stimulation, is of considerable importance in
the early defection and management of ;some
forms of diabetes and for detection of
certain tumors of the pancreas called in
sulinomas.
2.
Human Placental Lactogen (HPL)
RIA offers an easy and reliable method of
determining the levels of human placental
lactogen in pregnant women. Evaluation of
the concentration of this hormone enables a
clear differentiation of normal pregnancies
and abnormal/risk pregnancies.
3.
Human Chrionic Gonadotropin
(HCG)
Highly sensitive RIAsof p-HCG can detect
pregnancy even before the missed period
with a high degree of accuracy.
4.
Triiodothyronine (T3) and
Thyroxine (T4)
Very precise evaluation of thyroid hor
mones such as T3 and T4 in human serum by
RIA procedures is of great help in thyroid
function studies. Such estimations enable
clear differentiation between hypo and hyper
thyroids and normals, leading to better
planning and management of patient treat
ment. RIA offers a unique means of detec
ting neonatal hypothyroidism, thereby en
abling treatment before irreparable brain
damage sets in.
5.
Australia Antigen
Estimation of Australia Antigen at very
low concentration levels by RIA is of great
importance in screening of blood collected
by blood banks. The screening is essential
for ensuring that serum hepatitis which
causes high mortality rates, is not passed on
to the blood recipients.
6.
RIA of Drugs
Screening of the levels of Digoxin and
Digitoxin which are very useful but toxic
COW'.UNITY HEALTH CELL
326. V M«ln. I Block
caior«-660034
1g
drugs employed for treatment of heart
patients, is vitally important in monitoring
the progress of the patient and for optimisa
tion of digitalis therapy.
RIAs of Pituitary Gonadotropins and
Steroid Hormones
Rapid advances have been made during
the last two decades in the understanding of
the physiological interactions between the
brain, pituitary and the gonads. Perhaps no
other single methodology has contributed so
much to the advance of the study of repro
ductive endocrinology as has the develop
ment of the highly sensitive RIAs for all
peptide and steroid hormones.
7.
Profiles of serum levels of pituitary gona
dotropins in relation to ovarian or testicular
steroid hormones have helped in the under
standing of the feedback control mechanism
between the target gland hormones and the
pituitary and hypothalamic system. Thus it
is now possible to evaluate more definitely
the disfunction existing at each level. The
synthesis of hypothalamic hormones. Thyroid
releasing hormone (TRH), Gonadotropin
releasing hormone (Gn-RH) and their use for
diagnostic testing for pituitary has further
contributed to defining the site of the lesion.
Limitations of RIA
For a small diagnostic laboratory one
would like to have minimal necessary struc
ture which will have
1.
Counting room
2.
Storage and working room
Radioimmunoassay work involves the hand
ling and use of very small quantities of
radioisotopes usually not exceeding 1OOp-Ci
of I25l and other isotopes. The equipment
and facilities normally available in a hospital
or pathological laboratory can be readily
used for this work. In addition, a simple
electronic counter, a centrifuge and auto
matic micro-pipettes have to be procured.
The operative manipulations are simple in
volving often the employment of ready-touse RIA kits. In view of the very low
activities of the isotopes handled, hazards
due to possible radiation exposure and
personnel contamination are negligible.
In India, the Bhabha Atomic Research
Centre is working closely with medical
institutions to extend the benefits of these
advanced techniques to a large cross section
of the population. The following ready-touse RIA kits are available from the Isotope
Group, BARC.
The greatest single limitation of radio
immunoassay is that the results are not
available within a day or so. A batch of
samples is to be collected before they can be
processed and where results are required
before a clinical decision can be taken, such
waiting periods of several weeks would be
intolerable.
RIA kit for Insulin, RIA kit for Human
Placental Lactogen, RIA kit for Triiodothyro
nine and RIA kit for Thyroxine. These kits
provide isotopically labelled antigen of high
quality, standards of antigen (unlabelled) to
serve as controls, known quantities of anti
body having specificity and other reagents
required for carrying out the radioimmuno
assay.
How to start a RIA Clinic ?
This will depend upon the aims and
objectives of the set-up; whether it will be a
diagnostic aid only or it is going to be a
set-up where one would also produce anti
bodies and tagging of radioisotope, etc.
A limited radioimmunoassay service is
also offered to analyse and quantitate serum
samples supplied by user institutions. The
Isotope Group, BARC, also offers on-the-job
training in RIA to medical and paramedical
personnel.
March 1983
21
LEPROSY—a physical disease with a mental problem
Bro. PAUL
The article on Leprosy by Dr. Paul
Neelamkavil prompted me to also take up
this subject. There are a few people in India
who have travelled as extensively as the
writer and seen as many of the Catholic and
other Christian Leprosy programmes and
clinics. The range of Catholic activity in
leprosy is quite mind boggling. There are
large modern hospitals with the worlds most
sophisicated equipments to the smallest
remote clinics held in rural India to neat little
rooms in the worlds worst type of slums - and
all are clean. Not sterile but clean and the
majority have some small sign that shows
they are motivated by Christ's love.
The mode of treatment has changed in
the last few years and it is interesting to see
that some of the oldest clinics in India are
finding high incidences of 'Dapson resis
tance'. The basic cause of this is the poor
intake of tablets by patients. The only way
we are going to overcome this is by exten
sive health education. That will have to
start with ourselves. The only way to truely
understand a problem is to be part of it. Set
yourself a goal. "I will become a patient
today and start taking a tablet regularly"
(You could decide to take a small vitamine
tablet regularly), Now remember for religious
it is even easier as we have been trained into
more self-discipline and have such easy aids
as dining rooms where we can conveniently
put our tablets. We have each other to
remind us as we live in a close community.
Try and see how you manage on your own
without others help to take a daily tablet.
The long-term treatment plan must be an
integrated one as Dr. Paul said, to set up
clinics labelled "leprosy clinics" is to seperate not just the disease but the patient and
to immediately identify him with a problem
that ostracises more quickly and more
severely than any other disease.
It is
The emphasis is now on multidrug
ironical that a man may stray and contact therapy. This is not cheap but few religious
V.D. and then infect his wife—both later
institutes have to worry about this, and that
receiving treatment, the wife in love and
is good in a sense. The decision to start
compassion remains with the erring husband,
multidrug therapy however is a decision that
and if any of the other family members know,
needs careful planning. We must be sure
they are a little upset but forgiving in the
that the patients we start are regularly tak
strain of "no one is perfect" - but let a
ing their tablets; this is not just regularly
husband or wife become a leprosy patient
collecting their tablets. Plan house visits to
and see what happens. In endemic areas
see how many are in stock. Many clinics
where we need to limit our work to leprosy
and 'experts' give one or even two months,
let us have 'skin clinics'. This however tablets. I think this is dangerous as it leaves
means that we must be prepared to identify the patients too long without contact. It
may increase the work load, but the more
more diseases and to give prescriptions. The
often the patient comes to the clinic the more
cost of most skin ointments can be high
chance we have to promote 'care of the
unless we can supply or revert back to older
patient by the patient' - this is not only
and more simple compounds for such com
taking the little Dapson tablet but allows
mon problems as ringworms and scabies.
continued talks and encouragement about
22
Medical Service
hand and foot soaking. If by more visits we
feel that we are increasing our work load
too much, we must seriously consider
encouraging more women and students to
come and give voluntary help and service in
our clinic work. To involve more of the
people in our parish in this simple service
enriches and rewards every one particularly
the parishioner who often wants to help the
church but never gets the opportunity or the
chance. It is also very simple to check the
intake of Dapson of a patient by testing the
urine. This simple field test can be done in
any clinic. The cost of equipment to start
this testing would be less than Rs. 80/*.
(Write for details if you are interested).
The next most serious step in considering
not just multidrug therapy but in considering
the quality of our work is the need to have a
functioning skin smear technician. Medicine
is not a game and the patients are not just
'poor people*. The need to correctly classify
patients of leprosy and the need to have
correct records of their bacteria content is
now even more important. Remember that
as this multidrug programme takes even
more importance in treatment we may be
questioned by authorities as to the quality
of our work. Let us not shame the Lord who
gives willingly to us. Every Catholic group
involved in leprosy should have a skin smear
technician and equipped laboratory where
patients must be examined at least twice a
year and with multidrug therapy at least 4
times in the first year of multidrug therapy,
and at least three times in the second.
Absolute minimum. If you are unable to do
this, then either take steps to do so or stop
treating leprosy patients. That sounds
severe, but let us now realize that after more
than 30 years we have made little progress
in decreasing the problem. The poor
management of the patient taking Dapson
and our poor supervision - which includes
poor patient health education * has led after
March 1983
all this time to the terrible medical problme
of drug resistance. The time needed for
patients to become Rifampicin Resistent will
be less and more severe as it is a directly
related to anti T.B. drug. The charitable act
of handing out Dapson and other antileprosy
drugs without full control, checking and
follow up is not charitable nor Christian, but
damaging to the patient and society and a
reflection on our lives that must always
reflect the fullness of care. Simple handout
of any medicine is not care nor is it true love;
it is a sham.
Added to all this is the fact that most of
the rehabilitation work among leprosy pati
ents in India and the world generally is done
by Christian orientated groups. In India
many of us are involved in the work among
leprosy patients in colonies. The rehabilita
tion work already taken up is tremendous.
However, I raise the following points and
questions. The goods produced through
our efforts must at some time reflect a real
sign of rehabilitation and not justTsupport and
work. Work must have a true aim. If the
present goods being produced are only
being sold through our orders and in Europe
we must surely consider that this may one
day come to a sudden halt if the economy of
Europe, America and other Western countries
taking our goods change. As many have
experienced in the last [year or if the policy
of a government changes, that restricts the
movement of money in or out. We must
start now to protect not ourselves but the
patients for whom we claim to be working
for and helping. Aim at Indian markets.
This is not only difficult in an already com
petitive and highly unemployed country but
it is a real challenge to our activities. Try to
have a more realistic approach to what we
produce. Try to aim for no more than say
75% overseas markets in the next two years,
subsequently 50% and then only 25%, This
will mean that we have to go away from
23
'fancy and pretty' to local and serviceable
goods. The other fear that I have is that the
actual patient has very little real say in the
overall management of our rehabilitation
programmes. They are simply employed and
in fact the whole work would cease if we
walked out. This is not rehabilitation. It is
a form of showmanship.
Many of the readers may be slightlyoffended by these lines, but that does not
really worry me. In fact it has made you
think, then we can realistically go to the next
step.
The time has come for those of us who
are extensively working in leprosy to hold a
regional based series of seminars or meet
ings to discuss our medical programmes
rehabilitation objects and mutual co-opera
tion in such things as community buying of
medicines and goods, overall health educa
tion of the public and ourselves and the need
to have training courses for such programmes
as Leprosy, T.B., Vitamin A deficiency leading
to child blindness.
Bank With
Catholic Syrian Bank
A Bank with a tradition of over 62 years
in the service of the people
The Catholic Syrian Bank Limited
Estd : 1920 Reg. Office : TRICHUR
(Authorised Dealers in Foreign Exchange)
24
Medical Service
Medical Ethics Forum-31
Fr. George Lobo, S.J.
The New Latin Code of Canon Law and
the Medical Practitioner Introduction
While the whole Code touches the life of
every Christian in some way, some laws
affect medical personnel in a special way.
The new Code stresses the common obliga
tions and rights of all the members of the
Church. "All the faithful who are reborn in
Christ are equal in dignity and action which
each one according to one's proper condition
and role, contributes to the building up of the
Body of Christ." (Can. 208)
Role of the Laity
The laity are especially called to imbue
the temporal order with the spirit of the
Gospel (Can. 225,5). Hence the healing
activity of Christian doctors and nurses is to
be inspired by the saving and healing mission
of Christ.
The due freedom of the laity in temporal
matters is to be recognized, although they
have to be attentive to the teaching of the
Magisterium (Can. 227). Those who are
eminent in competence and prudence could
be called to be experts and counsellors to
the pastors of the Church (Can. 228,2.)
They have the duty and the right to acquire
sufficient knowledge of Christian doctrine
(Can. 229,1). This is all the more necessary
when they gain expertise in medical know
ledge and skills.
Right of Association
The faithful may form associations for
fostering Christian life or the apostolate
March 1983
(Can. 298,1). This applies to Doctors' and
Nurses' Guilds. No association is to call
itself Christian without the consent of com
petent ecclesiastical authority (Can. 300).
All such associations are subject to the vigi
lance of ecclesiastical authority in order to
preserve integrity of faith and morals
(Can. 305,1).
Sacraments in General
In case of necessity or real spiritual good,
provided there is no danger of error or indifferentism. Catholics may receive the sacra
ments of Reconciliation, Eucharist and Anoin
ting from a non-Catholic minister of a Church
in which these sacraments are truly found if
it is physically or morally impossible to
approach a Catholic minister (Can. 844,2).
In India this applies particularly to the Syrian
Orthodox Church. The need may particularly
arise when there is danger of death.
Catholic ministers may minister the same
sacraments to non-Catholic Orientals if they
ask of their own accord and are rightly
disposed (Can. 844,3). In danger of death,
or other need, according to the judgement of
the bishops, these sacraments may be given
to other non-Catholic Christians if they cannot
approach their own ministers, ask of their
own accord, have the Christian faith regarding
them and are rightly disposed (Can. 844,4).
In the administration of the sacraments,
the oil used should be from olives or other
plants. They have to be blessed by the
bishop (Can. 847,1), although the oil for
anointing, in the^case of necessity, can be
25
blessed by any priest during the celebration
(Can. 999,2).
Baptism
Baptism is not to be celebrated in a hos
pital unless the bishop decides otherwise, or
in case of necessity or other important pas
toral reason (Can. 860,2).
in danger of death, the infants of Catholic
or non-Catholic parents are licitly baptized,
even
if
the
parents
are
unwilling
(Can. 868,2).
The faithful who are in danger of death
from any cause are to be refreshed by
H. Communion or Viaticum (Can. 921,1). If
they are in a critical condition, even though
they have already received Communion that
day, it is highly recommended that they
communicate again (Can. 921,2). If the
danger of death continues, it should be
administered several times on different days
(Can. 921,3). The Sacred Viaticum is not to
be delayed too long. Care must be taken
to receive
it
in
full
consciousness
(Can. 922).
An exposed infant or foundling is to be
baptized unless it is clear after diligent inves
tigation that Baptism has already been con
ferred (Can. 870). If it is thought prudent
to give the infant be adopted by non- Catholic
parents, Baptism would not be advisable.
A sick or elderly priest, if he is not able
to stand, may celebrate sitting down, not
however before the people without the
permission of the local Ordinary (Can.
.
930,1)
An aborted foetus, if alive, is to be bapti
zed as far as possible (Can. 871). There
is no reference in the new law to intra-uterine
Baptism.
A blind or otherwise sick priest may
licitly celebrate Mass using any of the
approved texts, with the assistance, however,
of another priest, deacon or even a properly
instructed lay person (Can. 930,2).
Confirmation
In the danger of death, the parish priest,
and indeed any priest can minister the sacra
ment (Can. 883,3°). It can be given to
children of any age in danger of death.
In case of need, Mass may be celebrated
in any decent place (Can. 932,2), in which
case there must be a convenient table, and
always a table cloth and corporal (Can.
.
932,2)
Euachrist
Reconciliation
Small children in danger of death may be
given H. Communion if they are able to
discern the Body of Christ from common
food and receive it reverently (Can. 913,1).
A priest who has habitual faculties for
hearing confessions, by virtue of an office or
concession of the local Ordinary, can exercise
the same anywhere in the world unless the
Ordinary of the place forbids it (Can. 967,3).
One must abstain from food and drink,
except water and medicine for an hour before
receiving H. Communion (Can. 919,1). The
elderly and the sick as well as those caring
for them may receive the Eucharist even if
they have taken something within the hour
(Can. 919,3). Hence medical personnel on
duty are not strictly bound by the eucharistic
fast.
26
In the danger of death any priest can
validly and licitly absolve any penitent from
any censuries and sins, even if an approved
priest is present (Can-976).
Anointing of the Sick
Pastors and relatives should see that the
sick receive the sacrament in due time
Medical Service
(Can. 1001). It may be ministered to a
faithful "who having reached the use of
reason, begins to be in the danger of death
due to sickness or old age" (Can. 1004,1).
It may be repeated if the sick person, after
rallying, again falls into grave sickness, or if
in the same sickness, the danger becomes
graver (Can. 1004,2). In doubt about the
use of reason or the gravity of the illness,
the
sacrament
is to be ministered
(Can. 1003). Hence the sacrament must be
understood more as that of the sick than of
the dying.
The sactament may be conferred to a
sick person who at least implicitly asked for
it when he or she was conscious
(Can. 1006). It is not to be given to one
who obstinately perseveres in grave sin
(Can-1007).
Marriage
The New Code emphasizes the need for
proper preparations for marriage (Can. 1063).
Doctors and nurses may be called upon to
play an important roie in this.
Now an 'human act1 is required for the
consummation of marriage (Can. 1061,1).
Hence sexual intercourse by a drunken hus
band or one that is violently imposed would
not consummate marriage and make it
absolutely indissoluble (Can. 1141).
Marriage impediments have been greatly
simplified. For instance, only relationship up
till that of first cousins in the collateral line
invalidates marriage (Can-1091). There is
no more any impediment of affinity in the
collateral line (Can. 1092).
Impotence (inability to perform coitus)
that is antecedent and perpetual invalidates
marriage (Can-1084,1). According to a
decree of the S. Congregation for the Do
ctrine of the Faith, 13 May 1977, it is clear
that double vasectomy as such does not
constitute impotence. One may likewise
March 1983
conclude that women who have undergone
tubectomy, those with retroflexed uterus
or even those lacking postvaginal organs are
not to be excluded from marriage. It seems
also probable that even one with an artificial
vagina that is functional could validly marry.
Sterility neither prohibits nor invalidates
marriage (Can. 1084,3), unless it is purposely
concealed (cf. Can. 1098). Error regarding
fertility as such does not invalidate marriage
unless the quality is 'directly and principally
intended1 (Can. 1097,2). It may happen
that some persons, especially because of a
particular cultural background, may so desire
fertility in the partner that in its absence
marriage would not only be difficult but
absolutely inconceivable. In such a case an
error regarding the quality of fertility may
amount to error regarding the person and
thus invalidate marriage.
The expertise of psychiatrists would be
called in especially in evaluating the psychic
factors that would substantially vitiate the
marriage consent: 1) lack of sufficient use
of reason; 2) grave defect of judgemental
discretion concerning the essential rights and
duties of marriage to be mutually given and
accepted; 3) psychic causes that make a
person incapable of assuming the essential
obligations of marriage (Can. 1095). An
example of the last would be true homo
sexuality.
Children who are born at least 180 days
from the day of marriage or within 300 days
of the dissolution of marriage are presumed
legitimate (Can. 1138).
Funerals
The Church still strongly recommends the
pious custom of burial, but does not forbid
cremation unless it is chosen for reasons
contrary to Christian doctrine (Can. 1176,3).
27
Apart from notorious apostates, heretics
and schismatics, as well as those who have
chosen cremation for reasons contrary to the
Christian faith, ecclesiastical funeral is to be
denied only to other manifest sinners to
whom it could not be granted without public
scandal of the faithful (Can. 1184). Regar
ding suicides, we may doubt in most cases
about the existence of manifest subjective
guilt or the scandal could be averted through
proper explantion.
Penalties
Those who commit homicide or grave
mutilation are to be punished with various
expiatory penalties (Can. 1391,1).
Those who effectively procure abortion
incur ipso facto excommunication (Can.
.
1398,2)
The penalty, however, presumes
that deliberation and grave subjective
imputability
are
present
(Can. 1323
and 1321).
FOR THE FIRST TIME IN INDIA
BLOOD CULTURE MEDIA
( Stability : 12 Months )
Also Available :
Pathology Reagents
Bacteriology Kits
Biochemistry Media
Microscopy Stains
Antibiotic Sensitivity Discs
Indicator Solution etc. etc.
GLASSWARE
Distillation Assemblies
Blood Sugar Tubes
Specimen Tubes
All Glass water Distillation Unit
Micro-Slides & Cover Glasses
‘ANUMBRA’ (Czech) PETRIDISHES etc.
Photo-Electric Colorimeter (Price Rs. 2,000-00)
LABORATORY INSTRUMENTS
Spectrophotometers Flame Photometers Autoclaves-Portable & Heavy Duty Microscopes
Electrophoresis Apparatus Hot Air Ove Laboratory Incubators Hot Plates
Water Distillation Units Analytical Balances Water Baths Blood Sugar Tube Bath
Voltage Stablisers etc. etc.
PLEASE CONTACT:
LAB-TEX CORPORATION
109, JAI PRAKASH NAGAR, GOREGAON (East)
BOMBAY - 400 063
Tel, : 318459/693376
28
Cable : ‘LABNEEDS’, BOMBAY-63
( Please ask for our latest price list )
Medical service
Extract from a WHO Technical Report
on
Chemotherapy of Leprosy for Control Programmes
(Report of a WHO Study Group)
A Study Group on chemotherapy of
Leprosy for control programme was convened
at Geneva from 12 to 16th Oct. 1981.
The objectives of the meeting were :
1. To review information on problems
related to Chemotherapy and on Chemo
therapeutic^ regimens for Leprosy, which has
accumulated since the fifth meeting of the
WHO Expert Committee on leprosy in 1976.
2. To recommend for leprosy control
programmes appropriate multidrug regimens
for multibacillary cases including new,
treated, and drug resistant cases, whether
clinicaly suspected or proved.
(ii) the readjustment of tasks and the
priority of treatment activities, and the
information given to patients concerning
their disease and its treatment;
(iii) the study of cost effectiveness,
including a comparision of the costing of
effective combined chemotherapy at high
cost but of perhaps limited duration versus
low cost therapy of long duration and poor
compliance.
...The proposed multidrug regirnen is
designed for the treatment of all categories
of multibacillary patients, which includes :-
3. To recommend regimens for paucibacillary cases in control programmes.
(1) freshly-diagnosed, previously untrea
ted patients;
4. To identify further research needs in
the clinical and operational aspects of chemo
therapy in leprosy.
(2) patients who have responded satis
factorily to previous dapsone monotherapy ;
1.6.2.1. Need of revision of control
programmes
(3) patients who have relapsed after a
period of dapsone monotherapy; and finally,
Combined
chemotherapy
with more
potent and expensive drugs required to be
more closely supervised and monitored than
dapsone monotherapy. These extra activities
could not readily be superimposed on existi
ng leprosy control programmes, already often
overstretched for manpower and financial
resources. Therefore changes in broad policy
have tended to be delayed, especially those
concerning.
(4) patients who have relapsed with
foot-pad proven dapsone-resistant leprosy.
Duration of treatment
Combined treatment should be given
until the size of the bacillary population has
been reduced to such an extent that resistant
mutants are no longer present. Since the
time required to achieve this is not known,
combined therapy should be given for the
(i) the re-training and orientation of entire course of treatment which must be at
health personnel for the management of
least two years duration, and be continued
cases on combined therapy;
wherever possible to smear negativity.
March 1983
29
3.1.5. Recommended standard
ment regimen
treat
Rifampicin
- 600 mg once - monthly
supervised
Dapsone
- 100 mg daily self-adminis
tered
Clofazimine -
3.2.
300 mg once - monthly
supervised together with
50 mg daily self-adminis
tered.
3.2.3.
Short-course chemotherapy of pauciba
cillary leprosy should be introduced in the
following order:
1.
to all newly-diagnosed paucibacillary
patients;
2.
to all dapsone-treated paucibacillary
patients;
3.
to paucibacillary patients who are
currently on treatment with dapsone
monotherapy and who have not yet
completed two years of treatment.
Treatment of paucibacillary leprosy
Paucibacillary leprosy is (lepromin posi
tive) I, TT BT leprosy as diagnosed clinically
or based on histopathology, with Bl of /-2
according to the Ridley scale at any site.
Although a large proportion of patients
with single lesions do heal spontaneously, it
is still necessary to treat them because it is
impossible to identify those that will heal
spontaneously, while those that do not may
develop nerve lesions and others will be
downgraded to multibacillary forms of the
disease.
3.2.2. Recommended.a standard treat
ment regimen
The following regimen is recommended :
Rifampicin 600 mg once a month during
6 months plus dapsone 100 mg once a
month during 6 months plus dapsone
100 mg (6-10 mg/kg body weight) per day
for 6 months.
The administration of rifampicin should
invariably be fully supervised. The dapsone
may be given unsupervised. If treatment is
interrupted, the regimen should be recom
menced where it was left off to complete the
full course.
March 1983
Priorities
4.10
Training
With the introduction of multidrug regi
mens training of all categories of staff includ
ing those working in the primary health care
delivery system must be undertaken and
recognised to the new strategies being evol
ved and the possible bottlenecks and
complications that may arise. The training
must be planned and organised so that each
type of personnel is prepared to perform
clearly-defined activities and functions within
the overall context of the programme. Train
ing of medical students and refresher courses
for physicians should also form integral com
ponents of this activity.
A working manual should be prepared
for the guidance of all personnel engaged in
the programme. The manual should give
detailed instructions regarding drug com
binations, treatment delivery and possible
side effects that may arise, in simple lang
uage. The chain of referral and the
appropriate action to be initiated should be
precisely indicated..........
31
CHAI
NEWS
NOTES
Central Purchasing Service of CHAI and
Materials Aid
C.T. Thomas
From time immemorial Church and allied
organisations have been also in the arena
of distribution and handling of material aids
in connection with relief and development
projects and institutional programmes. True
to her universal character, the Church in
India also has been engaging in service
activities— health, education, developmentand receiving and expending enormous aids
in cash and kinds.
Of late many of the supporters and pro
moters of these various projects felt that
they could cover a large portion of the needy
people with the available resources, if they
could evolve a system of co-ordination and
procurement of material aids at economic
prices.
In this context the CHAI, in 1974, in
consultation with likeminded organisations
at home and abroad, took a lead by organisng the Central Purchasing Service (popul
arly known as CPS) with the permission of
the Govt, of India (Ministry of Commerce)
primarily to assist health institutions all over
the country in the procurement of material
aids irrespective of any religious affiliations.
Purchasing Assistance at Deemed Ex
port Price
One of the main activities of CPS is
providing co-ordination and consultancy in
the procurement of indigenously manu
factured quality engineering goods including
vehicles for projects of social objectives at
the "deemed export price*, against payment
in free foreign exchange by using the don-
32
ations that are being sanctioned by the
overseas charitable and voluntary aid giving
organisations. This service has been made
available after obtaining a specific sanction
from the Govt, of India on the principle of
'social-objectives*. The "deemed export
price*' is the rate worked out by the suppliers
after taking into account the export in
centives as applicable and allowed to them
by the Govt, of India such as supplementary
cash assistance in lieu of Central Excise
Duty, import replenishment licence, etc.
The percentage of price difference between
the deemed export price and the domestic
price varies from item to item and from time
to time, as the export incentives are always
subject to the review of the Govt, of India.
All the same the deemed export prices are
much lower than the domestic prices.
Conditions and Guidelines :
Given below are some of the important
conditions and guidelines as to how far the
CPS can be used for the procurement of
Indian made equipment at the said deemed
export price for use in projects of social
objectives.
Conditions (as laid down by the Govt, of
India) :
(i)
The donors are national or multi
national
voluntary
organisations
abroad and payment for the Indian
equipment is made in free foreign
exchange through banking channels.
(ii)
The supplies financed by the donors
are meant for donations to charitable
Medical- Service
and non-profit organisations in India
working in the field of health/social
welfare/education / rural d evelopment
on nonsectarian basis without con
siderations of religion, caste or creed.
(iii)
(iv)
The donors place the order with
Indian suppliers directly and payment
for the equipment is also made
directly from abroad.
same may be intimated to CPS to
gether with all possible information
on the materials including speci
fication, preference for a supply
source, etc., and the postal address
of the donor.
(ii)
CPS will then take an undertaking
from the project authorities to the
effect that the material shall be used
for the purpose for which it has been
sanctioned and an authorisation to
the effect that both CPS of CHAI
and BEGECA, West Germany, are
empowered to deal with all con
nected commercial matters on behaf
of the projects.
(iii)
Simultaneously, CPS will arrange for
the offers from suppliers, scrutinise
the same with particular reference
to specifications, quality, price and
commercial points like terms of pay
ment, delivery schedule, guarantee,
warranty period, after sales service,
etc., with the knowledge of the pro
ject authorities.
(iv)
After having verified and satisfied,
CPS will forward the offers to the
projects authorities for the approval
of the same by the legal holder of
the project.
(v)
The project authorities after having
satisfed with the offer so arranged,
will forward at least three copies of
the invoice to CPS duly approved.
(vi)
The approved invoice will then be
forwarded to BEGECA with necessary
direction to place firm order with the
concerned Indian supplier.
(vii)
On receipt of the advice and duly
approved invoice from CPS, BEGECA,
after confirming ihe availability of
funds from the donor concerned.
The equipment is sold by the supp
liers at export price.
In line with the above conditions the
following points are to be strictly adhered to
while availing of the services of CPS.
(i)
The projects for which the suppliers
are to be arranged under the deemed
export pricing scheme are necess
arily to be in any one of the areas of
social and development work men
tioned against condition No. (ii)
above.
(ii)
The projects should be legally bound
and organised.
(iii)
The funds required for the purchase
are to originate as donation from
overseas for charitable purpose and
shall not have any room for subse
quent adjustment against such don
ation in India.
(iv)
The donation required for the pur
chase should be transferred to
BEGECA, West Germany, by the
donor organisation at the appro
priate time.
(v)
In case the donor is an individual,
the donation is to be transferred
to|BEGECA through a voluntary donor
organisation abroad.
Procedures
(i)
Once the funds for the purchase of
the materials are sanctioned, the
March 1983
33
places firm order with the Indian
supplier, under intimation to all
concerned.
(viii)
After placement of firm order both
BEGECA and CPS follow up with
supplier for the delivery of the
ordered item.
(ix)
BEGECA makes payment directly to
the supplier in India through banking
channel as per the terms of payment
agreed upon.
(x)
In case of damages and losses to
the consignment in transit the matter
should be brought to the knowledge
of the transporters and suppliers by
the project holder under intimation
to CPS and BEGECA. Usually the
consignments will be sent under the
cover of insurance poilcy to the pro
ject in which case the project authori
ties will have to lodge claims
against insurance companies well
within the time specified for the
damages and losses, if any.
(xi)
In case of any defect in the supply
made it should be immediately inti
mated to the supplier under inti
mation to CPS and BEGECA who
would see that the reported defects
are rectified to the entire satis
faction of all concerned.
(xii)
In case of any delay in the install
ation of the equipment the same
should be intimated to CPS for tak
ing up the matter with the supplier
concerned.
(xiii)
The supplies received under the
deemed export scheme are covered
under the Foreign
Contribution
Regulation Act and such supplies
are treated as foreign donation in
kind and hence reporting to the
34
Home Ministry, Govt, of India, under
form No. FC-6 is a must.
One could observe from the above that
both CPS and BEGECA would take care of
the job in arranging the required Indian
made equipment of any nature, vehicles and
other supplies to the projects of social
objectives provided the project authorities
comply with these requirements.
BEGECA, Partner in West Germany
BEGECA is a procurement organisation
for church-related and/or charitable projects
in developing countries. The German Govt.
recognised BEGECA as a charitable organi
sation and is exempted from taxes. Thus
BEGECA is a donor's procurement agency
and trustee, based on which the Govt, of
India authorised them along with CPS of
CHAI for arranging the supply of Indian
made goods under the "daemed export
scheme" for the project of health, social
welfare, education, rural development, etc.
A Step Forward
In view of India's developing indigenous
industry there is a great potential for expan
sion of CPS. As it is becoming increa
singly difficult to export goods into India,
even as donation, and in view of the prob
lems of before and after sales service and
spare parts, CPS can be considered a sub
stantial step forward in local purchasing.
The CPS could be further developed for
providing information on matters relating to
appropriate technology, materials aid, pur
chasing of all kinds of supplies like equip
ment, medicines, vehicles, etc., shipping
and other concerns as may be required to
gether with training and development pro
grammes on materials management for the
benefit of projects of social objectives.
It would be only appropriate if the exist
ing infrastructure of CPS is thoroughly ex
Medical Service
ploited for the procurement of supplies at
all times within the country. Similarly, the
CPS could also be exploited in handling
products manufactured by rehabilitation
centres of our institutions.
♦
*
♦
Basic Heath Workers Training Report
of Nalgonda Diocese, A.P.
'We commenceo our basic health workers'
training on 3rd March, 1983. Twenty-three
women from 17 (seventeen) villages along
with 12 sisters participated in it. All these
women were married people and they
showed great enthusiasm and interest in
learning the subjects which we taught them.
In these three days we were very tight with
our programmes.
After the theoretical training of three
days we appointed them to different dispensarjes for practical training and meantime
in group of five each they will come to
Nirmala Hospital, Suryapet, for further theory
arid practicals in different departments,
especially in maternity ward and labour
room, for one week each group. During
this period there would be the evaluation
of the theory they already learm as well as
giving theory and practicals in other subjects.
At the end of this we decided to have a
3-day seminar for the whola group to share
the experience and the result of their learn
ing most probably on 27, 28 and 29 of May
1983.
#
*
♦
Employment
Wanted MBBS Doctor, fresh, experienced or
retired at Holy Cross Health Centre, Sanawad
(M.P.) for immediate appointment. In view
of starting a Maternity Centre we want a
Gynaecologist. Accommodation and other
facilities are available. Please contact:
Sr. Incharge
Holy Cross Health Centre
C/O Convent Deepalay
Sanawad, MP.. 451 111
March 1983
Training Programmes by Indian Hospital
Association, New Delhi.
The Indian Hospital Association, New Delhi,
is organising the following management
seminars:
1.
Management Seminar for Nurses
Date
: 11th to 18th August 1983
Place
: Lady Hardinge Medical
College School of Nursing
New Delhi 110 001.
Participants : Nursing officers from
Government and Voluntary
Hospitals.
Tuition Fee : Rs. 250/payable in favour of
Indian Hospital
Association.
2. Seminar on Hospital Management and
Administration
Date
: 1—10, December 1983
Place
: All India Institute of
Medical Sciences,
New Delhi 110 029.
Participants : Medical Superintendents,
Health officers Nursing
Superintendent etc. from
Government and
voluntary hospitals.
Tuition fee : Rs. 350/payable in favour of
Indian Hospital
Association.
For further details and registration, please
contact:
Dr. P.N. Ghei
Secratary General
Indian Hospiral Association
C-ll/72, Shajahan Road
New Delhi 110 011
♦
*
*
Promotion of Pro-Life Activities
A cassette of 60 minute duration (in
Tamil) containing six select playlets and
corresponding
messages depicting
the
heinousness of abortion is prepared by
Tuticorin Pastoral Centre and is available
for the benefit of others. Price Rs. 25'- -r
Rs. 5/- for packing and postoge. Available
from :
Fr. Stephen Gomez, Director, Tuticorin
Pastoral Centre. Cathedral PO Tuticorin 1
Tamil Nadu
35
Position: 2781 (6 views)