FRCH NEWSLETTER VOL.1-No. 2-6-JAN - 0CTOBER-1987
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- FRCH NEWSLETTER VOL.1-No. 2-6-JAN - 0CTOBER-1987
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January-February, 1987
Vol. I
No. 2
Health for All: Concept and Reality
Dr. N. H. Antia
CAN health be attained by all our people by 2000 A.D., within the present socio-economic system and health
was the question addressed in the seminar arranged by infrastructure. Several delegates felt that this should be
the Foundation for Research in Community Health possible because the targets that have been proposed are
(FRCH) at the Kalina Campus of Bombay University on very modest in themselves; and that we already have
November 15-16, 1986.
examples in several parts of the country, albeit on a
The Seminar, co-sponsored by the Indian Council of microscale, which have demonstrated the feasibility of
Social Science Research (ICSSR), and also supported by meeting these targets with modest inputs.
the Indian Council of Medical Research (ICMR), was a
Doubts were expressed that even if the national targets
follow-up of a previous study jointly undertaken by the could be achieved, aggregate figures may not reveal the
ICSSR/ICMR on Health for All: An Alternative Strategy, true situation. There exist great disparities not only
for which FRCH had provided the research input and between States like Kerala and Bihar but also between
secretariat. The study made a detailed analysis of the rural and urban areas and even within the cities and
health status of the people and of the existing medical villages. The achieving of targets through a selective
services, and recommended an alternative strategy for approach would negate the concept of Health for All.
achieving health for all within the existing social and
It was stressed that health, which is chiefly a problem
political system. At about the same time came the World of women and children, can only be achieved by improv
Health Organisation’s (WHO) Alma Ata Declaration on ing the status of women. The low female literacy rate, the
Health for All by 2000 A.D., to which India is a signatory. low status of our women, the excessive burden they bear
The Seminar was an attempt not only to review the in repeated child-birth and in supporting the family,—
achievement and failures, but also to reassess the policy they get the lowest calories in the family while expending
and strategies which would ultimately determine the the largest amount—and the indignities to which they are
success or failure in achieving the goal of HFA. Several subjected, virtually ensure that Health for All will remain
' background papers provided useful data, and served as a pipe dream of the planners and politicians.
the basis for discussion.
The reasons for our failure to improve the quality of
There was general agreement that the achievements in life of the masses, to achieve universal literacy, to provide
improving the health of our people had fallen far short gainful employment and improve the appalling state of
of expectations. Statistics reveal a continuing high rate of nutrition despite accumulating vast stocks of food grain,
infant mortality at about 114, and a death rate at 11.7 for lie in the skewed political and economic priorities which
every 1000 live births, and maternal mortality of 5 per have created wide disparities despite increase in the
thousand. The major causes of mortality and morbidity national wealth. The solution for this lies in the realm of
continue to be a communicable diseases like tuberculosis, political action.
gastroenteritis, measles, respiratory infections, leprosy,
The message that has emerged from this seminar is
filariasis and poliomyelitis, for which there exist relatively clear. Health for All cannot be achieved without the con
simple, cheap and effective measures of prevention, cure comitant transformation of the overall social structure and
and control. However, instead of providing basic primary political economy. It cannot be achieved under a social
health care for the rural masses, the emphasis has been order which favours a few at the expense of the rest.
on tertiary care for the urban rich. The only targets
The role of the professionals should therefore be t
achieved and exceeded have been in the production of demystify health which will also act as an important
doctors and drugs, which nevertheless only reach the means of developing confidence among the poor. It can
upper two deciles who have the monetary resources to help them to question the causes of their poverty and
purchase the available curative services.
initiate action in fields other than health.
The question was naturally asked whether it will be at
The seminar concluded on a positive note that the
all possible to attain the health targets set for 2000 A.D. future focus should be on developing and liberating the
innate energy of the people through a wide ranging
We wish our readers a very happy, fulfilling and approach to health and through a meaningful form of
health education which will create the necessary awareness
healthy New Year.
for their own action.
FOR PRIVATE CIRCULATION ONLY
To
The FRCH collective.
WE read your first Newsletter and found it very infor
mative and useful. We have a suggestion to make about
the future issues. Could you also cover the topic of
occupational health in your newsletter? Though this is a
vast topic, you may cover it to the extent it relates to the
doctors. Apart from the social responsibility of the
doctors, the law also clearly states that any practitioner
treating, a notifiable disease should inform the inspector
of factories. The penalty for not doing this is only Rs 50.
The problem is that due to non-reportage, there is no
change in the working atmosphere and working con
ditions in the factories. Workers in India do need to
become aware of the health issues and their own rights
regarding these; but the doctors too need to be educated.
Workers in Alembic glass works at Baroda came to
know that their lung problem is known as Silicosis. They
had to literally teach the doctor about Silicosis and how
they should be checked properly. The Factories Act asks
the doctors to notify any worker-patient of Silicosis. The
doctor who is unaware firstly, of the occupational disease,
and secondly that he can contribute to its prevention by
notifying the chief inspector, would inadvertently continue
to perpetuate the damage to workers’ health.
Take the example of dermatitis. Dermatitis due to
mineral oils, paints and other chemicals is listed. The
general practitioners around industrial areas treat many
patients for dermatitis, but do not enquire about
chemicals used at the work place nor to they inform the
authorities.
It is necessary that the doctors should be educated by
institutions like the FRCH. A campaign needs to be
organised/initiated in .order to include occupational health
as a part of the curriculum for the doctors. There are 22
diseases listed in the Factories Act, which are ‘com
pensable*. If doctors are informed and the informed
doctors in turn decide to record the conditions of work
in their observations, educate the workers, and inform the
authorities, it will be a great contribution towards a
healthier India.
Vijay Kanhere, Bombay.
Loy Rego, Bombay.
J. B. Patel, Baroda.
Pages from a Diary
Amirbanu Sumnani
AT last my long cherished dream came true! I was relieved
from my monotonous stenographer’s duties and was
assigned a new job as a health educator.
With great enthusiasm, I went for 15-day’s training—
learning different media of disseminating health educa
tion. The training was excellent. After the training, I was
all set to shoulder this new responsibility.
I resumed my duty and reported to my superiors about
my training. I started telling them about my future plans,
as to how I was going to launch my ideas into practical
experiment. But I was cut mid-way and was told to keep
aside the new ideas and start with the typing work.
I had no alternative but to do as I was told. I simmered
and started banging at the typewriter keys angrily. Yet I
kept hoping that sometime I would be able to carry out
my plans.
Finally after many arguments with my superiors, I was
allowed to go to a nearby school once a week for just one
hour. Even this one hour came as a bliss.
After a couple of lessons, however, I felt I was not
achieving my goal. The time I was given was too short,
nor was there any time to collect the relevant material and
make things to give health education. Besides, my work
as a health worker as well as, as a stenographer was
criticised. I felt weak and lost.
After this bitter experience, I didn’t feel like taking any
initiative in doing anything creative. Today I am back to
where I was. But today I also wonder, was the training
really as excellent as I had felt earlier?
Despite the lack of encouragement from the Organisa
tion, I did not give up hope. I decided to venture into this
new field on my own. With the help of a friend, I set out
with whatever health education material I had. We went
to a nearby slum area.
After much coaxing we managed to collect a crowd.
I started displaying the material and explained the
importance of cleanliness—which ultimately would keep
them healthy.
Although I realised that not many women were really
listening, I continued preaching. After some time one or
two women got up and walked away. My heart sank. What
if the whole crowd walked away?
But nothing of that sort happened. Instead, questions
from different directions were shot at me. “Oh! Bai from
where to get water to keep ourselves and our clothes
clean?” “Where can we find a clean and healthy environ
ment?” “Where to get money to buy soap and
detergents?” etc., etc. I was totally taken aback. I was not
at all prepared for such questions. I stood there gaping.
When they realised that I had no ready answers, they got
up murmuring, “We know all about cleanliness and other
things. You people can only preach. Just put yourself in
our place and then see what difficulties we go through”.
As I packed my things, I thought ‘Yes! in a way they
were right’.
FOCUS
The New Drug Policy
What does it have in Store for the People
Dr. Anil Pilgaonkar
unwarranted as they would have vested interest in this
issue, and this is more than likely to defeat the aim. It
is as ill-conceived as making a quality control manager
report to the production manager, and is therefore
unacceptable to the people.
2) Quality control: It is proposed to give statutory effect
to good manufacturing practices and also to introduce
a certification system under which, recognised institutions
with proven expertise and testing facilities would certify
the adoption by formulators of good manufacturing prac
tices and the quality of the formulations manufactured.
It is common knowledge that these have been the respon
sibilities of the Food and Drug Administration. The ques
tions that therefore arise are: What would be the role of
the FDA vis-a-vis that of this new certification system?
and (b) if these responsibilities are not clearly demarcated,
wouldn’t that allow room for manipulation and the
playing of one authority against the other?
3) Pricing: As against the existing three categories (viz.
category 1—40 per cent mark-up, category II—55 per cent
mark-up and category III—100 per cent mark-up) of drugs
and pharmaceuticals, hereafter there would be only two
categories. The first category will consist of drugs
necessary for the national health programme (some 40
drugs) and the second category, of essential drugs.
Formulations of the first category would have a MAPE
(maximum allowable post-manufacturing expense,
virtually the same as ‘mark-up’ used earlier) of 75 per cent,
and those of the second category of 100 per cent. This
implies that the rest of the formulations (and very likely
a very large number of them) would be out of the purview
of price control.
A High-level committee would draw up the list of drugs
to be included in the second category. Who would be in
this high-level committee? What would be the criteria for
deciding the essential drugs? There has been no attempt
to answer these questions—another area of studied
ambiguity.
It will be recalled that after the last (1978) drug policy,
the formulations of the I and II categories were scarcely
available whereas those of the III category and those out
of the purview of price control were in abundance. The
reason forwarded for this situation was that, because the
This authority would function as an advisory body on last two categories were the ones that were profitable, they
the development of the pharmaceutical industry. Among were the ones that were manufactured. If this is the case,
other things, it would go into the question of rationalisa and if the intentions of those in authority were to reduce
tion of the existing formulations in the market, including the drug list to conform with rational drugs only, then
the banning of harmful formulations and better control one would expect that the MAPE on formulations not
over the introduction of new drugs. While representation included in categories I and II should have been even lower
of the industry in NDPA in some matters is under than 75 per cent; but instead, the authorities have left
standable, that in respect of the question of rationalisa them out of the purview of price control (which would
tion of the formulations in the market, including banning mean high margin and high profits). The outcome of this
of irrational and harmful drugs is both surprising and
(continued on page 8)
EVER since the 1978 Drug Policy was announced, both
the consumer forums and the drug industry have been
seeking changes in that policy, albeit for diametrically
opposite reasons. The drug industry had consistently put
pressure on the government for allowing, a) greater mark
up on the formulations and b) greater freedom from con
trols. The people-i.e. consumer groups, health groups and
science groups had, on the other hand, sought for i)
availability of essential drugs (as drawn by the World
Health Organisation), at very reasonable prices, ii) restrict
ing the drug list to include only the rational drugs and
exclude all irrational and harmful drugs and iii) the
marketing of drugs and formulations under generic names
only. Further, they had also pressed for people’s participa
tion in the formulation of the drug policy. In fact, many
of the proposals of the Hathi Committee, 1975, were in
consonance with these very demands.
The present New Drug Policy pretends to make an
attempt at pacifying both the groups, though even the
most naive would be able to see through this move and
make out that the policy is very much against the interests
of the consumers and is heavily tilted in favour of the
industry. Virtually all the demands of the people—
drawing out of the essential drugs list, weeding out and
banning irrational and harmful drugs—have been placed
in the hands of the as yet to be constituted National Drugs
and Pharmaceutical Authority (NDPA). This inevitably
means delays and perhaps distortions, depending on the
composition of the NDPA. Secondly, everything that the
drug industry has been pressing for, has been conceded
in ample measure—higher mark-ups and greater freedom
from controls. It is therefore necessary to look into each
of the proposals available from the summary (which is
all that is available at the moment) and see how they would
affect the people on the one hand and the drug industry
on the other.
1) A National Drugs and Pharmaceutical Authority
(NDPA) will be created. This will have representatives
from all concerned agencies, including those from the
industry (emphasis added). While the question of who
these ‘all concerned agencies’ are, is left open, the
summary of the text makes it amply clear that ‘those from
the industry’ will be represented.
AIDS: If Slogans were
Vaccines...
Dr. Merges Mistry
THE dramatic advent of the acquired immunodeficiency public fear over the disease has descended on this country
syndrome (AIDS) since 1978, may well have provided to as well. This has been compouned by unprecedented
religious fundamentalists another clue of approaching announcements in Parliament, intensive media coverage
Armageddon; however it has had a remarkable effect on and the setting up of an elaborate surveillance network
the mobilisation of medical resources and scientific practicable principally on paper. Nevertheless, because of
acumen hitherto unknown.
the very nature of the superefficient pattern of global
The vast pool of information gathered on the somewhat travel and communication prevalent, and the existence of
unique tissue tropism of the virus, its molecular structure, high risk groups in every society, control of the spread
and facets of the immune response towards it, has para of infection remains an urgent priority.
doxically been instrumental in creating a fear psychosis,
since despite the considerable inroads made in the under
standing of the disease, full blown AIDS remains a 100
IN a special article in a recent issue of the New
per cent fatal condition. The treatment is either sympto
England Journal of Medicine, it was reported that
matic or hypothetical. The course of events after exposure
a million new cases of gonorrhoea are reported in
to the virus begin with extremely innocuous symptoms
the United States of America every year, despite the
such as fever, anorexia, weight loss, which, in the absence
fact that penicillin has been available as a single—
of a diagnostic test, would abet the evasion of a correct
shot treatment for several decades. Since there is now
diagnosis. Indeed the pattern of immunodeficiency in
an emergence of resistance to antibiotics, they have
AIDS resembles, to varied degrees, patterns noted in
recommended research in recombinant DNA
different diseases such as viral infections, malignancies,
techniques for developing a vaccine.
Burkitt’s lymphomas, infectious mononucleosis, tropical
splenomegaly, nutritional immunodeficiencies (IDS) and
China has successfully eradicated sexually
leprosy. In third world countries therefore, acquired
transmitted diseases including gonorrhoea and
immunodeficiency syndromes probably exist in vast
syphylis.
numbers but remain unlabelled in the right context.
This is the result of the revolution which has
Little information exists towards the recognition or
changed the social and sexual mores. Penicillin was
measurement of a protective immune response (ImR).
only an additional tool to deliver the coup de grace.
Epidemiological observations bear out that only 10 per
The eradication of STD therefore lies more in social
cent of those infected with the virus progress to active
change than in mere medical technology.
disease, a positive indication that a protective ImR against
the virus exists. Investigators were also elated when it was
computed that homosexual men exhibiting both antibody
positivity (an indication of Human Immunodeficiency
Epidemiologists feverishly grapple with “transients”
Virus infection) and abnormalities in blood cell numbers (anomalies due to the rate of spread of virus and the long
for a prolonged period, reverted to antibody negativity incubation period) to predict estimates for new AIDS
without exhibiting signs of AIDS related disease. This cases in the subsequent years. Even with a minimum of
disappearance of the virus coincided significantly with a pessimism and with a hope that new infections may be
measurable increase in a critical sub-population of blood eventually preventable, it is estimated that the epidemic
cells termed as suppresser lymphocytes.
in countries such as the USA will be five times larger than
In our "vacciphilic" era, it is inconceivable that any the number of cases observed so far.
control measures against AIDS would exclude the develop
Because of the identification of HIV as the causative
ment of a viral vaccine to AIDS. At this juncture, only agent in AIDS and the consequent development of culture
optimism abounds. Attenuated or live vaccines are techniques and serologic methods for detecting antibody
considered too risky for any proposed trial. The favoured to the virus, it is possible to identify both, symptomatic
approach lies in isolation and cloning of a viral structure and asymptomatic infected persons. Paradoxically again,
that may induce the formation of a protective ImR. this very widespread availability of simple, inexpensive and
Variation in viral structure either through environmental sensitive screening tests for antibody to HIV has further
pressures or genetic mutation provides another obstacle complicated the development and implementation of
to the development of a homogenous vaccine. The natural infection control procedures. The question becomes..
history of Human Immunodeficiency Virus (HIV) infec who to screen. This is a particularly important issue in
tions in Africa, where the virus is believed to originate, health care facilities where frequent and intensive exposure
must necessarily be different from that of other groups. to infected patients may occur. Protection to health
Adjustment to the virus over generations must play a role personnel would also have serious repercussions in clinical
in natural immunity/tolerance to the virus. This introduces management of AIDS’ patients as well as in early
the question of the-differential response to the vaccine reporting of AIDS cases.
in various ethnic groups.
It is not feasible to identify all infected patients even
With AIDS claiming its first victim in India in 1986, with the availability of screening tests. The risk of
nosocomial (relating to a hospital) transmission of HIV meaningless when screening for Hepatitis-B or VDRL
is extremely low even after accidental parenteral innocula- for syphilis is still not carried out routinely in a majority
tions. Again, special infection control precautions for of institutions despite being made mandatory since 1976.
patients known to be infected are not necessary in most
The highest incidence of AIDS is reported to have
health care settings at least in the developed countries.
occured in homosexual men, subversion of immune
The existing guidelines for reducing exposure to blood and
system probably occuring through the introduction of
other body fluids will protect workers who care for AIDS sperm through an abnormal route. The recognition of the
afflicted patients. The procedures recommended to heterosexual mode of contraction of AIDS has been
prevent contact with body fluids would reduce exposure
identified as an important way of introducing the virus
not only to HIV but also to other sexually transmitted
into populations not generally considered at risk. This
pathogens.
single fact may play a key role in the final containment
This is also the general lack of Prof. V. Ramalingaswami,
of the disease. Slogans such as “Give a Gift—Not Aids”,
the former Director General of the Indian Council of “Stick to your partner” are common sights in Western
Medical Research, who claims that though sexually
cities where generally the level of sexual promiscuity is
transmitted disease (STD) is widely prevalent, its preven
said to be high and indiscriminate sexual practices, socially
tion and control have been largely neglected: “The
condoned or even legalised. Given the relatively conser
opportunity of AIDS should be used to monitor and
vative sexual mores and practices in societies like ours,
prevent STD in general”.
the likelihood of the problem acquiring similar dimen
The remarkable mobilisation of scientific resources in sions everywhere is remote; AIDS cannot be caught easily
the US towards development of quick and relatively from a dirty toilet!
inexpensive screening procedures was largely due to the
If the trend of incidence continues, a study proclaims,
transmission of AIDS through Blood Bank transfusions
to hemophiliacs or to the users of blood products. Even over 50 per cent of all populations at risk will have con
though they constituted about two per cent of the total tracted AIDS by the year 1990. However, persuasive
AIDS patient, population, their impact on the control induction of behavioural change, and accurate public
measures was very significant. By a massive screening information have already begun to have an important
programme, where within 3 years, 20 million units of impact in markedly reducing the incidence of AIDS long
blood were screened, not only for antibody but also for before a vaccine is available. Far from any sense of
viral particles themselves, the risk of contracting AIDS helplessness that may arise from scientific means to
through transfusions in the US was reduced to a minimum control this affliction, there are a multitude of alternative
levels on which things can be done and multiple cultural
-1.77/1000 units of blood.
Given the prevalent condition of blood banking in this factors that will directly affect the progress of techno
country, screening for AIDS samples would appear logical advances in hand.
Amniocentesis Update
Dr. Sanjeev Kulkarni
A Committee to study the problem of sex determination
and female foeticide was formed by the government of
Maharashtra, under the chairmanship of Mr. Bhai
Sawant, the Minister for Public Health and Family
Welfare in September 1986. The Committee was formed
as a response to the raging public debate, due to the con
sistent campaign by the Forum against sex-determination
and sex pre-selection, and also because of the private
members’ bill presented in the legislative assembly. The
Secretary to the government of Maharashtra, department
of public health and family welfare, commissioned
Dr. Sanjeev Kulkarni of the Foundation for Research in
Community Health to conduct a short study of prenatal
sex determination tests and female foeticide in Bombay
city.
Some of the important findings of this study are:—
* About 84 per cent of the gynaecologists interviewed for
the study are performing amniocentesis for sex
determination tests. These doctors together perform on
an average 270 amniocentesis tests per month.
* According to this study, some doctors have been per
forming amniocentesis for 10-12 years. But a majority
of the doctors (over 85 per cent) have started performing
these tests in the last 5 years.
* About 74 per cent of the doctors said that over 50 per
cent of the women who come for the tests are from the
“middle class”. More than 85 per cent of the doctors
said that no lower class women had come to them for
sex-determination tests, though the areas selected had
a substantial lower class representation.
* A majority of the women have 2 or 3 daughters when
they come for sex determination tests and the percen
tage of women coming for sex-determination tests when
they have 4 or more daughters is relatively small.
Significantly enough, about 24 per cent doctors said
that in 20 per cent of the cases, the women had only
one daughter, when they came for the sex determina
tion tests.
* About 29 per cent of the doctors said that upto 10 per
cent of the women who come for s.d. tests already have
one or more sons.
* A majority of the doctors see the s.d. tests as a humane
service to the women who do not want any more
daughters. Some doctors also feel that s.d. tests are an
important family planning method in our country.
The study also reveals some other interesting features.
For example, one doctor advocates pre-planning of sex
by a method based on the characteristics of the x .and ybearing sperms. Another doctor performs s.d. by a nonallopathic, non-ayurvedic, spiritual method.
This report is now ready and is available at the FRCH.
Overpopulation and Poverty
Dr. Ramesh Awasthi
That overpopulation is the root cause of India’s poverty
is an absolute myth. What is the meaning of overpopula
tion? Is it the staggering total figure (1000 million by
2000 AD) that raises a spectre of despair? In that case,
will our reaction be different if India is divided into 25
independent states each having a population of only about
30 million, even less than that of UK or France?
That India supports 15 per cent of the world’s popula
tion with only 2.4 per cent of the world’s total land area
is often cited as a major handicap in solving the problem
of poverty. If population-land ratio is the criteria for
overpopulation, let’s have a look: some of the most
overpopulated countries are also among the richest.
Country
South Korea
Holland
Japan
Belgium
West Germany
U.K.
India
China
Population (Mid 1984)
Million per 100 sq.km land area
4.09
3.51
3.23
3.19
2.46
2.30
2.28
0.01
All these countries have a population-land ratio which is
larger than that of India. On the other hand a large
number of countries with a favourable population-land
ratio are among the poorest in the world.
Ethiopia
0.345
Zaire
0.127
Thailand
0.973
Indonesia
0.828
Uganda
0.636
Pakistan
1.15
(Source: World Development Report 1986, pp 180-181)
Is poverty a question of there not being enough for so
many people? Let us consider the consumption of
resources or the expenditure on food, health, education,
clothing and housing of the poor vis-a-vis that of the rich.
From the consumption expenditure data we know that the
top 10 per cent consume 7-8 times as much as consumed
by the lowest 10 per cent. Hence averting a birth in the
rich families will save 7-8 times the resources that would
be saved by a poor family having 1 child less. Extending
the same logic, if it was a question of limited world
resources, all population control effort should be aimed
at the industrial market economies where, considering on
ly in terms of energy consumption per capita (in kilograms
of equivalent oil) the consumption level in 1984 was 26
times that of India and 13.5 times that of India and China
together.
Another myth harboured by most educated elites is that
the poor remain poor because they have more children.
Without going into the rationale why the poor need to
have more children (high infant mortality, more hands to
earn the family’s food, lack of illness/oldage security etc),
let us put the question a bit differently—If the poor start
having lesser children, will they be better fed and clothed,
will they have access to good education, better health care
and adequate housing? The honest answer is ‘NO’.
How much the poor will get is determined not by the
number of children they have but by the level of
distributive justice in society. The poor can get more if
they consciously use the power of their numbers to en
force distributive justice.
We are not disputing the need to control the high rate
of population growth in India and in other developing
countries. What we have tried here is to put the relation
between poverty and population straight. We cannot find
excuses for the persistent poverty in high population
growth rate; rather the socio-economic factors have a
stronger bearing on the persisting high rate of popula
tion growth.
Practice of Medicine
Dr. Mukund Uplekar
TOXICITY of vitamin overdose
OUR every day diet contains most of the vitamins that
our body requires. Additional vitamin intake is only
necessary in a very few specific conditions. For these,
single vitamin preparations are necessary—B-1 in case of
beri-beri, B-12 for pernicious anaemia. The habit of in
discriminate prescription of multivitamins is unnecessary
and expensive. This habit is based on the false presump
tion that vitamin can only do good but no harm.
However, excessive intake of vitamins can be harmful.
and often produces toxic effects.
Vitamin
Average Daily Requirement Toxic Effects of Overdoses
A
750 micro grams.
cerebral edema resulting in
headacne, nausea and vomit
ing. Chronic liver disease.
Skin changes including
dryness, eruption and rash;
fissures, depigmentation,
itching, loss of hair.
Ingrowing toenails resistant to
treatment. Tenderness of
bones.
Psychiatric symptoms.
B 3
9-20 mgm.
Peptic ulcer, loss of hair;
itching; liver toxicity, abnor
mal heart beats, hypotension.
B6
2-3 mgm.
Dependency, peripheral sen
sory neuropathy and failure of
muscular coordination.
C
35-60 mgm.
Oxalate stones, possible
teratogenesis and carcino
genesis in very high doses,
multiplicity of minor
idiosyncratic symptoms.
D
400 I.U.
Possible mental deterioration
due to excess of calcium,
hypertension, hardening of
organic tissues due to deposi
tion of calcium salts.
E
5-15 mgm.
Increased anticoagulant action
of Warferin (an oral anti
coagulant drug).
K
100 mgm.
Hemolytic anemia, neonatal
jaundice.
A Workshop Report
Manish Mankad
A three days meet on documentation was organised at
Bombay from 12th December to 14th December, 1986 by
The Centre for Education and Documentation and
Bombay Urban Industrial League Development (CED and
BUILD).
33 participants attended this meet. Some of the parti
cipants had come from great distances-Calcutta and
Hongkong. A total of 7 papers were presented.
The emphasis was on the need, role and relevance of
documentation centres; sources of information; various
classification schemes, dissemination systems like
bibliographies, indexes, and publications; compatibility
between documentation centres in indexing, thesaurus and
filer codes and lastly automated systems.
A concensus was reached on the following points:
a. Keeping in mind the limited resources available to the
documentation centres, duplication should be avoided
as far as possible.
b. For this, a joint indexing of journals which are
subscribed by most of the centres, should be carried
out.
c. The joint indexing will result in a cumulative six
monthly index.
d. To facilitate the exchange of materials, a common
thesaurus was worked out. Each center will have the
freedom to add its new keywords or go in depth into
those topics which are not covered adequately.
e. To organise a training workshop for the automation
of documentation centres.
New?
What is
proprietary names (INN) for pharmaceutical sub
stances: cumulative list 606”.—Geneva, WHO: 1982,
p. 494.
Ghosha, Samarjit, “The turn: from poverty to prosperity”.
—Calcutta, Best books: 1986, p. 140.
Boston women’s health book collective, “The new our
bodies, ourselves”.—New York, Sinon Schuster Ina,
1984, p. 647.
Nissim, Rina, “Natural healing in gynaecology”, New
York: Pandora books, 1984, p. 238.
Freeman, Derek, “Margaret Mead and Samoa”, England:
Penguin books, 1984, p. 380.
Argyle, Michael (Ed), “Social encounters”, England:
Penguin books, 1981, p. 412.
Mead, Margaret, “Coming of age in Samoa”, England:
Penguin books, 1981, p. 240.
Greer; Germaine, “Sex and destiny: the politics of human
fertility”, London: Picador, 1984, p. 469.
Me Tavish, Don, “Comments on sociological methods”,
Meerut: Anu books, 1986, p. 42.
Copies of the following publications are available at the
FRCH:
* Bhore Committee report, 4 Volumes, p. 1201.
* Desai, A R (Dr), “Women’s liberation and the politics
Kalton, Graham, “Introduction to survey sampling”.—
of religious personal laws in India”, 1986, p. 100.
New Delhi, Sage publication, 1983, (series: Quantitative
* ICMR and ICSSR, “Health for all: an alternative
applications in social sciences), p. 96.
strategy”, 1981, p. 262 (English and Marathi).
Masters, W. H. and Johnson. V. E., “Human sexual
* UNESCO, “Health education intervention: an
inadequacy” (3rd print).-—Toronto: Bantam books,
annotated bibliography”, 1986, p. 103.
1981, p. 463.
* VHAI, “Banned and bannable drugs”, 1986 (2nd ed.),
Desai, Neera and Patel, Vibhuti, “Indian Women: change
p. 68.
and challenge in the international decade 1975-85"—
* FRCH, “NGO’s in rural health care”, Vol 1, 1986,
Bombay, Popular prakashan, 1985, p. 101.
World Health Organisation, “International non
World Health Organisation (Searo technical publica
tions: 1), “The-concept of services research”.—New
Delhi, WHO: 1983, p. 15.
World Health Organisation (Euro reports and studies: 68),
“Economic aspects of communicable diseases”.—
Copenhagen, WHO: 1982, p. 35.
World Health Organisation (Euro reports and studies: 80),
“Occupational hazards in hospitals”.—Copenhagen,
WHO: 1981, p. 68. .
United Nations Children’s fund, “Approaches to program
ming for early childhood development”.—Bangkok:
East Asia and Pakistan regional office, 1986, p. 36.
McWilliams, Peter, “The personal computer book”.—New
York, Precluda Press: 1983, p. 300.
Hoberaft, John and Cleland, John (Ed), “Reproductive
change in developing countries”.—London: Oxford
university press: 1985, p. 301.
Gottfried, Byron S, “Programming with BASIC”.—New
York: McGrawHill book company, 1986, p. 386.
Menon, M. P. S., “Pulmonary tuberculosis”.—New Delhi:
National book trust, 1983, p. 254.
Kurien, C. T., “Poverty, planning and social transforma
tion”.--Bombay: Allied publishers, 1978, p. 174.
k p.176.
Books in Brief
Mankad Manish
1. Ritchi, Lewis D., ‘Computers in primary health care,
practicalities and prospects*. London: William
Heinemann medical books, 1984, p. 162.
The purpose of this book is to explore the implica
tions of using computers in primary care.
—current issues and new developments in primary care,
—traditional manual records,
—previous experience of computers in National Health
Services,
—technical aspects of computers used in medicine,
—computer assisted medical records,
—interaction between man and machine and
—access and security of information contained in a
micro computer.
A glossary and an appendix provide valuable defini
tions of computer terminology, details of costs, and
sources of future information. The latter, however, pro
vides information only on UK based sources. There is
an extensive bibliography at the end, in addition to
good references at the end of each chapter. There are
10 chapters in all.
2. Hoinville, Gerald and Jowell, Roger, ‘Survey research
practice*. Hants: Gower publishing, 1985, p. 228.
As a companion volume to the more theoretical
treatment of survey research, this book deals with the
formidable organisational problems of conducting
sample surveys. All the stages of a survey are dealt with,
(continued from page 3)
is plain to see—a self-defeatist measure which will further
fatten the industry at the expense of the consumer. We
are informed that a “very strong monitoring system will
be evolved to keep an eye on the prices of drugs and for
mulations’; but then which government monitoring system
has ever been effective?
4) Licensing: The system of delicensing would be pro
gressively extended, subject to the following criteria:
(a) Bulk drugs whose imports are under OGL (open
general license); (b) Bulk drugs whose production is
limited to three producers or less; (c) bulk drugs whose
formulations are of essential and mass consumption
nature and (d) formulations and drug intermediates
related to bulk drugs which are delicensed. Though one
can appreciate the spirit behind this, it is also plain that
delicensing is likely to be misused and at any rate the
monitoring of drug production would be drastically
affected. On the other hand, if the licensing procedures
are made easy, that would serve the purpose better.
Broad-banding is also extended'to 31 groups of pro
ducts. (Which these are, is still not known). This would
mean that if one has a license to manufacture one product
in the group, it would automatically license one to
manufacture other products in that group. The experience
of earlier broad-banding exercises is not well known. But
the repercussions are likely to be similar to delicensing.
The ratio of bulk drug production to formulation pro
from the initial planning to the production of ‘clean’
data.
Each chapter takes the reader through the intricacies
of survey implementation, from the first principles to
more detailed advice, basing itself on the wide ex
perience of conducting social surveys acquired by the
authors in their work at their research institute.
Throughout, the authors systematically reveal the
‘tricks of their trade’ by exposing and clarifying the
methods by which the underlying principles of survey
research use are put into practice.
It has a good bibliography and an appendix contain
ing examples of questionnaires. The book has 10
chapters.
3. Iyer, K. V. and Kumar L. R., ‘Pollution control in
industry*. New Delhi: K. V. Iyer associates, 1986, p. 481.
The book covers in detail the evolution of the en
vironmental policy from the commencement of the five
year plans and the perspective for the year 2000. It also
contains the declarations by the United Nations and
other international and national agencies, the admini
strative setups and the role of the department of
environment at the centre and the state authorities. It
includes the environment guidelines for the siting of
industries, location of industries and the various
legislative enactments from the middle of the last
century till date.
The contents are organised in 6 sections. Each
section has its own page sequence.
This book can serve as an excellent reference source
on Environment, especially for its legal aspects in
India.
duction has been fixed (1:4 for FER A companies; 1:5 for
companies whose turnover is in excess of 25 crores; 1:7
for companies whose turnover is between 10 and 25 crores;
1:10 for companies with a turnover upto 10 crores). This
would seem to be relevant if effectively enforced but a
more pertinent and meaningful measure would be to make
the drug industry utilise 80 per cent of its capacity to
produce essential drugs. Particularly since the MAPE is
now substantially increased.
Generic vs brand names: The summary of the text of
the New Drug Policy does not make any mention of
‘marketing under generic names’—a recommendation
made after careful consideration by the Hathi Committee,
and one which the people have been pressing for a long
time and one which only the industry has been resisting
all along. Why?
In the final analysis, one fears that the new drug policy
would facilitate abundant production of non-essential,
irrational and perhaps harmful drugs which are profit
centered, at the expense of essential drugs. There would
be increased profits for the industry and as a corollary
increased tax revenue (hopefully) for the government, and
increased profits for the traders; an abundance of ‘gifts’,
‘incentives’, and ‘lures’ for the medical profession (thanks
to the absence of medical ethics) for the over-abundance
of non-essential but profit-centered formulations. And
who pays for all this?... You guessed it, the consumer!
It is a tragedy that the government of the people, by
the people is so very much against the people!
Edited by Sujata Gothoskar with the co-operation of Manish Mankad and secretarial assistance from Sunita Vichare and Amirbanu Sumnani.
Art work by Madhu Rokle and Vineeta. Produced by The Foundation for Research in Community Health, 84-A, R. G. Thadani Marg, Worii,
Bombay - 400 018. Printed by Modern Arts and Industries, A-Z Industrial Estate, Lower Pare!, Bombay.
March-April, 1987
Vol. I
No. 3
Action on the Drug Front
Padma Prakash
THE drug consumer movement in India is less than half
a decade old. And yet it has acquired a voice which is both
loud and deep, though not perhaps always strong enough
to be heard and recognised in high places against the din
of the drug industry and its supporters. What is surpris
ing is that this clear and coherent voice has emerged out
of a fluid agglomeration of myriads of groups and
individuals. And this perhaps is the basis for its poten
tial strength—that it draws its inspiration not from one
mainstream current of opinion or political perspective,
but several.
The drug consumer movement as we know it today,
took formal shape in 1982. The Voluntary Health Associa
tion of India (VHAI) called a meeting at Pune, to discuss
the issue of rational therapy. This was the genesis of the
movement. It was here that health professionals, jour
nalists, academics and church workers came together and
found that their experiences in the field were similar. It
was here in fact that most of the issues which were to come
up over and over again in the following three years were
first raised: the necessity of forming an essential drug list;
the non-availability and high cost of these drugs; low-cost
formulations to be produced as a group programme for
the voluntary sector to bring down costs; the need to set
up information cells and data centres on drug informa
tion; rational drug therapy; misuse and overuse of drugs;
etc. Among the important action plans taken up, was the
decision to launch a campaign against EP drugs on March
Sth, International Women’s Day; and a campaign against
the Depo provera trials. But significantly, the meeting’s
most important long term plan was the collation and col
lection of information in specific areas, such as antidiarrhoeals, tonics, antibiotics, analgesics, misbranded
drugs, drug industry advertising campaigns and the
preparation of material for the proper dissemination of
this data.
Briefly then, the focus of the discussion was determined
by the prescriber and was mainly concerned with the pro
blems felt at that level. Although the nature of the drug
industry was referred to, it was not the major concern.
The major participation of the meeting was from profes
sionals, health workers, of the VHAI and the CMAI, and
members of the Medico Friend Circle.
So great was the momentum generated by the first
workshop in some areas that a second meeting was held
in August the same year. The amount of groundwork put
in by the VHAI in this intervening period was quite amaz
ing and the second workshop in Jaipur discussed more
specific issues—misuse of drugs especially amidopyrines,
anabolic steroids, clioquinol, paediatric tetracyclines; ban
ning of drugs, ethical marketing code for drug companies,
support for the Bangladesh drug policy. The discussions
this time were much more technical and in fact, a major
debate was about the basis for seeking a ban on certain
drugs.
It was in the period between these two meetings that
the first campaign was launched seeking a ban on EP
drugs. Although many women’s groups included it in their
set of demands on March Sth, very few made efforts to
pursue the demand.
The main result of the campaign as it turned out, was
in the production of literature, poster etc. in collabora
tion with one women’s group in Delhi, articles and let
ters to the editor eta It would be a little unrealistic to con
clude that the government’s order of March 18 that year,
making it mandatory for manufacturers to introduce a
warning against its use in pregnancy was due to the cam
paign. Nevertheless, the EP campaign succeeded in
generating an awareness of the possibilities of such ac
tion, especially among professionals who had until then
looked askance at such moves.
By 1984, many independent groups of doctors, con
sumers, health workes, People’s Science groups eta had
become aware of the need for co-ordinating activities. In
July that year at a meeting at Wardha, the All India Drug
Action Network was born. AIDAN has been a loose net
work of a dozen organisations/groups, with each of them
actively involved in related activities in their particular
area.
It is perhaps too early to attempt to evaluate the drug
consumer movement. But it would be useful to look to
some of the macro and micro factors which possibly con
tributed to the genesis of the movement. We enumerate
some of the developments not necessarily in order of their
significance:
1. In the late 70s there was a lot of interest in and debate
on the drug industry and its functioning, especially in
third world countries which revealed the kind of con
SPECIAL ISSUE ON DRUGS AND DRUG POLICY
trol the multinational companies had over not only the
(... .continued oh page 12)
FOR PRIVATE CIRCULATION ONLY
Drugs in Pregnancy
Dr. Mukund Uplekar
Before the Thalidomide tragedy, it had often been
thought that the pregnant woman and the fetus acted as
a single entity and that drugs given safely to the mother
should not adversely affect her developing child. It is now
thought that almost all drugs taken by the pregnant
woman are transferred across the placenta to the fetus.
More importantly, the growing fetus is adversely affected
by drugs that are harmless to the mother.
In UK, where the standards of medical practice are
relatively high and where the medical practitioners prac
tice what they are trained in, a retrospective study of about
1000 mothers showed that excluding iron, drugs were
prescribed for 82 per cent during pregnancy and each
woman received an average of four drugs. In another
survey, all the pregnant women were given at least two
different drugs, 93 per cent received five or more and one
patient admitted to taking 32 different products. The
major classes of drugs prescribed were- analgesics,
vitamins, antacids and antiematics.
With little epidemiological data at hand, the use and
abuse of drugs in pregnancy in our situation can only be
left to imagination. If our own sample survey of prescrib
ing practices in Bombay is any indication, overdrugging
and indiscriminate and irrational use of drugs seems to
be rampant here.
Thus, drugs are used on a large scale by pregnant
women and despite a greater awareness of their potential
hazards, their usage has in fact increased. This is not simp
ly the result of changing obstetric practice, since drug con
sumption has increased in general in all sectors of the
community. The growth of the pharmaceutical industry
and the changing attitude regarding the need for drugs
as a form of treatment on the part of the patient have
also played their part.
Effects of drugs on the fetus:
Day 0 to 17
Exposure to foreign compounds during
this period probably results in an all or
none response. The pregnancy will either
progress or be aborted.
Day 18 to 55
This is the time when organs develop.
Teratogenic effects occur in this period
resulting in malformations.
Day 56 to term- In this period, the main abnormalities
resulting, are due to a reduction in size
and the number of developing cells. It
is important to note that the brain,
unlike most organs, continues to develop
actively throughout the whole of
pregnancy. This explains the abundance
of Central Nervous System effects like
microcephaly, mental retardation, etc.
Drugs used for treatment of minor ailments in pregnancy
Ailment
Pain
(Body ache, backache, etc.)
Drug(s)
Aspirin
Paracetamol
Nausea and Vomitting
Anti Emetics (Numerous pre
paration available like stemetil,
siquil, marzine, Avomine,
Pregnidoxine eta)
Heart-burn and Dyspepsia
Antacids
Constipation
Laxatives
Comments
—Commonest drug taken in pregnancy often selfadministered.
—Said to cause reduction in birth weight, increase in still
birth rate and affects the bleeding mechanism of the
body.
—Should be avoided in pregnancy, particularly in the
treatment of minor disorders.
—Not as extensively studied as Aspirin
—Generally safe
—Recommended as a mild pain killer of choice.
—linked to a number of congenital defects.
—Drug treatment necessary only if symptoms are severe
and prolonged.
—Reassurance, small frequent meals and avoiding large
amount of fluids often helps to control symptoms.
—Drugs containing meclozine or cyclazine are widely
used but are best avoided.
—Non absorbable antacids such as aluminium hydroxide
and magnesium trisillicate may be used
—When taken in early pregnancy, they have been
associated with an increased rate of congenital defects.
—Stimulant laxatives contraindicated (eg.Purgolax,
Dulcolax eta)
—Diet, high in cereal fibre and fresh fruits useful
—Bulk purgative like Bran, Isapghula and
methylcelluloze may be used safely.
As far as possible no drugs should be used in pregnan suggested:
cy, but some common ailments often require treatment a) drugs should only be prescribed when absolutely
for the comfoit of the mother. If pregnant women are to necessary, and only if the benefits to be gained clearly
continue to use drugs, certain recommendations have been outweigh the risks involved to the mother and the fetus.
b) public awareness of the potentially harmful effects of
drugs on the fetus has resulted .in ‘intelligent non com
pliance* to some extent. It is important to educate mothers
about home remedies for minor disorders and judicious
use of drugs as also the potential hazards of self
medication.
c) Doctors continue to prescribe drugs in pregnancy
despite the knowledge of their hazards. If doctors spend
more time in reassuring and explaining to the pregnant
woman rather than prescribing drugs, a lot of misuse
could be prevented.
The sedative ‘Thalidomide*, prescribed to pregnant women
for giving relief from morning sickness was found to pro
duce various developmental anomalies in the new born.
The commonest anomalies are ‘amelia*, total absence of
limbs and ‘phacomelia’, absence of one or more limbs.
The thalidomide tragedy has prompted various nations
to impose strict teratogenicity tests on new drugs before
their introduction into therapeutics.
Analgesic and Essential Drug Production in India
Dr Y K Amdekar
Dr Arun Bal
The plethora of analgesic drugs and formulation is truly
astonishing and shocking. Many of these drugs are sold
as OTC (Over The Counter) drugs. Most of these are ‘MeToo* formulations and are useless. In most of the trials,
relief of pain by an analgesic mixture has not been found
to be superior to that of single drugs. Analgesics are very
commonly used and over prescribed.
Use of analgesics in clinical practice requires an
understanding of the basic physiology of pain. Every
analgesic drug relieves a specific type of pain. Random
and overuse of different combinations of analgesics may
not bring about the desired effect. Use of preparations
with fixed dose combinations containing different drugs
have very dubious pharmacological value. Relief of pain
can be best achieved by judicious use of correct drug in
proper doses administered separately. Besides, the
majority of the fixed dose combinations are exorbitant
and have no advantage. These exorbitant prices are the
result of the undue emphasis on the brand names and
advertising, and have nothing at all to do with the quality
of the products. LOCOST manufactures drugs of the
same quality much more cheaply.
Besides, these nonessential and hazardous drugs are
marketed in India and not in the developed countries.
For this study 66 companies, 35 multinational and 31
national, were surveyed. These produced 2164 drugs of
which 716 were essential drugs and 1448 were, nonessential; 23 were banned.
The drugs included 1536 analgesics, of these 865 were
single ingradient formulations and 671 had multiple
ingradients.
Table 1: Comparison of prices* of some essential drugs produced by some pharmaceutical companies and
by LOCOST
Name
Amoxycillin
250 m.gms cap
Ampicillin
250 m.gms cap
Ampicillin
Syrup 125 m.gms
Chlorphenramine
Mal. 40 m.gms.tab
Chloramphenicol
250 mgms cap
Chlor/rpmazine
250 gms
Calcium Lactate
300 gms
Co-trimexazole
80 + 400 mgms
Co-trimexazole
Syrup 50 ml
* These are 1985 prices.
LOCOST Price
763/1000 cap
620/1000 cap
410/40 ml
660/1000 tab
290/1000 caps
36/1000 tab
14/1000 tab
285/1000 tab
290/50 ml
Price of Commonly Available
Popular Products
Mox (Gufic)
• Wymox (Wyeth)
1660/1000 cap
1900/1000 cap
Ampillin (Lyka)
Ampipen (Wyeth)
1318/1000 cap
1600/1000 cap
Ampillin (Lyka)
731/40ml.
Cadila
IDPL
1584/1000 tabs
1517/1000 tabs
Chloromycetin (Parke Davis )
445/1000 caps
Chlorpromazine
(May & Baker)
141/1000 tab
Bombay Drug
23/1000 tab
Ciplin (Cipla)
648/1000 tab
Ori prim (Cadila)
1326/50 ml
DRUG POLICY INTERNATIONALLY
compiled by Sujata Gothoskar
The Case of Nicaragua
The health policy adopted by Nicaragua after the
Sandinista revolution which overthrew the 40-year-old
Somoza dictatorship is a vivid example of the political
will and commitment towards the health of the people.
Some achievements of the Nicaraguan Unified National
Health System (SNUS)*:-
needing the support of special diagnostic techniques.
2. Three hundred and forty?five drugs whose use requires
clinical pharmacological knowledge, the support of
diagnostic tools or, in the absence of these, the clinical
skill of a consultant. With these, and those in group 1,
100 per cent of primary health care and almost all secon
dary health care can be guaranteed. The supply of some
of them has top priority.
3. Seventy six drugs whose use is associated with substan
tial risks, and therefore require the keeping of adequate
records. It is considered top priority to have certain but
not all of these drugs available.
Drugs were also classified according to the level of the
health systen where they are to be used, with the aim of
better planning their supply and distribution.
The achievements of Nicaragua are all the more im
pressive as these are being maintained against highly un
favourable ‘external’ conditions, its initial underdevelop
ment on the the one hand and continued economic
blockade and external aggression against the revolution
on the other.
• The percentage of the working population covered by
social security has doubled, from 16 per cent to 32 per
cent. Most of the newly covered groups work in the
formerly neglected agricultural sectors in outlying parts
of the country.
• More than 80 per cent of the population now has
some regular access to medical care.
• Since 1977, hospitalisations and surgical procedures
have risen more than 50 per cent, outpatient medical visits
have nearly tripled, and the number of vaccinations ad
ministered has more than quadrupled.
• There are two and a half times more primary health
units, while the number of hospital beds has risen only
Source: “Drug Policy in Nicaragua—between needslightly.
oriented activities and aggression” by Joan Ramon—
• Equitable distribution: in 1980 there was a 4:1 ratio
Laporte and Gianni Tognoni in Development dialogue,
between areas with the highest and lowest rates of outpa
1985:2.
tients visits per capita; by 1982 this was reduced to a 3:1
spread. In the same period, the variation in hospitalisa
tion rates was reduced from 2.5:1 to 2:1. In 1980 the varia
The case of Sri Lanka
tion in doctors per capita between the best and worst serv
ed areas was 16:1, while for nurses it was 5:1; by 1982 these
Although a comprehensive drug policy has not been
had been reduced to 3:1 and 2.5:1 respectively.
formulated in Sri Lanka, some important components of
• 'Health campaigns: immunisation, malaria pro such a policy have been in force for many years now. Some
phylaxis and sanitation campaigns. Upto 10 per cent of of these include the appointment of a national formulary
the people in the country were mobilised as health committee (NFC) by the Minister of Health. This NFC
volunteers (‘brigadistas’) there are now 25,000 permanent decides and exercises a tight control on the drugs for use
‘brigadistas’.
in the state medical institutions as well as the drugs
• It is estimated that between 1978 and 1983 infant allowed to be imported or manufactured locally. This has
mortality decreased from 121 to 80.2 per 1000 live births; prevented the marketing of drugs of little or no therapeutic
value as well as irrational combinations and drugs with
life expectancy at birth rose from 52 to 59 years.
a
low benefit-risk ratio, for which a demand could be "
• The number of reported malaria cases has decreased
created
by heavy promotional activities of the manufac
by 50 per cent; polio cases have not been reported for two
turers
of
these drugs.
years; no measles cases were reported in the first half of
Drugs required for the proper implementation of a na
1984.
• Diarrhoea has fallen from the first to the fourth most tional health policy have been identified by the NFC, par
ticularly for use in medical institutions. Important selec
common cause of hospital mortality.
tion criteria have been: proof of clinical efficacy and safety
* Data from Garfield, R.M., and Taboada, E., American on the basis of controlled clinical trials, and cost, par
Journal of Public Health, 1984, 1138-1144.
ticularly where several therapeutically equivalent drugs are
The criteria for including drugs in the National For available. This list of drugs is constantly reviewed and new
mulary were those of the WHO report on essential drugs, drugs introduced if they offer distinct advantages over the
i.e. proven efficacy, acceptable risks associated with their drugs previously selected.
use, favourable cost, and need. Drugs were classified in
Essential drugs: with the aim of meeting the rational
therapeutic groups following the general classification of needs of the people for drugs in the public sector, the NFC
the WHO Technical Report, and they were divided accor which meets once a month examines applications for in
ding to certain criteria into three priority groups:
clusion of drugs in the state medical institutions. The ap
1. Sixty-five priority drugs, of general use, which can be plicant, usually a consultant in a state hospital, has to give
used by physicians and nurses, since they are associated reasons why the particular drug is necessary. The com
with small risks. They are used at all levels of health care, mittee takes into account the comparative efficiency and
and they can help to solve almost all pathology not safety of the preparation as well as the cost, in making
0))
0)
a decision. Unbiased information regarding newly
approved drugs is circulated by means of the quarterly
journal,The Prescriber, published by the NFC.
In this way a list of essential drugs has been in existence
for the public sector since 1959. No drug outside this list
can be purchased for use in state medical institutions.
region in 1979 was:
Bangladesh (before the radical Drug Policy of 1982)
63.8%;
44.3%
Nepal
30.5%
Thailand
24.5%
Burma
18.8%
India
7.5%
Sri Lanka
Rationalising the supply of drugs
A State Pharmaceuticals Corporation (SPC) has been
References
set up for the purpose of procuring drugs from various
sources for the state medical institutions. The needs of 1 Drug Policies including traditional medicines in the con
text of primary health care W.H.O., 1979.
the private sector are met both by the SPC and private
importers who have been allowed to import drugs. A fixed 2 Dr V.T.H. Gunaratne, “Pharmaceuticals, drug policies
and health care”, 1979.
sum is allocated for this purpose. One of the ways adopted
by Sri Lanka to reduce the drug budget, while at the same
time increasing the availability of useful drugs to the com The information about Sri Lanka only covers the period
munity, was the devising of a sound system of procure upto 1979. Since then, there seems to be no information
ment in the international market. An outstanding exam in any of the medical or other journals on the issue. If
ple of this is the procurement of Diazepam, which could any of our readers have any access to such information,
be obtained at one-fiftieth (2%) of its previous cost.
please do write to us.
Control on drug prices, which had been in force for
several years, was abolished in the 1970s. The private im The Bangladesh drug policy is another important and suc
porter can sell drugs at any price, but is prevented to some cessful policy. It has however been covered and discussed
extent from doing so because of the low prices fixed by in many forums and journals. Some of the important
the SPC for the wide range of drugs imported by it. This sources are:policy of the SPC has helped a great deal in keeping the • Roll, Francis, “Pills, Policies and Profits”.—London:
prices of drugs sold to the public in check. If the prices
War on Want, 1985.
of drugs are high, the drugs that could be procured within © Melrose, Dianna, “Bitter Pills: Medicines and the Third
the limited budget are bound to be severely restricted. The
World Poor”.—Oxford: Oxfam, 1982.
SPC in its report for 1976, reveals foreign exchange sav © Muller, Mike, “Health of Nations: a North South
ings to the tune of over $ 112,000 on the purchase of just
Investigation”.—London: Faber and Faber, 1982.
ten items of drugs, as a result of careful "world-wide- © World Health Organisation, “Drug policies including
shopping” as against the old practice of purchasing it
traditional medicines in the context of primary health
from the local market”.
care; Report and background documentation of the
In Sri Lanka, most drugs are generically named while
technical discussions held during the thirty second ses
in the case of a few, the brand names are permitted to
sion of the WHO regional committee for South East
be printed in half the size of generic names.
Asia, September 1979”. New Delhi; WHO, 1979.
A great deal still needs to be done in Sri Lanka. Some • Tiranti, D.J., “Essential drugs: the Bangladesh
of the problems-areas are:
example—for years on, 1982-86: — Oxford: IOCU,
1986.
* Quality Control
*.
one of the serious problems associated
with the procurement of drugs for use in the country
is the need for quality assurance of the products
Mozambique established its own essential drugs list
imported.
in 1977, nearly a year before the WHO list was
* There is no legislation which provides for the inspec
published. Today, the country limits its drug imports
tion of pharmaceutical manufacturing firms and ran
to the 350 or so products listed in its national for
dom checking of the pharmaceutical products.
mulary. Cost-effectiveness is the main criterion for
* There is no legislation regarding the sale of drugs and
inclusion: each year the Mozambican Phar
any drug can be sold without a prescription except those
maceuticals Commission can spend only one US
which come under the Poisons, Opium and Dangerous
dollar per head of the Mozambique population.
Drugs Act.
There is no money to waste on medicines that are
Even so, Sri Lanka has been able to achieve a great deal
of poor value. To reduce costs further,
with respect to the rational use of drugs. In developing
MEDIMOC—a state purchasing agency—was
countries, the most important determinants of health are
established to bulk-buy the most convenient and
availability of adequate and nutritious food, drinking
economical dosage forms of essential generic drugs
water, sanitation and decent housing. Yet in many of these
by competitive tender. Today Mozambique spends
countries, the drug budget still represents a sizeable pro
no more on drugs than it did before independence
portion of the total health expenditure, 30 to 50 per cent
in 1975, despite world price inflation during the in
or more of the total cost of health care, particularly on
tervening eight years, and an overall improvement
account of the promotional activities of the manufactur
in health care.
ing concerns which create a demand greater than the
Hanlon, J: “Essential drugs for Mozambique” in
actual needs.
World Health, June 1983, Quoted in Beardshaw,
The expenditure on drugs as a percentage of total health
Virginia, ‘Prescription for Change’, 1983.
expenditure in some countries of the South-East Asia
Misinformation—at what cost?
Sujata Gothoskar
In the month of November 1986, just before the New 2. They say...
Drug Policy was to be introduced, the Organisation of
The WHO has recommended a “model” list of essen
Pharmaceutical Producers of India (OPPI) spent lakhs
of rupees and issued three advertisements in the leading tial drugs which now contains 258 bulk drugs (active in
national dailies. These advertisements were presumably gredients in medicines). What is not realised as widely as
issued “in the public interest” and contained misleading it should be, is that these 258 bulk drugs can be manufac
and dangerous mis-information. The following is an at tured into thousands of formulations or dosage forms.
We say. ..
tempt to answer to this tirade of mis-information based
This
is a sleight of hand. The second sentence above
on a systematic appraisal of the drug situation in India
by Dr. K. Balasubramaniam, of the International is the OPPI’s mis-interpretation of the WHO statement.
People who have not seen the WHO document referred
Organisation of Consumers Unions.
to,
may perhaps accept the OPPI statement. But the WHO
1. They say....
Expert
Committee took particular care not only to list
We do not have too many drugs... Much smaller but
the
essential
drugs, but also listed the various dosage
developed countries, whose population is a fraction of
forms
(eg.
tablets,
capsules, ampoules and powder for in
ours, market a far greater number of formulations than
jections,
suppositories,
creams, ointments, inhalation,
India, as the following table shows:
etc.), the routes of administration and the strengths of
each of the various dosage forms that would have to be
Country
Number of
Number/
made available in any country. The fact that an advanced
Formulations
Million
developing country with a strong private pharmaceutical
Marketed
Population
sector can formulate and implement a national drug
West Germany
70,000
1,139
policy based on the WHO’s concept of essential drugs is
USA
45,000
191
shown by the example of Mexico, which is already im
Japan
39,000
331
plementing the exclusive use of generic names not only
Switzerland!
35,000
5,380
in the public sector, but also in the private sector. The na
Italy
12,000
213
tional drug formulary now contains 330 drugs in about
India (estimate)
45,000
60
450 dosage formulations. Currently Mexico is producing
45 per cent of its bulk drugs for the manufacture of about
We Say...
This indeed is a ridiculous “number game”. No, it is 77 per cent of the essential drugs in the national
more. A deliberate attempt at fooling the people. There formulary.
is absolutely no valid correlation between the number of 3. They say...
type offormulations a country needs and the size of its
There are reasons why it is not in the public interest
population. It is not the total quantity of drugs that is to arbitrarily restrict the number of medicines available
being referred to; but the number or type of formulations. in the market. The nature of the disease and the
Their argument is equivalent to saying “how can 1.5 physiology of the human body dictate the need for a wide
million infants die of diarrhoea every year, when the type range of dosage forms, and modes of administration...
of germs per million population are so few”.
Syrups or oral drops are more acceptable and safer for
Secondly, “what is not evident in the given table is that, children...
whereas, in all the five advanced countries listed, the
We say...
thousands of formualtions are marketed over and above
It is in fact in the public interest to reveal that a vast
the list of essential drugs which are available to every one,
majority
of the 45,000 formulations are all either iden
in India, there is an acute shortage of the basic life-saving
essential drugs because the limited national budget for tical or highly similar dosage forms, but merely sold under
pharmaceuticals is allocated for the manufacture and different names and many of them incorporating a wide
variety of active ingredients often in irrational combina
distribution of thousands of irrational formulations.
tions. The WHO model list of essential drugs and dosage
Besides, the OPPI refuses to quote the number of for
forms together with the experiences of countries like
mulations in other countries, where the health care system
is better, where the drug policy is rational, the availabili Mexico, Sri Lanka, Bangladesh... clearly demonstrate
ty of essential drugs far better and the number of for that a limited number of dosage formulations would ade
quately serve the health needs of India.
mulations are far less.
4. They say...
Drug prices in our country are among the lowest in the
Country
Number of Formulations
world
see table.
Marketed
Norway
We say...
1,906
Mexico
450
The OPPI has quoted but not compared drug prices.
Mozambique
2,600
In the Asian countries mentioned in the table, there is an
Bangladesh
2,258
extremely wide variation in the prices of each of the eight
Sri Lanka
900
drugs, depending on the manufacturers. For example, the
Sweden
2,432
price of metronidazole 200mg x 100 tablets in Malaysia
Table
Name of the Drug
Chloramphenicol
(antibiotic)
Metronidazole
(anti-diarrhoeal)
Ferrous Sulphate
(anti-anaemic)
Ibuprofen
(analgesic)
Propranolol Hcl
(anti-hypertensive)
Salbutamol
(anti-asthmatic)
Nifedipine
(cardiac drug)
Cimetidine
(Price to the consumer in Rs)
India
Pakistan
Sri Lanka
Indonesia
U.K.
250 mg/12 caps.
6.87
8.32
18.89
18.43
21.30
200 mg/10 tabs.
2.76
5.74
6.74
. 43.52
25.54
150 mg/15 caps.
8.46
9.36
13.15
200 mg/10 tabs.
6.13
4.68
10.34
10 mg/250 tabs.
48.78
116.50
112.42
2 mg/10 tabs.
1.11
3.40
2.97
10.24
4.57
10 mg/10 caps.
6.00
31.65
5.49
20.48
29.59
200 mg/10 tabs.
7.96
36.41
17.54
49.92
35.59
Unit
12.03
12.80
7.67
70.95
varies from 30 to 108 Malaysian dollars; in neighbouring analgesics, those containing amidopyrine as well as
Thailand the price for the same varies from the equivalent phenacetin, e.g. dolagin, antalgin, A.P.C., dristan,
of M $ 50 to 200. How does one compare the prices of codopyrin, spasmindon and many others.
— metronidazole in these two countries?
6. They say...
9 Secondly, the drugs chosen for quoting are essential There is no unanimity in the action taken by different
drugs. In India, a selective pricing mechanism is in opera countries for the withdrawal of drugs. A drug banned in
tion. The profit mark up for 43 essential drugs is kept
one country may continue to be marketed in another. This
at comparatively low levels of 40 to 45 per cent. The other
is because each country has its own needs and arrange
countries in the tables do not have such selective price
ments. There are genetic, dietary, climatic and other
mechanism. And in India, the drugs which are not in the
differences.
“essential” list do not have the low levels of profit mark
We say...
up. The prices of these eight essential drugs, therefore,
Poison will kill whether consumed in the US or in
cannot be used to draw valid conclusions for the whole
of the drug market. Thirdly, analysis of international drug India! Drugs or combinations of drugs that are banned
policies indicates how erratic drug prices are. Whereas in other countries including oxyphenbutazone, amido
some drugs are low priced in a country, certain others are pyrine, phenacetin, penicillin-streptomycin, and chloramhigh priced in the same country. It is therefore possible phencicol—streptomycin combinations, anabolic steroids
to select groups of drugs and countries to draw valid con as growth promoters, DES and other harmonal prepara
clusions to suit diametrically opposite hypothesis. The tions for pregnancy testing and tetracycline syrup for
OPPI table with no details as to source, data or manufac young children are dangerous in every country and this
has absolutely no relation to genetic, dietary, climatic and
turer, therefore, tells us nothing.
Fourthly, straightforward currency conversion can never other differences.
In fact, dietary conditions will always operate against
be used to compare drug prices between India and a
developed country. By such comparison Indian drug Indians compared to our western counterparts, making
4 • prices will be much lower. Such direct price comparison us more susceptible to the harmful effects of drugs.
is misleading because it ignores vast differences in the Climatic conditions too would operate more against
gross national product of the two countries and the pur Indians than those living in. temperate climates.
chasing power of the people. Not only drugs but several
other basic needs including food, beverages and transport
are several times cheaper in India than in UK on a
straightforward currency conversion. But this does not
mean that an average Indian will have easier access to
drugs and other basic needs compared to the average per
son in UK.
5. They say...
No drug can be imported, manufactured or marketed
in India unless it is approved by the Central Drug
Controller.
We say...
Several drugs banned by the Central Drug Controller
years ago continue to be manufactured^ prescribed and
distributed widely. Some of these are the fixed dose com
binations of Ergot, of vitamins with analgesics and tranquilisers, of cortisone with analgesics, of atropine with
Dangerous Drugs:
Supreme Court ruling a setback
Vimal Balsubrahmanyan
The Supreme Court’s ruling on March 4, 1987, that
judicial proceedings are not the appropriate method for
solving the problem of the continued sale of harmful
drugs comes as a disappointment. Although the Court
did acknowledge that hazardous drugs should be elimi
nated from the market and called on the Central govern
ment to take appropriate steps, the stand taken by the
Court on the role of the judiciary is undoubtedly a major
setback to the movement by activists for a rational drug
policy.
For over four years now, the All India Drug Action Net
work has been campaigning hard for a ban on irrational,
harmful and unnecessary drugs, but with little impact on
the government authorities. The new drug policy an
nounced in December 1986 has totally ignored this basic
demand and contains only a vague, and far from reassur
ing, proposal to set up an ‘advisory’ body to go into this
matter. Keeping in mind the judiciary’s so-called inability
to do anything more than to direct the government to fulfil
its responsibility, people’s action against harmful drugs
becomes imperative.
An informed public can refuse to consume harmful
drugs. But how is this informed public to be created? In
recent months a number of booklets have been brought
out by health action groups, in India and abroad, on
harmful drugs which should be avoided. For various
reasons, these sources of information tend to remain cir
culating within the activist network, and unless the mass
media takes the initiative to pick up this information, it
is unlikely to reach the general public. Not only can the
general media help spread information about harmful
drugs, but also create awareness on the rational use of
drugs. Informed patients will then begin to ask their doc
tors appropriate questions about side-effects, contrain
dications, how long to take the drug, what foods and
drinks are to be avoided while on the drug eta
The media clearly has a potential to fulfil, particularly
in the light of the lukewarm stand taken by the Supreme
Court. Health activitsts lobbying for a rational policy need
to think of adequate strategies for empowering the public
with knowledge. For example, it seems worthwhile to de
mand the inclusion of patient-oriented package inserts
giving the kind of information about drugs which doc
tors ought to be giving to patients but rarely do. All this,
however, will only help to some extent, with the small sec
tion of literate and conscious consumers, while the
illiterate remain the victims of an unscrupulous drug
industry, a callous medical profession and an irresponsi
ble drug policy.
Consumer representation in the formulation of drug policy
—Dr. N.H. Antia
There are primarily six agencies concerned with drugs tions which they now themselves demand.
and drug policy.
In this scenario of opposing interests, the role of the
1. The government.
government and the drug controller should be to protect
2. The drug controller.
the interests of the people—the consumers, and ensure
3. The organisations representing the producers—The that they get an adequate supply of essential drugs at
Organisation of Pharmaceutical Producers in India reasonable cost: that drugs which pose a danger to the
(OPPI), The Indian Drug’s Manufacturers Association health of the people be banned and inessential drugs like
(IDMA), The Indian Drugs And Pharmaceutical tonics, vitamins, digestives, be prevented. This is impor
Limited (IDPL) and those representing the producers tant as they divert money from food to medicines, thus
in the small-scale pharmaceutical industry.
producing further malnutrition and ill-health among the
4. The distributors of pharmaceutical products—the poor, who have to spend almost 90 per cent of their total
pharmacists,
expenditure on food.
5. The doctors
Unfortunately, the nodal ministry for drugs is the
6. Consumers and their organisations.
Ministry of Chemicals and not that of health, with the
The interest of the producers and distributors of the result that drug production is perceived more as a chemical
pharmaceutical products is in maximising profits, i.e., the industry, rather than as a health issue
production and distribution of the largest quantities of
With the monetary power at their disposal, the phar
drugs at highest prices.
maceutical industry has been able to secure strong
The changing prescription habits of the doctors which representation in government decision-making and in the
have resulted in gross overprescribing of drugs is the result type and quantity of drug production. The consumers and
of the combined influence of self interest in an increas their representative organisations, who are chiefly volun
ingly materialistic society and the pressure salesmanship tary workers’ organisations, and who work on a shoe
of the pharmaceutical industry.
string budget are virtually ignored in this decision-making
The interest of the consumers (without who there would process which is vital to the interests of the people.
be no doctors or drug industry) is in the availability of
This is reflected in the perfunctory manner in which
essential drugs at the lowest cost. As a result of mystifica the consumer organisations are treated during consulta
tion and misinformation by the medical profession and tions, which are supposed to be in the public interest.
the pharmaceutical industry, even they have been hooked
If the government is truly interested in protecting the
on to unnecessary and often dangerous drugs and injec interest and health of the people, it will have to
demonstrate its sincerity by ensuring that the consumer
interest is given as much, if not more representation in
decision-making bodies, like the proposed National Drugs
and Pharmaceutical Authoriy (NDPA).
It is not good enough for the government to have
separate discussions with the consumers, producers and
distributors. What is necessary is for all those represen
ting varied interests to meet together, so that the govern
ment may hear all the opposing view-points before any
decisions on such crucial issues are taken.
If this is not undertaken, it will erode the credibility
of the government in the eyes of the public, who are the
consumers of these drugs.
In view of the paucity of the funds available to the con
sumer organisations, as opposed to the almost unlimited
funds at the disposal of the industry, it is necessary that
the government provides support to the consumer organi
sations for participating in these discussions and also for
informing the public about the mis-information provided
to them by those interested in profits rather than in
people’s health.
"Physician, Heal Thyself"
Dr. A.S. Deshpande
A new group of diseases ‘Iatrogenic diseases’, literally
meaning “doctor caused diseases” but now commonly in
dicating “drug induced diseases” has become an enor
mous and growing medical problem. Nearly as many as 28
per cent of the patients under specialised care hospitals in
developed countries suffer from adverse reaction to their
medication. It has been calculated that in US and Britain,
more people are killed by prescribed drugs than by road
accidents. The picture in this country and in other third
world countries may only be guessed.
There are two parties variously responsible for this
systematic and slow genocide-the medical profession and
the drug producing & pushing pharaceutical companies.
My twenty years experience in. the medical profession
had convinced me that this medical profession, which
should be proud of its past notable contribution towards
the welfare of human society, has become a robot in the
hands of drug manufacturing industries and has become
‘an honourbale money-spinning business’. And this has
taken place even though every medical practitioner is and
should be aware of the fact that “All drugs, whatever their
virtues, are inherently dangerous”. In actual practice
however, physicians are grossly undereducated in areas
associated with drugs and are not given the scientific
background necessary to evaluate the claims made for
them. This is one aspect of their heavy dependence on
the biased and totally subjective information supplied to
them by the profit-seeking drug manufactures.
Today the complete medical profession is captured,
ruled, moulded and guided by the giants managing the
pharmaceutical industry. Though a majority of the physi
cians prescribe from a range of only forty to fifty drugs,
there is a litter of more than 25,000 therapeutic substances
in the market. These have been the main sources of druginduced diseases.
Each antibiotic is capable of making a valuable con
tribution to human welfare provided it is correctly used
and not treated as a universal medicament. When the
wonder drug penicillin was introduced, almost all
staphylococcal infections (like abscesses) responded
favourably. But due to its low toxicity, doctors indulged
in casual prescribing resulting in overuse and misuse. This
naturally led to the development of resistant strains of
bacteria. Now 90 per cent of staphylococcal infections
acquired in hospital have become resistant to penicillin.
The sole responsibility for this, lies on the shoulders of
the medical profession which has tried to find shortcuts
for its survival by resorting to unscientific overprescrib
ing and misusing this wonderful antibiotic.
Everybody is too scared of the anaphyllactic shock due
to penicillin injection which leads to instantaneous death
of the patient right on the examination table of the doc
tor. For this it is necessary to give a test dose of penicillin
intradermally and wait for about fifteen minutes to look
for any adverse but local reaction which could appear.
But a busy practitioner does not want to waste his time
in this procedure as it is not going to pay him extra.
Naturally this leads the doctor to switch to higher an
tibiotics like Chloromycetin, terramycin, garamycin etc.
etc. These antibiotics are thereby used in conditions where
they are not indicated and also they are not given for sufficient period of time required. This results in the develop
ment of resistant strains of bacteria.
This has happened in Latin America in 1970, when
more than 20,000 people died by dysentry and typhoid
bacteria which had developed resistance to chloramphenical the drug of choice in this case just because of
its indiscriminate use in the past.
These higher antibiotics are known to produce adverse
reactions like fatal aplastic anaemia. But since this
development does not take place immediately and not on
the examination table of the doctor and that it gives im
mediate relief from the fever, infection, septicaemia with
which the patient is suffering, there is all the praise for
the doctor and only the patients fate is blamed for the
subsequent fatal toxic effects.
According to Dr. Dale Console, “The pharmaceutical
industry is unique in that it can make exploitation seem
a noble purpose”. According to Dr. Robat Arics, the
multinationals spend more money on publicity and in
formation as compared with that on research and
development.
If health of our millions is really our concern, the
following points need to be focused on:a. The precondition for better health is absolute
minimal medication.
b. More than eighty per cent of the diseases can be
prevented by making clean, potable water available for
drinking, together with cheap but well balanced diet and
an unpolluted atmosphere. All our resources should be
channelised in this direction for the betterment of
humanity.
Lastly I would like to say that eighty per cent of the
ailments do not require interference by a physician and
eighty per cent of the ailments in which physician
interferes are aggravated by his interference.
Drugs which boomrang
Dr. Anil Pilgaonkar
Drugs are double-edged weapons. They can ‘heal* and if list of essential drugs and these are just seven in number.:
unwisely used, they can harm. Funnily, a drug may not 1) Co-trimaxazole (sulfmethoxazole + trimethoprim), an
have a ‘potential for cure*, but it always has a ‘potential anti-infective drug; 2) Sulfadoxine + pyreimethine, an
for harm’. Important drugs in this category, are the Fixed anti-infective; 3) Levodipa + carbidopa, and anti
parkinsonism; 4) benzoic acid + salicylic acid, anti
Drug Combinations (FDCs).
fungal drug; 5) neomycin + bacitracin, an anti-infective;
Most FDCs are irrational, because:
6) ethinylestradiol + levonorgestrel, an anti-infective;
i) They increase the cost of the drug unnecessarily.
ii) They increase the chances of drug interactions 7) ethinylestradiol orethisterone, a contraceptive. In addi
tion, only aluminium hydroxide + magnesium hydroxide
considerably.
iii) They make the monitoring of adverse interactions may be considered as rational.
difficult.
Here, we look into three groups of FDCs which take the
iv) They conjuse the consumers and the medical major chunk of the consumer’s money. These are
profession.
A) Combination cough preparations; B) Digestive tonics;
The only rational FDCs are the ones listed in the WHO and C) Vitamin tonics.
Combined Cough Preparations
a) Combined cough preparations have
8 no place in the treatment of respiratory
§ diseases.
u
S
Vitamin Combination Preparation
Digestive Enzyme Tonics
a) In almost all the cases that these
are prescribed, they are not required
and merely pass through the body
without playing any positive role,
because there is in fact no deficiency
of these vitamins.
a) Digestive enzymes which the
digestive tonics contain are pepsin/
papain, pancreatin, diastase/ fungal
diastese etc. Under known conditions,
CQ
these enzymes are never deficient in
(
the system except in a condition called
D
o
achlorhydria when pepsin alone in the
C
as
presence of hydrochloric acid is
<
required.
< b) Many of these contain LARGE
b) Bj, B,, B12, combinations are
b) In infants who suffer from milk
Q number of ingredients in sub-therapeutic marketed as nerve tonics. There is no intolerence, there is a deficiency of an
Z doses.
evidence at all in any of the textbooks enzyme called disaccharidase (which
<
for this claim.
none of these formulations provide).
Therefore the use of these formula
tions is UNWARRANTED.
tn c) Most of these also contain ingredients
with opposing effects, in particular, the
inclusion of expectorants (agents to
2 facilitate cough production), along with
q anti-histamines, sedatives, and cough
suppressants.
8
1) Benadryl expectorant,
( Parke Davis;
2 2) Avil exp., Hoechst;
3 3) Cadistin exp, Cadila;
Q 4) Cheston, Cipla;
Z 5) Cinaryl, Themis;
5 6) Clistin DMR, Ethnor;
“ 7) Contac-cc, Eskaef;
= 8) Corex, Pflizer;
O 9) Dilosyn exps, and MANY
other products.
B-Complex Formulations:
Becousules, Pfizer;
Cobadex forte, Glaxo; .
Bividox, Abbot;
Bivinal Forte, Alembic etc;
Multivitamins:
Multivitaplex, Pfizer;
Becadexamin, Glaxo; etc.
BP B6, B12:
Neurobion, Merck; Trika/
Trinergic, Unichem;
Neuroxin Forte, Cadilla,
and many others.
a) If a demulcent (throat soothing)
a) Wholesome food provides all these
E action in required, simple lump sugar is vitamins.
p adequate as well as safe.
< b) If cough needs to be suppressed, co- b) In case of need, preparations of
2 diene phosphate is recommended. Cosingle vitamins may be taken
F diene phosphate as such is not in the
2 market. The nearest brand is MIT’s LincM tus codeine co. (Astra-IDL). However,
8 even this preparation has unnecessary ino gredients like citric acid and syrup tolu.
Bestozyme, Biological Evans;
Digiplex, Rallis;
Dispeptal, Boehringer Knoll;
Dizytone, Unichem;
Lypzyme, Lupin;
Molzyme, Fair Deal;
Unienzyme, Unichem;
Vitazyme, East India;
Papyta Forte, Anglo French;
Vizylac, Unichem;
Taka-Combex, Parke Davis;
Taka Diastase, Parke Davis;
Orizyme, Kopran and many others.
“Indigestion” is a loosely used term
which really implies distress associated
with intake of food; and is manifested
in one of the following ways:
i) heaviness, bloating and gas
formation, remedies, restricting food
intake/moderation in eating habits.
ii) Irregular bowel movements.
remedy: requiste alterations in food
intake.
AFTER the Second World War, the Allies broke up LG.
Farben into effectively three companies: Hoechst, BASF
and Bayer. Twelve top LG. Farben executives were sentenc
ed to terms of imprisonment for slavery and mistreatment
offences at the Nuremberg war crimes trials. I.G. built and
operated a massive chemical plant at Auschwitz with slave
labour; the I.G. facilities at Auschwitz were so enormous
that they used more electricity than the entire city of
Berlin. Approximately 3,00,000 concentration-camp
workers passed through I.G. Auschwitz. At lest 25,000 of
them were worked to death (Borkin, 1978: 127). Others
died in LG’s drug testing programme. The following
passage in a letter from the company to the camp at
Auschwitz demonstrates the attitude of LG. Farben to the
subjects of its drug testing:
In contemplation of experiments with a new soporific
drug, we would appreciate your procuring for us a number
of women... We received your answer but consider the
price of 200 marks a woman excessive. We propose to pay
not more than 170 marks a head. If agreeable, we will take
possession of the women. We need approximately 150... .
Received the order of 150 women. Despite their emaciated
condition, they were found, satisfactory. We shall keep you
posted on developments concerning this experiment... .
The tests were made. All subjects died. We shall contact
you shortly on the subject of a new load (Glover, 1977-58).
After the war, the Allies insisted that none of the
convicted war criminals be appointed to the boards of the
new I.G. companies. Once Allied control loosened,
however, Hoechst in June 1955 appointed Friedrich
Jaehne, one of the twelve war criminals sentenced to im
prisonment at Nuremberg, to its supervisory board. In
September of that year he was elected Chairman. Bayer
appointed Fitzter Meer, sentenced to seven years at
Nuremberg, as Chairman of its board in 1956.
Source; John Braithwaite “Corporate Crime in the
pharmaceutical industry”. Routledge and Kegal
Paul, London, 1984.
What is New?
Books
Korten, David, “Community organisation & rural
development: a learning process” - New York: Ford
Foundation, 1987, pp. 32.
Computer Maintenance Corporation, “Online access to
international databases” - New Delhi: CMC Ltd, 1986,
pp. 73.
Borkowski, M. “Marital violence: the community
response”: London: Tavistock publications, 1983,
pp. 230.
Delhi Science Forum, “Drug industry and the Indian peo
ple” - New Delhi: Delhi science forum, 1986, pp. 333.
Morley, David et. al., “Dharavi project: 1985” Edinburgh: Edinburgh university, 1985, pp. 155.
Sanders, Donald, “Computers today” - Singapore: McGrawhill, 1987, pp. 648.
Mahadeven, L, “Health in India in 2000 AD. a
preliminary exercise” - Bombay, Indian institute of
technology, 1977, pp.50.
Rose, David A., “Health interview surveys in developing
countries’— London; Evaluation & planning centre,
1984, pp 142.
Lokayan, “On antivoluntarism” — New Delhi: Lokayan,
1986, pp. 63.
Bogue, Donald, “Demographic techniques of fertility
analysis” — Chicago: Community & family study cen
tre, 1971, pp. 116.
Banerji, D., “Political economy of western medicine in
third world countries” — New Delhi: Centre of social
medicine & community healh, 1982, pp. 48.
Reprints
Purandare, Hema (Dr.), “Is sex selection ethical?” —
1986, pp. 6.
World Health Organisation, “Risk evaluation in
chorionne villus sampling” — 1985, pp. 16.
Banerji, D., “The case of leprosy” — 1984, pp. 41.
Bangladesh, “Drug control ordinance — 1982”, 1986,
PP- 2.
AHRTAG, “AHRTAG resource list: Health education on
diarrhoeal diseases” — 1987, pp. 6.
British Medical Journal, “Psychotropic drugs”, 1986,
pp. 3.
British Medical Journal, “Black & white health gap in
the USA” — 1987, pp. 2.
New Scientist, “Drug firm pays price for deception” —
1987, pp. 1.
Byron, M.A., “Treatment of rheumatic diseases” — 1987,
PP- 3.
Zhangfu, Yuan, “Family planning in a Siachen village”
— 1987, pp. 87.
Jeffery, Roger., “Social sciences in health: An alternative
paradigm” — 1987, pp. 1.
Ohrig, Jamie, “A rational study of analgesics & an
tipyretics” — 1985, pp. 24.
Lancet, “Withdrawal of three antibiotic combinations”
— 1986, pp.1.
Apart from our foundation, information on the issue of
drugs is available at:
All India Drug Action Network and Voluntary Health
Association of India, (AIDAN & VHAI)
40 Industrial Area,
South of I IT (near Quatab Hotel),
New Delhi-110 016.
LOCOST
1st Floor, Premanand Sahitya Sabha Hall,
Opp. Lakdi Pool
Dandia Bazar
Baroda-390 001.
Centre for Education & Documentation (C.E.D.)
3 , Suleman Chambers,
4 Battery Street,
Bombay-400 038.
Association of Consumers Action on Safety and Health
(ACASH)
Lawyers Chambers
Room No 21, R.S. Sapre Marg,
Bombay-400 002.
Books in Brief
Manish Mankad
In this volume Leontief & Duchin use input-outpu
1. Mead, Margaret, “Coming of age in Samoa” —
model in an analysis of the complex issues surroun
England: Penguin books, 1981, pp. 240.
ding the impact of computer driven automation on the
Margaret Mead an authority on education & upbring
labour force in the recent past through to the end oi
ing. This book is a vivid account of the life of girls in
the century. Following a general discussion on the
a primitive society. Beautifully written, it brings the
impact of automation on employment, the authors
readers close to the daily lives of the Samoan village and
focus on four specific sectors within four areas of
describes their trials, their scandals and their triumphs,
economy, manufacturing office work, education .&
so that they seen like neighbours, just down the road. A
health care.
good contribution in anthropology.
Leontief & Duchin conclude that by the year* 2000,
The book is in paperback edition and has 14 chapters
automation will not cause dramatic unemployment if
and appendices.
the economy is able to achieve a smooth transition from
2. Borkowski, Margaret et al., “Marital violence: com
the old to the. new technologies. The bok has 6 chapters
munity response” — London. Tavistock publications,
and 2 appendices. One of them provides historical
1983, pp. 230.
database from 1963 to 1980.
This book is based on research into the way practi
tioners in the medical, legal and social services view mar
4. Carmi A. (ed.), “Disability”. —Berlin: Springer Verlag,
riage and violence. Taking samples from groups of doc
1984, pp. 253.
tors, solicitors, social workers, health visitors and women’s
Despite the great strides made by rehabilitation
aid refuges, the authors have investigated the ways in
medicine in improving the physical wellbeing of dis
which different agencies and practitioners respond to pro
abled persons, there remain many barriers to their full
blems of marital violence. They have used combination
participation and to equality in communities where
of statistical information and interviews. According to the
they live.
authors, marital violence is still widespread, they make
recommendations about ways of improving the services
The authors of this volume bring together legal,
available to help battered women.
medical and psychological aspects of disability to allow
3. Leontief Wassily and Duchin Faye, “The future impact
those involved in the case integration of the disabled
of automation on workers’—New York: Oxford
to benefit from the experience of others. Their contri
University Press, 1986, pp. 170.
butions include such topics as problem with the impleWassily Leontief, who is the author of this book was
mentaion of anti-discrimination laws, compensation
awarded the Nobel prize in 1973 for his input-output
for addicts and the medico-legal problems of steriliza
approach to economic analysis.
tion of retarded persons.
(... .continued from page 7)
drug market but on the drug policy as well.
2. The Hathi Committee’s report and recommendations
were widely debated among academics, and many in
the government became sensitised to the issues.
3. The New Drug Policy, with its near complete rejection
of the Hathi Committee recommendations, caused
consternation and debate.
4. In the late 70s, the issue of drugs was a focus of new
groups like the Medico Friend Circle (MFC), compris
ing largely of doctors and health workers. Although
the MFC is numerically small, its influence on the
movement has been significant. Many of the early
discussions of the MFC have been on rationality of
the use of particular drugs, (its campaign for proper
treatment and management of diarrhoea, is a case in
point) and of the drug industry’s manipulations among
medical professionals for obtaining support for par
ticular medicines, etc.
5. Two other movements which gathered momentum in
the early 80s have also played a significant role in get
ting the movement off the ground. —the people’s
science movements in Maharashtra, the Kerala Shastra
Sahitya Parishad (KSSP), and the West Bengal Doc
tors’ movement. The first (especially the KSSP) with
its vast campaign against irrational science and its
abuse exposed the nature of scientific enterprise and
also prepared the ground for questioning the ‘scien
tific’ myths being perpetrated by the drug companies.
The latter, generated an organised forum which con
cerned itself with all aspects of health care including
drugs, its testing etc.
6. Drug costs had risen steeply and many, especially the
large number of voluntary health groups which bad
also became more numerous in this period, had
become very conscious of the need to reduce drug
costs. This was perhaps one of the first motivations
for the VHAI to become interested in the issue.
Thus, the drug consumer movement has emerged out
of a long period of debate and discussions. And like the
people’s science movement, it has been able to bring
together those who have traditionally controlled the pro
duction of knowledge and those who consume it. And
this is also why it is unlikely to fizzle out in the near future
although it might well change its character and re-examine
its strategies.
Edited by Sujata Gothoskar with the co-operation of Manish Mankad and secretarial assistance from Anuradha Naik and Sunita Vichare. Produced
by The Foundation for Research in Community Health, 84-A, R.G. Thadani Marg, Worli, Bombay 400 018. Telephone: 493 86 01. Typeset by
Economic and Political Weekly, Bombay. Printed by Modern Arts and Industries, A-Z Industrial Estate, Lower Parel, Bombay.
CONMMr 1
a—e , ©
47/1. (First flee.-) stnae)
Dangelor - 560 09L
NEWSLETTER
May-June, 1987
Vol. I
No. 4
Health Personnel in India
Ravi Duggal
Sex
Female
Male
(in percent ages)
1. Allopathic physicians and
surgeons
2. Ayurvedic, Unani and
Homeopathic doctors
1 31 Pharmacists
‘ 4. Dental surgeons
5. Public Health physicians,
dieticians and nutritionists
6. Unclassified physicians &
surgeons
7. Nurses, midwives and health
visitors
8. Para-medical technicans (dental
& pharmaceutical assistants,
X-ray technicians,
Optometrists & opticians).
9. Vaccinators, innoculators and
medical assistants
10. Unclassified health technicians
11. Other medical scientists and
technical persons
12. Veternerians and veternery
assistants
13. All health personnel
Area
Rural
Urban
(in percent ages)
Total
Number
Ratio Per
100,000
Population
15
85
.72
28
202636
29.57
5
6
9
95
94
91
44
52
83
56
48
17
120054
176029
8367
17.52
25.69
1.22
13
87
54
46
21013
3.07
6
94
44
56
45982
6.71
89
11
61
39
221963
32.39
10
90
66
34
22912
3.34
7
24
93 .
76
38
53
62
47
47914
225340
6.99
32.89
10
90
83
17
22063
32.22
1
27
99
73
36
56
64
44
6017
1174450
8.78171.40
According to the 1981 Census (5 per cent sample
estimate), there are 1174450 health, medical and nursing
professionals and technicians in India. In addition, there
are 267117 unclassified non-health workers in health in
stitutions indicated.
Health professionals constitute 16.55 per cent of all pro
fessional and technical personnel. Of all the health and
medical personnel (excluding nursing personnel), 91 per
cent are males and 57 per cent are located in urban areas.
If we include nursing professionals, male dominance gets
reduced to 73 per cent but urban concentration remains
almost unchanged at 56 per cent.
Further, if we look at all allopathic doctors separately,
it is revealed that 72 per cent are located in urban areas;
and among all these physicians and surgeons, only 15 per
cent are women.
It must be noted that the data presented in the adja
cent column refers to ‘main workers’. Thus, if the doctor
is a full time teacher or a researcher s/he will not be
recorded as belonging to the cadre of health and medical
personnel. For instance, in 1981, there were 2687-12 doc
tors registered with State Medical Councils.
With regard to the personnel working in primary health
care in government’s rural institutions the following data
for the year 1982 has been culled from Health Statistics
of India (CBHI):
a. Auxiliary nurse midwives
61504
b. Lady health visitors/female health assistants 10625
c. Male health workers
53096
d. Male health supervisors
14875
e. Doctors at PHCs, allopathic dispensaries
& ISM dispensaries
16303
f. Pharmacists
12024
g. Nurse midwives
7006
h. Laboratory technicians
3667
FOR PRIVATE CIRCULATION ONLY
(continued on page 8)
AREN'T WE BEING DANGEROUSLY OVERDRUGGED?
Mukund Uplekar and Madhu Rokle
When thousands of pharmaceutical units producing tens Dr. Z
of thousands of their formulations use their persuasive
A) Injections:
skills to make the doctors push these drugs down the
1. Ampicillin
throats of the people, is it incorrect to assume that we are
2. Dexamethasone
being overdrugged?
3. Garamycin
In order to study the quality of overdrugging, we thought
B) Oral drugs
of a quick way of asking the general practitioners directly,
1. Paracetamol
the most common drugs they use in their practice, of both
2. Chloromyecetin
the injectable and oral drug preparations.
3. Ampicillin
100 G.P.s practising in slums, middle and upper class
localities in Bombay were requested to state the three most
INJECTIONS
common injections and three most common oral drugs
they use in their practice. Generally those busy practi
tioners who had about 10 patients waiting in their dispen
sary were included.
Here are some of our findings:
About half (46 per cent) of the doctors stated that the
most common injections used by them are antibiotics. The
antibiotics mentioned, in the order of frequency of use
were:
k Tetracycline
2. Ampicillin
3. Gentamycin
4. Chloramphenicol
5. Amoxycillin
6. Penicillin and Streptomycin
The commonest injection used by 24 per cent doctors
was a vitamin preparation usually a B-Complex. About
equal numbers used an injectable painkiller most fre
quently. Only 4 per cent mentioned ‘vaccinations’ like
tetanus toxoid or triple antigen as the most frequently used
injections.
Oral antibiotics are being used equally freely (30 per
cent) next only to painkillers (68 per cent). The drugs in
cluded Co-trimoxazole, Tetracycline, Ampicillin, Chloram
phenicol, Sulfonamides and Penicillin in order of fre
quency. Aspirin as a painkiller or antipyretic is used by
very few doctors. Most prefer paracetamol while some
prescribe analgin.
*
It may be worthwhile to mention a few good and notso-good ‘sample’ replies:
Dr. X
A) The three most common injections I use in my
practice are:
1. Terramycin
2. Chloramphenicol
3. Ampicillin
B) The three most common oral drugs I use in my
practice are:
‘As above’
Dr. Y
A) Injections
1. Inj. Tetanus toxoid
2. Inj. Triple antigen
3. Inj. Streptomycin (for TB only)
B) Oral drugs
1. Paracetamol
2. Multivitamin
3. Sulfadiazine
We assume that we have been able to get correct replies
from the respondents. However one fact has left us
wondering. When the first author personally met 10 drug
distributors supplying drugs to G.P.s practising in the
areas surveyed, all of them told him that ‘Dexamethasone
injection’ is also one of three top-selling products. But
it had failed to figure in our statistics. It is said that many
doctors add a small amount of Dexamethasone to every
injection they administer. Presumably, they say, it is ad
vantageous in three ways. One, it minimizes the chances
of a drug reaction, Two, it gives the patient a transient
sense of well being. Three, it gives a quicker temporary
relief. There is no evidence however to indicate whether
this actually happens or should happen. And besides, is
it ethical at all to pump cortico-steroids into unsuspec
ting people, who are told nothing whatsoever of the ef
fects of such drugs?
Leprosy Control by a People’s Programme
'A New Concept in technology transfer’
N H Antia
The most outstanding performance in the field of tion and control of the most major killing and maiming
leprosy treatment is of China. China has demonstrated diseases can best be undertaken by the people themselves
to the world how leprosy can be controlled in a popula with support from the medical services.
tion of such size and with limited financial but unlimited
China has also demonstrated that the control of com
human resources. This has been achieved using only DDS municable diseases including leprosy requires a low level
therapy and with relatively simple facilities for microscopy of technology but a high level of cultural understanding
and with few, if any, inputs into research. China has clearly of the people and respect for their intelligence and prac
demonstrated that we already possess adequate knowledge tical abilities. The present top-down approach of most
and tools and not only for the control of leprosy, but also countries only creates a sense of dependency without any
for most communicable diseases. These diseases have con solution to peoples’ problems. Since this has continued
tinued to take their toll because of the absence of the over several decades it only indicates that those few who
delivery component which needs a strong political will to decide the fate of the majority are either ignorant of the
look after the welfare of the masses.
problems and the abilities of the poor, or have vested
We have heard enough about the wonders of modern interests in keeping them in this state.
medical science, which, without the necessary political will
As in the case of tetanus, the problem is not of drugs or
have failed to solve the problem of diseases that are vaccines but of their delivery. In countries with limited
responsible for the majority of the morbidity and mor resources and large population, distributed in remote
tality that affect people of this world and for whose villages, there seems to be no alternative but to teach the
prevention and control we have the necessary knowledge people to look after themselves and provide the necessary
and technology. Science without its application to the supportive services. It also increases their self-confidence
welfare of society is at best a sterile intellectual exercise in fields other than medicine and reduces dependency.
and often diverts attention and money from simple and
effective measures to expensive technology and managerial
practices. The example of the USA demonstrates how
health and medical research can become big business next The New Drug Policy in Nigeria
only to armaments without commensurate improvement
Amar Jesani
of the health of the people.
In March 1987, the Nigerian Government decided to
Having spoken to many people and having observed
the general health and leprosy services, one is convinced adopt a National Drug formulary and to compile a list
about the statistics which indicates the remarkable of 205 “essential” drugs. The Government will make cen
achievements of China using predominantly simple ‘bare tral purchases of the rational, safe and cost effective
foot’ doctor approach. I am not at all surprised at these generic drugs for all three levels of health care delivery.
achievements because experience at our Mandwa project The list of such drugs will be reviewed every year.
This decision of the Nigerian government has come
has shown that semiliterate village women, given simple
available medical knowledge and technology could achieve after a statement made by its enlightened Federal Minister
in five years many of the targets set for the year 2000 AD. of Health, Prof. Olikaye Ransome-Kuti, in February last
This under extremely difficult conditions, without any in year, that 60 per cent of drugs imported into Nigeria were
puts in nutrition, water supply, sanitation, and opposi unnecessary. Because of its size and influence in Africa,
tion from the health personnel and the local political Nigeria has been over the last many years, an important
leadership. These women, by their constant presence en centre for the pharmaceutical companies to push irra
sured a high rate of compliance, with the result that there tional and even hazardous drugs, through unscrupulous
were no new deformities. Moreover, by spread of infor sales practices. An analysis of the drug order lists for one
mation by simple word of mouth, they overcame the fear state done by a WHO team in 1986, showed that 25 per
of leprosy in 30 villages, so that people came voluntarily cent of all drug expenditure was spent on three branded
for early detection and were rehabilitated once again in products which are disapproved of by many medical
authorities and no longer used in many countries (The
their own family and community.
The medical profession has an unscientific fear of the Lancet, April 4, 1987).
This decision has already started a wave of protest,
disease and has failed to give the necessary leadership.
Nor do they have any desire to involve others or let them though it is still not heard very loudly. The low-keyed op
position is also due to the fact that this decision will af
undertake the work.
The leprosy services have therefore evolved as a vertical fect government health services only. Further, the govern
service, carrying its own stigma. The scientists see leprosy ment has also sought co-operation from doctors and other
chiefly as a laboratory problem. There is hence an un health workers. Only time can show whether the govern
fortunate lack of an objective approach to leprosy. Like ment will be able to get positive cooperation or the in
most diseases, leprosy has been ‘medicalised’ and the dustry and doctors will combine to thwart government ef
socio-economic and cultural factors have been relegated forts. In any case, it is certain that this decision will go
a long way in initiating a debate as well as a change in
to the background.
Our experience shows that the vast majority of the pro the pharmaceutical scene and the prescribing practices in
blems of health as well as diseases, including the preven Nigeria.
Recent trends in the Family
Planning Campaign
Manisha Gupte
The assessment of Ministry of health and family welfare
states that the crude birth rate (CBR) at the end of 1984
should have been 32.6 per 1000 population, whereas ac
tually it was slightly higher—33.6. Whereas 29.4 per cent
of the couples were ‘protected’ by the end of 1984
(sterilisations accounted for 23.7 per cent of these), a CPR
(Couple Protection Rate) of 60 per cent is desired by the
turn of the century. To give the family planning programme
a boost, especially in backward areas, partial assistance
from DANI DA, ODA(UK), UNFPA, USAID and the
World Bank has been received to cover 63 districts in 14
states as ‘Area Projects* for intensive development of
health and family welfare. ‘The objectives are reduction
of fertility and reduction of maternal and child mortality*
(GOI, 1985).
The government has introduced the concept of Net
Reproduction Rate Unity (NRR-1) in its family welfare
programme... ‘After considerable experience in this
regard (need to control population growth), the country
has set before itself the long term demographic goal of
achieving NRR unity by 2000 AD, with a birth rate of
21.0, death rate of 9.0 (life expectancy at birth being 64.0
years) and infant mortality less than 60.0. In order to
achieve this goal, the National family welfare programme
has been and will be strengthened. It is a voluntary pro
gramme. . (GOI, 1985).
In the context of these new goals set by the Indian
government, the stranglehold of family planning over the
already small package of maternal and child health
(MCH) services can be fully understood. In fact, the first
UN Advisory Mission, as early as 1966, had gone as far
as to insist that ANMs (Auxiliary Nurse Midwives) should
be ‘relieved from other responsibilities such as maternal
and child health and nutrition’ so as to concentrate efforts
on family planning (UN Advisory Mission, 1966).
determination (amniocentesis, chronic villi biopsy) or
through sex pre-selection (Ericsson, Japanese method) is
inbuilt within the government’s population control (PC)
policy.
The government’s emphasis on ‘child survival’ rings
another ominous bell. Welcome in itself, the slogan is
reduced to ‘spacing methods’. The earlier mentioned
report of the maternal health and family welfare states
that, ‘since child survival is amongst the foremost factors
which induce the couple to adopt the two child norm,
maternal and child health programme has been given due
importance* (page 116). The strategy becomes clear when
along with the slogan of ‘child survival*, the government
has markedly increased its budget for family planning in
the Seventh Five Year Plan period and the emphasis will
now be on spacing methods for women. It is estimated
that by 1990, spacing methods will account for 20.0 per
cent of ‘protected’ couples against the present level 5.5
per cent. A contraceptive marketing organisation has
been registered to promote spacing methods (GOI, 1985;
p. 107).
The full and part time paid voluntary workers with the
Intra Uterine Contraceptive Devices (IUCDs) had always
regarded women as the major target group. But the
government admits that one third of all IUCDs ever in
serted are removed and one fifth are expelled. The official
ly accepted dropout rate for IUCDs therefore is 53.3 per
cent (GOI, 1986). Naturally, the proponents of popula
tion control would be desperate to design a centralised
and foolproof system that leaves little choice and control
in the woman’s hard to withdraw the contraceptive and
it is in this context that the importance of injectable con
traceptives (ICs) or implants should be understood.
Though ICs as yet do not form a part of the family
planning programme, a pilot study on ICs (Net-En) at
But what is more dangerous, because of its subtlety and PHCs attached to 15 medical colleges is underway. Based
cunning is the recent trend that the government has been on the results of this pilot project it is hoped to introduce
this spacing method soon. Infact, according to official
following.
plans it was to.be introduced in 1984-85. The ICMR is
The first double edged tool within the family planning also conducting its studies with Norplant—an implant for
programme came in the form of the Medical Termination women. An appropriate version of this contraceptive was
of Pregnancies (MTP) Act in the early seventies. Regarded to be available by the end of 1985 to start the programme
by feminists as a much desired means to control one’s fer introduction studies at the PHCs (GOI, 1985; p. 107).
tility, the legalisation of abortions is in itself welcome.
The interests of the multinational drug companies in
However, the government’s interest in this legalisation
becomes clear when.one notes that by the end of March this becomes clear when one realises the tremendous
1984, in alj, 4,553 institutions were rendering MTP ser potential market they have in healthy women all over the
vices as compared to 4,170 at the end of March 1983. In world. Three to five million women in seventy countries
Bombay city alone, 50,000 MTPs are registered annually were on depo provera alone, in 1978 (Corfman, 1978). Ac
(Karkal, 1984). The immense potential of MTPs where cording to the 1981 Census of India, 43.4 per cent of all
women are in the reproductive age group and of these
avertion of births is considered, is self evident.
80.48 per cent are married. That makes for 11.6 crores of
The official acceptance of NRR-1 by the government married women in the reproductive age group only on the
is especially sinister because in lay person’s terms, it spells Indian subcontinent. Since injectables are to be used as
that only one daughter should replace her mother. Bet a spacing method, all of these women become potential
ween the lines therefore, female foeticide through sex targets at least once in their lifetime.
It is therefore easy to understand the direct and indirect
involvement of drug manufacturers in research related to
long acting contraceptives and the implicit bias underly
ing all these research studies. Even ‘prestigious* interna
tional bodies such as the International Planned Paren
thood Federation (IPPF) describes all injectable con
traceptives as a ‘most dependable and useful method of
family planning (IPPF, 1978). Contraceptive technology
is more under the control of multinationals than that of
women.
of women trained to motivate for family planning. These
corps will be nonpaid and interestingly, acceptors of
family planning method themselves. Another significant
move by the government in the near future is to disband
all male community health volunteers. Through the IUCD
programme, it has been learnt that male motivators can
not do the job where spacing methods are concerned.
Male health workers have experienced embarassing con
sequences while having to explain Copper-T insertions to
a woman or to her husband. To close all loopholes
therefore women motivators exclusively would approach
It has also been decided to initiate two million corps* women targets, henceforth.
People’s Perception
The tragedy is that so many ambitious programmes have been launched in the name of India’s poor masses
and when the programmes fail or falter, these poor masses are blamed. For example, it is generally believed
in New Delhi that the Ministry of Health and Family Welfare has created a vast network of health infrastructure
throughout the country whose under-utilisation is very high and health administrators are unable to explain
this persistent phenomenon in the face of the high levels of mortality and morbidity, particularly in rural
areas. It is also contended that the Ministry of Health and Family Welfare has created a vast network of
personnel, right from medical officers at the block level, down to trained dais and Village Health Guides
at the village level but this huge staff. is not able to get the requisite sterilisation cases for fulfilling the family
planning targets. This implies that the staff is not working efficiently. In short, it is contended that our
health and family planning programmes are not working well because the infrastructure remains unutilised
for some mysterious reason and the health personnel are not putting in their best, again for some mysterious
reason.
Against this official perception of the administration of our health and family planning programmes,
we have the other side of the story based on people’s perception. The questions the masses would like to
ask are as follows: Why are doctors not available at the Primary Health Centres and ANMs not available
at the sub-centres? Why are medicines not available to the poor? Why is there no follow-up of acceptors
of sterilisation? Why are women brought to the PHCs for laparoscopic operations in government vehicles
but not taken back after the operation? Why are the X-ray machines not working in so many PHCs and
hospitals? Why is there no facility for oxygen and blood transfusion even in upgraded PHCs? Why are the
government doctors so indifferent to rural patients? Why do the PHC buildings have often no proper water
and electricity facilities? Why are the new sub-centres and residential houses built for ANMs so sub-standard
and located in such forlorn places? Why did the contractors get away with the sub-standard construction
under the so-called foreign-aided Area Projects?
Ashish Bose, “For whom the target tolls? a critique of family planning incentives, cash awards and targets’’
National Commission on Self-Employed Women
The Department of Women and Child Development, and agarbattis.
,
Government of India, has constituted The National Com 2. Vendors.
mission on Self-Employed Women, to conduct a com 3. Service workers—domestic help, washer women,
prehensive examination and study of self-employed scavengers, rag pickers and prostitutes.
women and the entire group of unprotected women 4. Process workers—traditional and non-traditional.
workers. To assist its working, the Commission has con 5. Manual workers—agricultural, construction.
stituted various Task Forces. One of the Task Force is on
health aspects. The following members constitute the Task
We would like to appeal to individuals/groups/organisaForce:tions and all of those who either work on these issues or
— Convenor
1. Dr. A. S. Desai
know about information on these, to contact us and make
— Co-Convenor
2. Dr. Saroj Jha
the entire exercise a useful one by helping in a fuller
— Member
3. Dr. Kashyap
documentation of problems and strategies relating to the
4. Ms. Srilatha Batliwala
health aspects of the lives of women working in the
5. Dr. Rani Bang
—
unorganised sector.
6. Dr. Veena Shatrugna
—
Task Force on unprotected women workers
7. Ms. Manisha Gupte .
—
The scope of the women workers to be covered by the address:- c/o Tata Institute of Social Science
Sion-Trombay Road., Deonar,
Task Force would include:
Bombay - 400 088.
1. Home based workers e.g. garments, dyes, chemicals.
COMMUN. :
47/1. (First Floor) St. Mioul
FRCH News
In the last 6-8 months, four new projects took off nearly dholdings, the income distribution, the food and con
at the same time. These research projects deal with dif sumption expenditure, (including expenditure by class),
ferent aspects of the health needs of the people and health health care and expenditure and ultimately raises relevant
services offered and made available to them. Each of these methodological issues.
Here we very briefly note some of the findings on health
research projects hopes to explore different methodologies
care and expenditure only.
in the field of health research.
These projects are:
HEALTH CARE AND EXPENDITURE
* “Strengthening health education services—an
action—research study”. This is a four year project and
For the reference month (January 1987) 459 illness
is being carried out in Pune district, and will cover ap episodes inflicting 455 persons have been reported in the
proximately 30,000 population.
sample population (3524). The number of illness episodes
* “A study of primary health centres in Maharashtra”. reported here exclude ongoing chronic ailments for which
The main aim of this research project is to study the pro no cure was sought in the reference month. This works
blems faced by the health personnel in the primary health out to a monthly morbidity rate of 130.3 per 1000 popula
centres and family welfare programmes in the rural areas tion or 4.2 per 1000 population daily. This is a fairly low
of Maharashtra. Secondly, to study people’s knowledge estimate. January is considered to be a “healthy” month
and opinion about these programmes and the PHCs.
and morbidity is expected to be the lowest at this time
* “The awareness of the General Practitioners regarding of the year (winter). Among all households only 50 per
the Health for all objectives and the major national cent reported at least one illness episode.
programmes”.
In an earlier study “Critical study of health services
Inspite of government hospitals and PHCs, it has been
in
rural Maharashtra” which covered a population of 4567
estimated that the general practitioners cater to over seven
ty per cent of the people in both the rural and urban areas. persons, in 1984, in 4 different districts over a 5-month
The aim of the study thus, is to make the general practi reference period (January to May) the morbidity rate
recorded was 6.74 illness episodes daily per 1000 popula
tioners aware of the real health needs of the people.
* “Health expenditure in India: case study of a district”. tion. Therefore with the inclusion of chronic episodes the
This is a 4 year research project and the pilot study has morbidity rate in the present study would be comparable.
just been completed. Some objectives of this study are:
The rural-urban differential with regard to morbidity
a) to understand health expenditure both at the macro and indicates a higher morbidity rate of 4.65 illness episodes
micro level.
daily per 1000 population in rural areas as compared to
b)to document private health expenditure of households 3.35 illness episodes daily per 1000 population in urban
as a proportion of their consumption expenditure.
areas.
c) to disaggregate and critically analyse the various com
It is important to note that the definition of illness dif
ponents ‘of health expenditure.
fers among classes not only for cultural reasons but also
d)to identify and document differentials of health expen simply because of the availability of disposable income.
diture based on seasonality, socio-economic strata and Therefore reporting of illness is dependent largely on the
social geography and,
respondents’ perception. However, investigators were
e) to evolve a methodology for the study of health asked to specifically proble for illness episodes even where
expenditure.
no treatment was sought.
These objectives are to be realised through:
As regards treatment, an overwhelming 75.85 per cent
a) a national data search of State (Central and State sought the aid of private practitioners and private
Governments) financed health expenditure, with hospitals. There is no significant variation between rural
case-studies,
and urban areas with regard to the use of private practi
b) a sample study of corporate sector health financing, tioners. In the urban areas 79.88 per cent went to private
c) a sample study of private practitioners and hospitals, practitioners and in the rural areas 78.21 per cent did so.
d) and a comprehensive study of private household exThe total health expenditure in the sample population
penditre in a representative population.
works out to Rs 18.88 per capita per month. This amount
In its review, the Project Advisory Committee recom is 12.5 per cent of reported income and 10.5 per cent of
mended that a pilot study be carried out in a represen total consumption expenditure (after including medical
tative sample, initially for a period of one year highlighting expenditure within it). Since the reference month is a
methodological issues and disaggregating various com healthy one this expenditure would consequently be on
ponents of medical expenditure and subsequently the the lower side. As a percentage of expenditure on food
study, after review, be extended for its full period of 4 health expenditure works out to 18.8 per cent.
years.
Further, on an average, for every illness episode
Therefore the study was commenced with a household reported, Rs. 144.91 was spent on it. This means that each
based field study in a representative district (Jalgaon in time a person falls ill, a phenomenal 95.5 per cent of
Maharashtra), ignoring the macro analysis for the time his/her monthly per capita income or 80.6 per cent of per
being. The study was designed and the methodology capita consumption expenditure or worse still 128 per cent
developed in consultation with Prof. K. Ramchandran of of per capita food expenditure is* spent on getting cured.
AllMS, who is an informal advisor for the study.
At the given morbidity rate (which is a low rate) every
The pilot study is a fairly detailed analysis of the fin individual is expected to fall ill on an average 1.6 times
dings. These include the analysis of agricultural Ian(continued on page 8)
Child Labour and Child Health
Sujata Gothoskar
The 1981 census estimated India’s total population at
638.8 million, of which 42 per cent were children. The
number of children has increased from 250 million to 264
million during the period 1971-81. Nearly 14 per cent of
the children born'in India die before their first birthday.
Around 60 per cent of preschool children suffer from sever
malnurition. It was estimated that “of the 23 million
children expected to be born in 1983, only 3 million will
be healthy and fully productive citizens. Of the rest, 4
million will die in childhood and 16 million will become
adults with poor physical and mental abilities caused by
malnutrition... An expert recently warned that about 65
per cent of India’s children suffer from mild to modest
malnutrition, whereas 30 per cent were victims of acute
malnutrition”. The mortality rate for children below 4
years is 4® per cent compared to7 per cent in most
developed countries.
In the context of this, the low literacy rate is not a
shocking fact. Though, the enroll ment of children in the
age group 11-14 years has increased from 12.7 per cent dur
ing the last 25 years, yet nearly 50 million children in the
6-14 age group are still out of school. Of these 71 per cent
are girls. (The discrimination of girl children, which begins
from before their birth through sex-determination tests,
then greater undernourishment, is evident in their meagre
access to primary education as well). Out of every 100
children, who enter the first grade, 64 per cent leave the
school before completing their primary education upto
class V and 77 per cent leave school before completing
their education upto class VIII.
One of the causes as well as the consequences of this
situation is child labour, though both these relate to
another more basic situation—immediate survival. 90 per
cent of the families of working children in Madras were
found to have an income below Rs. 500/- per month. The
figures for Bombay and Delh were 78 per cent and 88 per
cent respectively.
Hence child labour is considered to be a problem mainly
of poor and destitute families, where the parents can af
ford neither the education expences of the children, nor
the minimal expenses of their lodging and boarding,
without the children contributing to their own upkeep.
And families who cannot “feed any extra mouth” con
stitute some 80 per cent of the population of this coun
try. The result is obvious. Every ‘mouth’ also has ‘two
hands’, and they have to be put to work. In the last 15
years, child labour population has increased from 10.7
million to an estimated 20 million and in states like Tamil
Nadu, constitute almost 6 per cent of the total workforce.
In 1980, the ILO estimated that there were 50 million
working children in the world. Of these 38 million in Asia
alone. India constituted a third of Asia’s child labour and
a fourth of the world’s working children. It employs the
world’s largest child labour force.
The Asia Labour Monitor, quoting a survey conducted
by the Operation Research Group, writes that there are
44 million child labourers in India. “Every third household
in India, has a working child and every fourth child in
the age group 5-15, is employed. Approximately 83 per
tent of tender age (sic) children in the urban areas work
for 7 hours or more per day”.
However, the Encyclopaedia of Social Sciences warns
us, “long hours of work, late hours or night employment,
continuous standing, sitting or use of single set of muscles,
emphasis on the finer neuromuscular coordinations with
attendant nervous strain,... carrying heavy lods... are
unsuitable occupations and provide harmful conditions
for the growing child particularly susceptible to certain
deformations and diseases”.
However, according to a report in the Economic Times,
“Out of the 310 million children by the end of 1985, the
number of working children will around 110 million and
the number of child labourers in the total labour force
has been increasing over the years”.
References
1. K.C. Seal, ‘Children in employment’ in ‘Profile of the
child in India: Policies and Programmes. Ministry of
Social Welfare, Government of India, 1980.
2. K.D. Gangrade and J.A., ‘Gathia, Women and child
workers in the unorganised sector’, 1983, Concept
publishing compny, New Delhi.
3. “44 million child workers in India”, in Asia Labour
Monitor, Malaysia.
4. Gita Balachandran, “Working too early in life”, Social
welfare, Vol XXIII No. 2, May 1986.
What is New
Central statistical organisation, “National seminar on
social statistics—Vol. I and II” - Bombay: Allied
publishers, 1977, pp. 410 & 442.
Goyal, M.R., “Anatomy of medical education” - New
Delhi: Central subscription agency pvt. Itd., 1986,
pp. 306.
Jarin, A.P., “Report of the study group on hospitals” New Delhi: Government of India, 1968, p. 262.
Seal, S.C., “Plague: Conquest and eradication in India”
- New Delhi: ICMR, 1987, pp. 272.
National institute of mental health and neurosciences,
“Manual of mental health for multipurpose workers”
- Bangalore: NIMHANS, 1985, pp. 62.
National institute of mental health and neurosciences,
“Manual of mental health for medical officers” Bangalore: NIMHANS, pp. 112.
Central bureau of health intelligence, “Medical education
in India” - New Delhi: 1986, pp. 375.
Grossinger, Richard, “Planet medicine: from stone age
Shamanism to post industrial healing” - Boulder”
Shambhala publications, 1982, pp. 436.
Hussein, Abid, “Report of the CSIR review committee:
towards a new perspective” - New Delhi; CSIR, 1986,
pp. 99.
Tietze, Christopher, “A world review 1986: induced aborlion” - New York: Allan Guttmacher institute, 1986,
pp. 143.
Books in Brief
1. Seal S.C. “Plague: conquest and eradication in India”
- New Delhi: ICMR, 1987.
The author had an opportunity to study plague
through field and experimental work covering all the
epidemic phases, eg. pre-epidemic, post & inter
epidemic, through follow up work for 28 years from
1948 to 1976.
This compendium is an attempt to consolidate all his
findings in the background of the chronological
development of knowledge. In fact, it is only when the
subject is viewed from the historical standpoint that
we can realise the magnitude of debt to the pioneers
of the past and the task which still remains to be
accomplished.
; .
2. Singh Andrea Menefee & Vittaner Anita Keller - (Ed),
“Invisible hands: Women in home-based production”
- New Delhi: Sage publications, 1987.
This collection of original articles examines women’s
home-based production in diverse cultural, occupa
tional and home-based production in India, in areas
like beedi-rolling, electronics, crafts, garments, dairy
production and petty trading.
It takes up issues like visibility of home based work,
its nature and context, the legal aspects, future
strategies and ideology of this type of work.
3. Demonte, Darryl, “Industry versus environment, three
controversies”, New Delhi: Centre for science and en
vironment, 1985, pp 285.
This bok gives an account of three environmental
controversies. They are: The Silent Valley Hydro
electric project which was stopped due to environmen
tal reasons, the Mathura Oil Refinery, a subject of the
most extensive studies in the world on the effects of
pollutants on monuments, and the Thal-Vaishet fer
tiliser plant. The book examines various alternatives
and concludes that development and environment, far
from being in opposition to each other, infact, go hand
in hand.
4. Mach, E.P. and World Health Organisation, “Plann
ing the finances of the health sector: a manual for
developing countries”. Geneva: World Health Organisa
tion, 1983. pp. 124.
This book deals with a methodology for carrying out
detailed analyses of the financing of health services.
It suggests ways of collecting and organising data on
the expenditure and sources of finance. It also suggests
how this information might be utilised in the formula
tion of policies. Particular attention is paid to primary
health care, in view of its high priority in terms of cur
rent health policies. A series of tables presents models
that provide an analytical framework for national plan
ning. Summary tables have been devised for the use
of policy-makers.
(from page 1)
This means that only 15.25 per cent of all health per the remaining 50 per cent, 90 per cent is spent on surgery,
sonnel work in the rural primary health sector of the diagnostics and hospital costs and the remaining 10 per
government (34.61 per cent of all rural health personnel). cent on diet, rituals, baksheesh/bribes, etc... (please note
Further only 5.05 per cent of all doctors work in PHCs that "this breakup is tentative only).
It must be noted that this expenditure excludes loss of
and government rural dispensaries (13.15 per cent of all
rural doctors).
earnings as a result of illness. With regard to rural-urban
These are then some of the glaring inequalities in the differentiation in health expenditure,it is interesting to
distribution of health personnel in India.
note that in rural areas the monthly per capita health ex
(Sources : 1. Census of India, 1981, part II—special series I—India, penditure is higher (Rs. 17.07) as compared to urban areas
* Report and Tables based on 5 per cent sample, Census (Rs. 14.76). The variation needs to be looked into carefully
Commissioner, New Delhi, 1984.
to isolate the factors, besides the higher rural morbidity
2. Health statistics of India, Central Bureau of Health rate, determining it.
Intelligence, Ministry of Health and Family Welfare.
Government of India, New Delhi, 1983).
(from page 6)
in a year. This would mean about Rs. 231.86 per capita
per annum or Rs. 17,389.50 crores for the whole country
per year at current market prices. And this is not the total
health expenditure in the country—it is only the portion
borne by households out of their own income.
Disaggregating this private household health expen
diture (medical expenditure to be more precise), we see
hat 42.7 per cent of this total is spent on doctors’ fees
md medicines (since in a large number of cases doctors’
fees and medicines could not be separately accounted for,
the two categories have been combined). Another 7.2 per
cent is spent on transport costs to avail of medical care.
These constitutes 50 per cent of the expenditure and of
Copies of the following publications are available at the
FRCH:
* Bhore Committee report, 4 Volumes, p. 1201.
* Desai, A R (Dr), “Women’s liberation and the politics
of religious personal laws in India”, 1986, p. 100.
* ICMR and ICSSR, “Health for all: an alternative
strategy”, 1981, p. 262 (English and Marathi).
* UNESCO, “Health education intervention: an
annotated bibliography”, 1986, p. 103.
* VHAI, “Banned and bannable drugs”, 1986 (2nd ed.),
p. 68.
* FRCH, “NGO’s in rural health care”, Vol 1, 1986,
p. 176.
Edited by Sujata Gothoskar with the co-operation of Manish Mankad and secretarial assistance from Sunita Vichare and Anuradha
Naik. Produced by The Foundation for Research in Community Health, 84-A, R.G. Thadani Marg, Worli, Bombay - 400 018. Typeset
by Economic and Political Weekly, Bombay and printed by Modern Arts and Industries, A-Z Industrial Estate, Lower Parel, Bombay.
NEWSLETTER
Vol. I.
July-August, 1987
No. 5
Occupational Health: Some Issues
Vijay Kanhere
“ALMOST all the agents that have been recognised as be
ing carcinogenic in humans, have been identified as such
in the occupational setting”,—Encyclopaedia on occupa
tional health and safety by the ILO.
The greater the number of chemicals used in industries,
the greater are the number of affected persons. The ef
fects of chemicals in their acute form are obvious.
Thousands of persons affected due to MIC in Bhopal,
posed a grave problem to community health. And what
about the workers in the factory, who were slowly and
regularly being affected not only by MIC, but also by
other chemicals like phosgene? Are not the workers also
a part of the community?
Let us take the example of silicosis. It is usually treated
as tuberculosis. This has happened in Mandsaur in
Madhya Pradesh and Baroda in Gujarat. Workers in
Alembic Glass Works had to struggle for being treated
as patients of silicosis. What is the effect of these patients
on the community? Their lungs are affected, their
resistance to disease goes down and they readily contract
tuberculosis. This increases the occurrence of TB in their
families and the community.
Noise pollution in the community has been widely
discussed. It was a topic dealt with in a popular televi
sion serial as well. However, what is hardly ever mention
ed is that workers are day after day, for years attacked
by noise—in the textile mills, in engineering units, on
boilers, compressors... As the hearing capacity of
workers gets affected, apart from many serious possible
accidents, their irritability increases. Within the family,
it creates tensions. Everybody has to speak up so that the
affected worker.can understand. He/she too judges the
capacity of others from his/her or own and so starts talk
ing in a louder pitch, which irritates other family members
in turn.
There are carry-home diseases such as asbestosis.
Chemicals reach homes through overalls, clothes, un
washed body parts and they affect family members. One
ESIS doctor informed us that the majority of the cases
he treats are those of dermatitis, induced by exposure to
chemicals.
No longer can one think of occupational diseases as
an exclusively urban problem. In Punjab and
Maharashtra, there are areas where insecticides are sprayed
aerially by helicopters. These insecticides affect
agricultural workers and farmers. Chemicals used in
agriculture are increasing at a fast rate. In rural areas,
where residential areas and work-places are not sharply
differentiated, the effect of these hazardous substances
are going to be all the more.
The National Commission on Labour in its report in
1969 commented, “... the slow and agonising process of
an occupational disease may not stir the community as
much as it would in countries with chronic labour shor
tage, although to the near ones, it is a tragic occurrence.
Relief gets organised soon after the event, but prevention
gets side-tracked”.
However, in countries like India, relief too takes a very
long time. The Bhopal disaster made national and inter
national news. However, almost 7 months after the
gruesome event, conscious doctors had to move the
Supreme Court merely to get the supply of the proper
medicines. (Dr. Vohra Vs. the State, 1985). Even in a
metropolitan city like Bombay, relief has not been effec
tively organised even in cases of chlorine leakages.
In fact very often it is even difficult to get diagnosed
as a victim of an occupational disease. Workers suffering
from asbestosis even in cities like Bombay, have to go
through a tiresome process merely for being diagnosed
properly as patients of asbestosis.
There are various reasons for this state of affairs. For
one thing, any talk about health and safety at the
workplace is seen as a direct threat to the profits as well
as to the power of the management. This also relates to
the lack of political will to take the health of the workers
seriously. This reflects in the content and approach of the
curriculum in medical colleges. Thus even the knowledge
about ‘notifiable diseases’ is absent with most doctors,
including those working in industrial areas.
This is glaringly brought forth in the fact that from the
year 1960 to 1980, there was not a single case reported
of 11 out of the 22 ‘notifiable diseases’. In this period only
30-32 cases of diseases have been reported per year, while,
with a much better technological set-up in the factories,
almost 20,000 cases of asbestosis are reported each year
in the US despite better preventive measures.
From this it is obvious that the doctors can and must
play greater role in learning about, diagnosing and repor
ting various industrial and occupational diseases. It is also
necessary to make this information available not only to
the industrialists and government agencies but more im
portant to the workers themselves, their relatives and the
public at large especially the poor who are most exposed
to these hazards. This is one important weapon to stop
the mindless and inhuman maiming of lives in this
country.
FOR PRIVATE CIRCULATION ONLY
To
The FRCH collective.
I acknowledge, with thanks, the receipt of the BiAnnual Report of your Foundation and the latest issue
of FRCH newsletter.
Both these publications bear your stamp and put forth
loudly and clearly the messages that need constant re
emphasis in our country.
I must confess that I cannot agree with all that is said.
Working, as I do, in a public hospital, full time, I see the
need for such hospitals and for specialities such as mine.
The poorest need excellent service no less than do the wellto-do and I feel that it is imperative that we keep our
public teaching hospitals in the forefront of patient care.
Unfortunately, these days it is the 5 star hospitals that are
in the forefront, whilst the public hospitals are starved
and downgraded.
Whilst there is no dispute regarding the need for effi
cient measures to improve public health, prevent disease,
educate the population at large and generally do all that
is possible to improve the economic status of the villagers
in particular and labourers in general, I see the ill effects
of these being pitted against development of the large
teaching hospitals. I feel that this is wrong. BOTH NEED
ATTENTION, DEVELOPMENT.
Sunil Pandya
Neurosurgeon
K.E.M. Hospital
Bombay
Notes from Medical Journals
Mukund Uplekar
Is our pursuit of a healthy body—a major threat to
health?
Ivan Illich, a long time critic of the medical establish
ment no longer views doctors as the major threat to
health. He has discovered a far more dangerous pathogen
the pursuit of a healthy body. Once again we have found
the’enemy and once again he is us. Complacently we have
stood by while a multimillion-“health industry” has taken
over, offering advice and handholding to the fibre eating
health magazine readers whom the doctors are too busy
to see. These new pseudoscientist healers diagnose yeast
cells in the blood as a cause of your tiredness, and cure
it with a garlicky remedy that only they sell. They analyse
your hair to find out which mineral or vitamin you need
to buy from them. They measure your body fat by pin
ching you with calipers; determine your skin’s resistance
and electro-magnetic balance with galvanometers; and
perform stress tests, conveniently combined at health clubs
with a massage, a sauna, or the whirlpool. Various “Car
diovascular” exercises are carried out perched on a sta
tionary bicycle while hooked up to a pulse monitor that
lights up as you reach the top of an imaginary hill.
How harmful are these practices other than wasting
people’s money? Illich rails against these “sundry holistic
well-being programes” this “curious mixture of opionionated and detailed self care practices”. He thinks this
mumbo jumbo could cause even more harm than 100,000
patients being seriously injured each year by
hospitalisation.
Antibiotics in Antidiarrhoeals
In Antibiotics: the wrong drugs for diarrhoea’ Health
Action International draws attention to the WHO state
ment that “antimicrobial drugs are not indicated for the
routine of acute diarrhoea”. Health Action International
claims that spending on antidiarrhoeals (nearly $ 150
million a year) diverts attention and resources from oral
rehydration which is a lifesaving treatment.
Products containing neomycin, streptomycin, chloram
phenicol and sulfonamides are singled out as being the
“worst of a bad lot”. For example, widespread and irra
tional use of streptomycin has led to the development of
bacterial resistance to the drugs for the treatment of tuber
culosis. And despite the well recognised risk of bone mar
row suppression, chloramphenical is present in 12
products.
Of the 12 regions surveyed, only Hong Kong has
stringent regulations to prevent the registration of an
tidiarrhoeals containing an antimicrobial. The report will.
be sent to health ministries, drug regulatory agencies and
medical schools around the world.
Interaction Between the Government, NGOs and the
Private Sector in Implementation of HFA
Abhay Bang
1.I deological basis of cooperation: The cooperation can the NGOs assume, especially if they want to increase
between the government and the NGOs in the health sec their impact by interacting with the government which
tor was always on the basis of common ideology and alone has the political responsibility and resources to pro
interests. Thus different categories of NGOs were col vide HFA?
laborating at different times with the then ruling govern
The following roles may be posible
ments. Christian missions were actively cooperating with
1. Research and Innovation
2. Demonstration
the British rulers with common imperial interests. The
3. Training
Gandhian constructive institutions were active in col
laboration with the Congress government with their com
4. Evaluation
mon roots in the freedom movement and ‘Congress’
5. Building public opinion for changes in
ideology. The gates were opened for the voluntary agen
government policies.
cies with closer links with the ‘opposition’ parties (when
While the last one is not cooperation with the govern
these came into power under the name of Janata Party) ment in the narrow sense, this role is extremely impor
by allowing a major role to NGOs in the National Adult tant. The history of public health is studded with examples
Education Programme. Now with the free market ideology as to how this role has greatly improved the government
of the Rajiv Gandhi government, the private sector shall policies and programmes. The Sanitary Movement in
have more role. The talk of social marketing, of delegating Great Britain in the 19th century or the work of the en
the responsibility of advertisement of the national pro vironmentalists today are glaring examples. However, the
rest of the discussion in this paper does not include this
grammes to private agencies arc a few examples.
Where do the NGOs in the health sector ideologically type of role.
stand today? Inspite of their tremendous diversity and dif 3. Issues in Government-NGO Interaction: In any work
ferent religious or economic roots, most of them explicitly ing together,compatibility on the following points is im
or implicitly believe in the welfare state with a mixed portant, and hence needs attention.
1. Ideology and Goal
economy. Obviously they do not find- any major
2. Objectives (specific)
ideological problems in collaborating with the various
3. Organisational structure and culture
governments in India. Even those who profess to have a
4. Procedures and rules
radical ideology usually do not have problems in
5. Personalities
cooperating with the government as long as they can con
6. Finance
tinue to attack the system while retaining their safe posi
The ideology and the goal being similar, these don’t
tions in the urban universities and institutions. Many other
grass root workers or activists strive for limited reforms pose much problems in the actual working together. But
by opposing government policies; and yet in the long run the different emphasis due to the different objectives may
they too work with the government as their reforms are pose a problem. Down in the field, primary health care
seems to be reduced to fulfilling targets of a few vertical
accepted.
Thus most of the NGOs today have no major programme objectives. Family planning (FP) tops the list
ideological barriers for cooperating with the governments with immunisation and blindness control coming next.
Rest of the programmes or indicators like infant mortali
in India.
2 Role of the NGOs: Inspite of hundreds of failures of ty count little. The NGOs may have different or broader
implementation, the National Health Policy is more pro objectives and hence a tussle for priority may ensue. A
gressive than most of the NGOs. At least at the concep NGO may not be willing to go all out for the numerical
tual level, the Primary Health Care is oriented to preven targets of FP while for the government health officer, it
tion, outreach and use of paramedics, while most of the is a sacred cow.
There is a contradiction in the structure and function
NGOs are still curative oriented, running charitable
of
the Primary Health Care strategy. The National Health
dispensaries or hospitals or diagnostic camps. Gone are
the days of Albert Schweitzer or Father Demain when Policy has abandoned the unipurpose organisational
such individuals or NGOs outreached where no govern structure. Now we have buildings and a large number of
ment care reached. The most important outreach agen health workers so that an organisational basis is created
cies today are the government or the private practitioners. for continuous and comprehensive health care. And yet,
Thus in Gadchiroli district which is probably the most the health programmes are still conducted in the form of
difficult district in Maharashtra, there are 3 NGOs in campaigns which need a mobile structure and large scale
health, 34 PHCs, with 230 subcentres and 700 CHVs and propoganda rather than buildings and accessible workers.
about 300 General Practitioners (including Registered
In its relationship with the government organisation a
Medical Practitioners).
NGO is likely to face what may be called the ‘middle level
A recent study by FRCH on the NGOs in health in constraint’. At the top, the officers can take a broader view
Maharashtra concluded that the NGOs are concentrated about cooperation. The bottom level functionary may be
in the developed districts rather than the backward areas. happy to work with a.NGO because of more humane and
With the tremendous expansion of the government
health sector or the private practitioners, what new role
(continued on page 8)
Industrial Accidents: Whose Life, Whose Responsibility?
Sujata Gothoskar
EVERY five minutes, one of the world’s workers is killed
and fourteen permanently disabled as a result of accidents
at work or occupational diseases, according to an estimate
by the International Labour Organisation (ILO). In In
dia, over the 30-year period from 1950-1980, 36,000
workers have been reported killed and 6.4 million injured
in accidents at work in the factories in the organised sec
tor, mines, ports, docks and railways alone. The number
of workers killed or maimed in the unorganised industry
can only be a guess. And over the years, statistics indicate
that injuries due to industrial accidents continue to
increase.
The number of fatal accidents has risen by 225 per cent
in the last 30 years, from 248 in 1950 to 806 in 1980. Nonfatal injuries, equally dangerous *, have been rising even
more rapidly, from 76,000 in 1951 to 355,000 in 1980—a
393 per cent increase.
Increase between the years 1950 and 1980
Increase in average daily employment
Increase in fatal injuries
Increase in non-fatal injuries
120 per cent
225 per cent
393 per cent
An international comparison also indicates that acci
dent rates in India are exceptionally high. It is difficult
to compare statistics for non-fatal accidents since criterion
for reporting are different in different countries, but fatal
accidents can more easily be compared.
The figures for India are based on accident reports
received by the Factory Inspectorate, and therefore relate
only to ‘reportable’ accidents, i.e. those which lead to an
absence from work of two days or more.
Moreover, it is well known that even reportable ac
cidents are very often not reported by employers, as they
wish to avoid paying compensation or getting prosecuted
for non-compliance with the law. And the law does not
even cover construction workers or workplaces with power
employing less than 10 workers and workplaces without
power having less than 20 workers (and most contractors
take care not to have more than 19 workers on any one
site), so that some of the sections, which are subjected
to most hazards—in small-scale industry, construction,
contract workers, etc,—are not included in accident
statistics at all.
Finally, these figures do not include the enormous
number of people who are killed or disabled by oc
cupational diseases. Taking this into account, it appears
that a significant proportion of the total working popula
tion suffers from some form of injury, upto and including
fatal injury, due to occupational hazards. In short, the
situation is appalling, and it is getting even worse.
This points to the extreme urgency of monitoring ac
cidents. This is of course not an easy task. Nevertheless
most accidents cause immense misery to workers and their
families and most accidents have a clear cause (i.e. they
*Every non-fatal accident has the potential to become a
fatal one the next time it occurs.
are not really ‘accident’alat all) and this cause can be and
has to be pinpointed and removed. This process of pin
pointing and removing the cause of industrial accidents
and occupational diseases has important implications.
Number of fatal injuries per million human hours worked
Countries
number in
1979
1980
U.S.A.
U.K.
Japan
Yugoslavia
India
0.03
0.03
0.02
0.07
0.15
N.A.
0.03
0.01
0.08
0.15
To begin with, it puts a halt to deaths and mutilations
of more workers. Secondly, it asserts that workers have
a right to work without their lives or well-being being •
jeopardised. Thirdly, it gives workers the right to know
and act in favour of their own safety according to the
knowledge they have gained about the work process. Four
thly, it makes a political statement about the primacy of
workers’ safety vis-a-vis either management prerogatives
or the blind profit motive.
Theories of Accidents
The standard explanation for most accidents is that they
are due to either unsafe mechanical or physical conditions,
or unsafe actions, or both. However, the actual causes of
accidents cannot be attributed simplistically, but are much
more complex, especially, if ‘unsafe actions’ are attributed,
as they usually are, to workers.
For example, one could consider the accident at Union
Carbide, Bhopal, in which Ashraf Khan was fatally in
jured. He was splashed with phosgene while opening a
pipe for maintenance work, panicked and removed his
safety mask before decontaminating himself, inhaled a
fatal quantity of the toxic chemical and collapsed. The a
management took the position that it was his unsafe •
action—removing his safety mask—which resulted in his
death. Yet the fact is that the pipeline was supposed to
have been properly evacuated and put under vacuum, ac
cording to the company’s own laid-down procedures. The
pipe-line should have been empty. Ashraf had no reason
to think he would be splashed with phosgene, and in the
circumstances, his panic was an entirely normal human
reaction. Thus to say that this accident was due to both
an unsafe action and an unsafe condition is really to
misrepresent its cause. If the design and processes can
not pre-judge and plan according to entirely human
responses of the moment, clearly such designs and pro
cesses are at fault? As the safety manager at Siemens put
it, ‘the work place and work processes have to be not on
ly full-proof, but also fool-proof. Even ‘deliberate ac
cidents’ should be planned against in the original scheme
itself. One did not even ask for that much in the Bhopal
case.
Again, take the finding that contract workers have a
higher incidence of accidents, especially fatal accidents.
For example, in a petroleum plant in Bombay, a contract
worker, working in a pool of liquid which he believed to
be water, threw a lighted match into it, it turned out to
be oil, however, and he was burnt to death. This would
be considered a clear case of an unsafe action but the
cause of the accident was ignorance on the part of the
worker. Thus to say that the cause of this accident was
an ‘unsafe action’ would be completely erroneous, because
to use untrained and uninstructed workers for work with
hazardous chemicals is to create an inherently unsafe
situation.
cident Prevention’ Industrial Safety, Health and Welfare Cen
tre, Central Labour Institute, Bombay)!’
If the accident proneness of a few individuals is not
responsible for most accidents, are there other factors
which are within the control of workers? Could there be,
for example, self-infliction of injuries in order to get timeoff from work? Or could a large number of accidents be
due to the carelessness of workers?
Of those interviewed, not even management represen
tatives thought that such causes could account for a
significant proportion of accidents. Nor does it seem likely
that workers would court death or mutilation if they could
There are unlimited instances, indicating the fact that avoid them. Most of the accidents are such that even if
it is absolutely necessary to go beyond the superficial the actual injury is minor, it could easily have been much
category of ‘unsafe action’ and investigate why the un worse—and therefore to inflict it on oneself would involve
safe action took place.
incurring the risk of serious injury or disablement. Our
Another theory explaining the occurrence of accidents, investigation shows that where workers do take such risks,
attributes the majority to a few individuals who are it is for reasons beyond their control—e.g., because the
predisposed to have a high rate of mishaps. At three places work-situation itself forces them to do so, because they
out of twenty where we obtained interviews, one worker are ignorant of the dangers, because they are asked to do
was identified as a victim of repeated accidents, and in jobs for which they are insufficiently trained, and so forth.
On the other hand, the conditions and actions which
a tyre factory and in the docks, there were a few such
workers. But in most places, there were no such ‘repeaters’, routinely lead to accidents are within the control of
and even in cases, where a few workers repeatedly had ac management; and it is in recognition of this that most
cidents due to drunkenness and negligence, they were far modern health and safety legislation lays the responsibility
from accounting for even a significant proportion of the for providing a safe and healthy workplace on the
employer.
accidents.
This article is based on discussion and research work
Our findings were confirmed by other studies:
done
for the Accidents bulletin: No. 10, of the Union
“Numerous studies carried out by research workers have fail
ed to prove conclusively that any group of persons in a given Research Group, Bombay and the several discussions with
sample can be separated as accident-prone. Dr. Schulzinger, Rohini, Vijay, Ram and Jairus, and going through their
after careful study of 35,000 injury cases,... suggests that notes and jottings.
most accidents are due to the relatively frequent solitary ex
perience of a large numer of individuals. The total number
of accidents suffered by those who injure themselves year
after year... is relatively small... Professor Edwin E.
Ghiselli... advises that the term accident proneness should
never be used in studies of the causes of accidents and in
juries, as it is according to him “dangerous and misleading
and contributes nothing of practical value to our understan
ding of the causes of industrial accidents and injuries”. (Ac
References
R.R. Nair, Workplace accidents are increasing, Science Today, September.
1982.
K.C. Gupta, Challenges in the area of Occupational Safety and Health
in the coming decade, paper presented at International Congress on
Safety, Health and Environment, February, 1987.
H. Ganapathy, Prevention of accidents in building construction, Central
Labour Institute.
Ban EP Drugs: An Appeal to SC
Ravi Duggal
The hearing of the Public Enquiry commissioned by
the Supreme Court (SC) regarding banning of the
highdose Oestrogen Progesterone (HDEP) combination
was held on 14th July in Bombay. Like the earlier three
hearings in Madras, Delhi and Calcutta it was also a farce.
The very nature of the enquiry needs to be questioned.
The SC must look into this matter seriously because this
sort of an enquiry is the first of its kind and is going to
form a precedent. And a bad precedent would be both
unjust and dangerous.
First of all the Drug Controller (DC) cannot constitute
the authority to sit over such a hearing because it is par
ty to the decision-making process (in this case banning
or continuing the production and sale of HDEP). Given
the political economy of our country, aptly illustrated by
the Justice Lentin Commission’s exposure of the Drug Ad
ministration of Maharashtra, the impartiality of the DC
office cannot be assumed. The pharmaceutical industry
is too powerful a lobby and the DC authority is highly
influenced by the former. This was too obviously apparent
during the proceedings of the various hearings.
The SC should also question the manner in which the
concerned drug companies have gathered evidence in sup
port of HDEP, when internationally its hazards are well
recognised. It was amply evident during the hearings that
most gynaecologists and other medical and phar
macological experts who submitted in favour of the drug
companies did so for reasons other than their own belief,
practice and conviction. The written submissions given
by many gynaecologists and doctors are mere signatures
on standardised statements obviously circulated by the
drug companies.
Further, the entire focus of the public enquiry has been
on technical issues relating to HDEP and the clever use
of legal loop-holes. The DC and the drug companies, as
well as their supporters, have completely ignored social
realities that are crucial in making decisions concerning
human lives. The panel conducting the hearing compris
ed only of “technical” persons from the DC’s office. No
social scientist, lawyer, gynaecologist, or representative of
consumer and civil right groups were, there on the panel.
Worse still no woman was represented on the panel. Isn’t
it ironical and unjust that the fate of a drug consumed
only by women is being decided by men who’ll never have
to experience the hazards of the drug! Why does it always
happen that any question that involves women’s rights,
security and health is treated with neglect, carelessness
and apathy? These shortcomings in itself make the nature
of the enquiry questionable.
The most important issue that should concern this en
quiry and has totally been overlooked is the nature of
medical practice in India. In general the type of private
medical practice prevailing in the country is grossly
unethical and irrational. The checks and control by the
Medical Council of India and the Drug control Ad
ministrations is virtually non-existent. One doesn’t have
to hunt around to gather proof for this. It is well known
and documented. The Lentin Commission has adequate
ly exposed the misdeeds of both the drug companies and
the Drug Administration. The dangerous and misleading
practices indulged by the medical profession in India to
make a fast buck are well known. General Practitioners
will administer injections, tonics, steroids and antibiotics
for ailments like headaches and colds or give an in
travenous drip of calcium gluconate to a patient complain
ing of tiredness. Gynaecologists will reconstruct hymens
to reassure virginity, conduct sex-determination tests, help
preselect sex of foetuses and do ceaserians and hysterec
tomies even when not required.
The prescription practices of an overwhelming majority
of doctors is largely unethical and irrational and this is
the danger that concerned people supporting the ban of
HDEP fear most because HDEP is being grossly misused
by doctors, like many other harmful and also relatively
harmless drugs. I will not go into the misuses and hazard
of HDEP because a lot has already been written and
documented about this.
What should the supreme court look into? First of all
it must scrutinise the adequacy and fairness of the enquiry.
The general experience of the hearings has been that the
fundamental basis of the enquiry was faulty and therefore
the enquiry invalid. More thought needs to go into for
mulating the structure and nature of the enquiry. The SC
must review this seriously because we don’t want a poor
and unjust enquiry to become a historical precedent. The
SC must assure impartiality and justice—a properly con
stituted unbiased enquiry commission, that seeks indepen
dent evidence and is not an interested party to the deci
sion, somewhat similar to the Justice Lentin Commission,
should do an adequate job.
The SC should also immediately put into effect the
earlier ban of HDEP that was made by the government
on the recommendation of the Indian Council of Medical
Research, the premier medical research institution in In
dia. When many developed countries after bitter ex
periences have already banned or withdrawn HDEP on
grounds of well known health hazards, associated with
the drug then why wait for further evidence to ban the
drug. Do we want another thalidomide type disaster? How
can the SC and the government permit a known hazar
dous drug to be produced, marketed and consumed free
ly in the country? Even an iota of doubt about the harm
fulness of drug is sufficient reason to ban it, especially
considering social realities of our country. It is indeed in
human to let loose a harmful drug on an uninformed and
oppressed people.
Therefore it is important that the SC in reviewing this
public enquiry should reassess the basis of formulating
terms of reference and assure that social aspects of the
concerned issues are taken into account adequately. And
it is our fervent appeal to the Chief Justice of India to
ban HDEP with immediate effect in the larger public
interest.
PESTICIDE POISONING
Amar Jesani
Pesticide poisoning, including attempted suicide by in
gesting pesticide, is a significant health problem, par
ticularly in the third world countries. In our country
reliable statistics on pesticide poisoning are very difficult
to obtain, although there are some estimates and these
suggest an increase in the number of people suffering from
this problem. Of the third world countries, some studies
are available from Sri Lanka. A survey covering hospita
lised patients between the years 1975 and 1980 revealed
that 79,961 patients were admitted due to pesticide poison
ing, 6083 of whom died. Organophosphate compounds
accounted for 76 per cent of these poisonings. Further,
on analysing data for the year 1979 in this survey, it was
found that 73 per cent of these cases were due to attemp
ted suicide.
From the data of this Sri Lankan survey and others,
certain new and disturbing medical aspects of
organophosphate pesticide poisoning are emerging. The
most commonly seen, and known symptoms include
cholinergic crisis, with miosis, sweating, salivation, etc.
This is treated with high doses of the anticholinergic drug
atropine, cholinesterase reactivators (oximes) and pyridine.
In addition to this acute cholinergic-toxicity phase,
observed in all cases of organophosphorous pesticide
poisonings, some people suffer after two to five weeks of
exposure, from a delayed peripheral polyneuropathy in
volving the distal muscles of the extremities. This syn
drome is also known, though not properly documented
in our country.
Recently, in the March 26, 1987 - issue of the New
England Journal of Medicine, Senanayake and
Karalliedde have described another new syndrome of the
neurotoxic manifestation of the organophosphate poison
ing. They observed,in 10 out of 95 patients (in Sri Lanka),
muscle weakness after 24 to 96 hours after the cholinergic
illness, involving primarily the proximal limb muscles,
neck flexors, certain cranial motor nerves and the muscles
of respiration. The effect on respiratory muscles is indeed
very serious. Seven of these ten patients had difficulty in
breathing and' three of them died of respiratory failure.
The authors have called it “an intermediate syndrome”
and the condition does not respond to atropine and
oximes.
This expansion in the clinical profile of the
organophosphorous poisoning has very serious medical
as well as public health implication, especialy in the third
world countries where these pesticides are liberally used,
carelessly packaged and dispensed and are the favourite
of those who want to commit suicide.
Jeyratnam, J de Alwis, Seneviratne R. S., Copplestone
J. E, “Survey of pesticide poisoning in Sri Lanka” Bull.
WHO, 1982: 60: 615-9.
What is New?
Books
40(5), 194-199, 1986.
WHO Chronicle, “Maternal mortality: helping women off
the road to death”.—WHO Chronicle, 40(5), 175-83,
1986.
British Medical Journal, “Measuring morbidity”.—BMJ,
294, 263, 31st January 1987.
Maria Mies, “Why do we heed all this? a call against
genetic engineering and reproductive technology”.—
women’s studies I nt. forum, 8(6), 553-560, 1985.
Robinson Jean C., “Of women and washing machines
employment, house work, and the reproduction of
motherhood in socialist China”.—China quarterly, 10,
32-57, March 1985.
Flavin Christopher,* “Reassessing nuclear power: the
fallout from Chernobyl”.—Washington: World Watch
Institute, 1987, pp.91.
Fukuoka Masanobu, “One—straw revolution: an in
troduction to natural farming”.—Rasulia: Friends rural
centre, 1986, pp.181.
UNICEF, “Learning together from the Sri Lankan ex
perience”.—Geneva: UNICEF, 1984, pp.112.
Zaidi Akbar S., “Issues in the health sector in
Pakistan”.—Islamabad: Pakistan institute of develop
ment economics, 1986, pp.20.
Mitra Ashok and Mukherji Shekhar, “Population, food
and land inequality in India: 1971”.—Bombay: Allied Prakash Padma, “Sexism in medicine” (paper for 3rd na
tional conference on women studies, Chandigarh.—
publishers, 1980, pp.112.
pp.28, October 1986.
Eastman kodak company, “Information age
technology”.—Singapore: Addison—Wesley, 1986, Barreto Luis (Dr.), “Unemployment among doctors: its
roots in socio-economic development in India”.—MFC
pp.654.
India, Government of, “Health information of India:
meet, 10, January 78.
1986”—New Delhi: Directorate general of health ser
Duggal Ravi and Gupte Manisha, “XYZ of sex”.—Indian
vices, 1986, pp.292.
post; 31st May 1987.
Ford Foundation, “Banwasi Sewa ashram (Anubhav: Ex
periences in community health)”.—New Delhi: Ford Awasthi Ramesh and Gupte Manisha, “Our destiny floats
with the clouds”.—Indian post, 14th June, 1987.
Foundation, 1987, pp.32.
Duggal Ravi, “Why population won’t fall”.—Indian post,
Reprints
13th June, 1987.
Fulop Tamas, “Health personnel for health for all"—
progress or stagnation (part 1):—WHO Chronicle,
Duggal Ravi, “You can’t blame third world all the
time”.—Indian post, 30th May, 1987.
Books in Brief
Manish Mankad
Indian Council of Medical Research, “Medicinal plants
of India: Vol. 2"—New Delhi: ICMR, 1986, pp.600,
Rs.136/-.
The need for a systematic compilation of data on
medicinal plants in India has been felt by almost all
research workers engaged in the study of medicinal plants.
In 1976, Indian Council of Medical Research published
a first volume comprising of information on nearly 350
species of plants presented in alphabetical order (A to G).
The present 2nd volume extends the same (H to P). It pro
vides in addition, separate indices for botanical names,
chemical constituents as well as names of plants in English
and regional languages of India. Further, classified lists
of plants according to their pharmacological activities are
furnished in one of the indices. This volume also contains
coloured plates of plants.
World Health Organization, “Concepts of health
behaviour research (Searo regional health papers no. 13).
New Delhi: WHO; 1986.
The global strategy for Health for All by 2000 recognis
ed the need for health behaviour research (HBR). Despite
this good start, research efforts in relation to national
primary health care programmes were initially slow in
recognising the need for and committing resources for
social science research. HBR was needed to help reorient
the planning and implementation of primary health care.
(continued frontpage 3)
This document defines the scope and future direction of
HBR within WHO/SEARO. HBR is viewed as part of
health systems research and an integral complement to
all primary health care components.
Feminist review, “Sexuality: a reader".—London:
Virago, 1987.
The book includes discussion of issues relating to sexual
politics, the social construction of feminity and masculi
nity, psychoanalysis, lesbianism, pornography and
representation, sexual violence and adolescence, with each
article set in its time and context by a series of prefaces
especially written for this volume.
Fukuoka Masanobu, “One straw revolution: an introduc
tion to natural farming”.—Rasulia: Friends rural centre.
1986, pp.181.
The author describes the events that led to the develop
ment of his natural farming methods and the impact that
it has had on his land, himself, and the thousands of
people he has taught. He feels that natural farming pro
ceeds from the spiritual health of the individual. He con
siders the healing of the land and the purification of the
human spirit to be the same process and proposes a way
of life and a way of farming in which this process can
take place. More than merely indicating methods, this
book aims at changing attitudes: about nature, farming,
food, human—physical and spiritual health.
necessarily accompany government grants. In both ways,
the NGO looses its qualities or autonomy and speed.
How can government money be made available to
NGOs and yet not have these side effects is an issue for
discussion.
liberal treatment. It is at the middle level where the pro
blem of rivalry and sharing of power arises and hence a
great resistance or even hostility may start.
A maze of procedures and inscrutable rules which are
characteristic of government functioning pose two types
of problems. NGOs often understand the intricacies of CHV Experiment: A Case of NGO-Government
Interaction
these or can be easily trapped into immobility while
working with these. On the other hand the NGOs have
When conceived, the CHV was to be a volunteer bring
the advantage of autonomy and flexibility in their own ing with him/her the qualities of NGO, i.e. autonomy,
structure and their partnership with a government institu motivation, community participation, etc. And yet
tion or officer who is tied by the procedures may be like during implementation he was converted into the lowest
a pair of unequal bullocks resulting in strain and category of government worker with little financial
dissatisfaction to both.
remuneration. He was subordinated and internalised by
Even in the seemingly faceless and impersonal govern the government health structure.
ment system, the success of cooperation may depend
A fate similar to that of CHV must be avoided by giv
heavily on personalities. A single person with vision and ing attention to the various aspects of interaction discuss
openness for new things can make a world of difference. ed above. And yet, this is a new area of organisational
Whether NGOs find a cooperative government officer or research and innovation. Only through a process of trial
an obstructive one in their path depends on their luck or and error, experimenting and learning that a feasible
on political manoeuvering. How to match compatible per model will emerge. Respect for each other and openness
sons* from two sides so that smooth working is possible is an essential prerequisite on either side.
is a major issue.
Government money should be available to NGOs in
Abbreviations
health if they too are working for HFA. And yet if NGOs
NGO : Non-government organisation
take money from the government, they are either subor
HFA : Health for All
dinated by political weapons or they are trapped and im
FP
: Family Planning
CHV : Community Health Volunteer
mobilised by the endless restrictions and procedures which
Edited by Sujata Gothoskar with the co-operation of Manish Manked and secretarial assistance from Anuradha Naik and Eleuterio Fernandes.
Produced by the Foundation for Research in Community Health, 84-A, R.G. Thadani Marg, Worli, Bombay 400 018. Telephone: 493 86 01. Printed
by Modern Arts and Industries, A-Z Industrial Estate, Lower Parel, Bombay.
Health of Half the Humanity Neglected
THE health of women is one of the most neglected areas
in life and in research. This is because it is considered
unimportant by the policy and decision-makers in society
and in the household. This is especially true for the vast
majority of labouring, poor women, those who are
unorganised, unprotected, those who are self-employed
or those who work for a wage or even without it. Though
this situation exists not only in the area of health, it is
all the more glaring in this area, because in more ways
than one, the opportunities available to especially these
sections of women to participate in other areas of life,
depend crucially on their access to the opportunity to be
healthy.
On the other hand, the obstacles to their achieving even
the simple state of well-being are tremendous and emanate
from almost every institution and structure they are
remotely in relationship with. Poor women cannot be
educated, leave alone be trained; and in order to make
both ends meet, they have to work, most often in the
unorganised industry, where working hours are long, and
the pay meagre. They have little choice to deny jobs hazar
dous to their health. On the other hand they cannot take
time off from their work, either for illness, or before and
after their delivery. Their access to health care is reduced
considerably due to the greater distances to health care
facilities, the difficulty in ‘choosing’ from available health
care facilities, the non-availability of enough time to go
there, the problems in making the other members of the
household interested in their health. These very factors
make the women more vulnerable to various chronic and
acute illnesses, most of which like anaemia, they carry and
suffer along with them, till they become acute and fatal.1
The health status of women in India as indicated by
demographics and statistics is a matter of serious con
cern. The higher mortality rate and lower life expectancy
are only a few of the many grotesque indicators of their
poor health status and poor access to health care facilities.
Statistics on health facilities and their use, indicate that
women go to hospitals and contact medical functionaries
less often than men. Women approach the health care
system only for serious problems. Studies also indicate
that the amount of money spent by individuals and
families for medical treatment is greater for men.2 This
discrimination begins at a very early age—at childhood.
This is all the more true for sections of people with limited
SPECIAL ISSUE ON THE HEALTH OF POOR,
LABOURING WOMEN
resources. If there is money only for one person to have
access to health care facilities, it is the man who gets it—
the head of the household, the bread-winner. This is true
also where women are the main supporters of the families.
The preference for sons ensures that the health facilities
will be used more by boys than by girls.
A detailed field study in a village of Western UP to
identify the prevalence, if any, of discriminatory practices
against girls and women, found indications of indirect
discrimination against baby girls in breast-feeding. When
the first child was a daughter, the mother tried to become
pregnant immediately for a son.3 Soon after they con
ceived, women stopped breast-feeding the baby daughters.
In contrast, when the first child was a son, an attempt
was made to postpone the next pregnancy through
abstinence. In the distribution of more nutritious food
like milk, butter and eggs, sons were shown preference.
Even in the Morinda study in the state of Punjab, the most
significant determinant of nutritional status was found
to be sex.4
The low intake of food and nutrition by women results
in their being “lighter than their desired weights”. Women
have no energy reserves for emergencies and hence fall
ill or at least feel ill more often. Also their mortality rates
are higher in the event of an epidemic. This could also
result in early wearing out of cells, and hence early ageing.
Besides these, there are a considerable number of pro
blems women, especially poor, labouring women suffer
from. These are menstrual and menopausal problems,
dysmenorrhoea, white discharge, uterine bleeding, back
pain, migraines....
Besides, these there are many health problems that
women face related to the work place. These problems in
turn affect women’s general health problems and com
pound them. For example, the hazards of pollutants on
women affect not only the women themselves, but could
also be and often are dangerous to the foetus—especially
during, but not necessarily only during pregnancy and
lactation.
References
1. Shatrugna, Veena. Women and health, Research Centre for Women’s
Studies, 1986.
2. Nirmala Murthy. Providing health care to rural women in India: some
management issues paper presented at the conference held by the
Equity Policy Centre, Washington, U.S.A. in June 1980.
3. World Health Organisation, Maternal mortality: helping women off
the road to death, 1985.
4. World Health Organisation, Health implications of sex discrimina
tion in childhood, 1986.
FOR PRIVATE CIRCULATION ONLY
Women Workers in the Service Sector
THESE include women domestic workers, washerwomen,
women rag-pickers, sweeper-women, prostitute women
and many other sections of women workers. However, here
we will discuss only the relationship between work and
health of the domestic workers.
Housework has been considered, especially in today’s
society as an unskilled and not-so-strenous job; more so
the work of domestic workers. Yet the personal experiences
of domestic workers which have been documented, in
dicate a number of fairly serious health hazards.
Though domestic workers exist also in rural areas,
working in the homes of rich farmers, the majority of the
domestic workers live in hutment colonies which have
sprung up all over the cities and towns. Hence, problems
like inadequate water supply, poor sanitary facilities,
substandard housing and alcoholism which are the pro
blems of most slums, are also the problems faced by the
domestic workers.1 It is generally difficult to guage the
exact number of women in this occupation, as workers
in this category are not surveyed as such by the census.
According to the Report on working conditions of
domestic servants in Delhi by the Ministry of labour,
Government of India, nearly 90 per cent of domestic ser
vants are women. According to the national survey2 con
ducted by the School of Social Work, Mangalore, women
constituted 87.09 per cent of domestic workers in Kar
nataka, 82.38 per cent in Ranchi, 78 per cent in Kerala,
90.81 per cent in Trivandrum, 90.20 per cent in Bombay,
51.75 per cent in Andhra.
Problems faced by the women domestic workers are:
1. Deplorable wages.
2. High level of insecurity.
3. Illiteracy and lack of marketable skills.
4. Lack of confidence in securing other productive jobs.
5. Long and unregulated working hours.
6. No paid holidays.
7. No paid sick leave.
8. No maternity benefits.
9. Immense work load.
10. Health problems.
Wages-. Despite the spiralling price-rise, year after year,
wages have not kept pace. In fact, they have miserably
lagged behind. The organised sector in many cases has
won the dearness allowance, which at least to some ex
tent, offsets the increase in price-rise. However, for the
unorganised sector, which includes the domestic servants,
every price-rise cuts into their wage, depressing their real
wage even further, which, in the conditions in which they
live, means a further nutritional deficiency for them. This
is especially so, as many studies in Pune and Bombay in
dicate that women domestic workers ate often the sole
supporters of their families.
Wages are most often paid in cash. But sometimes in
the agrarian economy, work is paid for in kind—
foodgrains, household articles or cash crops. Payment is
often irregular on the pretext that the domestic worker
is “part of the family”.
Housing; In the bigger towns and cities, government and
municipal officers and authorities are allotted servant
quarters. These officers employ domestic workers and in
return for the quarters make them work for as low a wage
as Rs. 20-30 a month or even free. The logic is that the
woman provides the labour free and the husband is sup
posed to work outside and provide for her in return for
accommodation which is possible due to her working
gratis for these officers!
Connected to the problem of housing, is another pro
blem that women in slums face—lack of toilet facilities.
Lack of public latrines seems to have affected the health
of these women. “Modesty allows them to attend the call
of nature only after sunset. In some places in Pune they
have to squat on Congres grass which causes skin
disease”.1 Having to go after dark, also makes rural
women more vulnerable to snake, scorpion and other
bites.
Insecurity
According to the national survey, conducted by the
school of social work, Mangalore, “In Calcutta only 6
per cent of the workers had made some contract with the
employers, while in the other regions it is just 1 to 2 per
cent. While the majority of the workers have no contracts
made and their jobs are totally insecure”.2 For those who
have contracts, the contract is made with a third party
or agent or the parents of the workers. Hence, the exploita
tion runs beyond the employer-employee relationship and
children from villages are sent by their parents to towns
and cities to work as domestics, while the wages are paid
directly to the parents of the child. They are often kept
in bondage till the debt is cleared”. By and large, the
majority of domestic workers have no security of employ
ment and their jobs can be terminated at a moment’s
notice.
Long working hours
The working hours of the women domestic workers are
not fixed and hence they rarely get any free time for
themselves. This increases the workload without any pro
spects for overtime payment.
According to the report of the national survey on dome
stic workers, “Rest is considered a necessity in industry
and is required after every 4 hours of continuous work.
In domestic service, it is usually considered a luxury by
the employers. In Maharashtra and Ranchi, 40 per cent
are not given any rest period. Part-timers have no time
to relax at all”.3 Even according to the Warangal study,
“extra payment is not made for working extra hours”.4
A maidservant’s day starts at 4.00 am. Often her day
of paid labour begins at 7 am till 11 am. After this is her
day of unpaid labour again. At about 2 pm she starts her
afternoon round till 6 pm, returning home to start
cooking, feeding, washing and taking battering and abuses
from her husband and finally goes to bed some time after
midnight.
Leave and Holidays
The women domestic workers have neither a regular
weekly off, nor paid leave. According to a study of women
domestic workers in Bombay, “most of the domestic
workers work right through the week and through the
year.5 In the Warangal study. “Only in the case of three
respondents, holidays upto 15 days were given with full
payment. Generally, employers cut wages whenever the
domestic workers do not turn up for work, even when the
reasons are genuine, such as sickness, some function in
the house, etc. There is no pay for maternity absence. In
a few cases the domestic workers have to send subsititute
workers whenever they cannot go to work. In most cases
children are sent. Conversely, some employers engage their
own ‘substitutes’ and the wages of absentee domestic
workers are cut accordingly”.
The national survey comments, “Though the hours of
work are regularised in Kerala, 76 per cent of its workers
do not enjoy any holidays”
The domestic workers of Warrangal reported that
medical aid from the employer’s side was not available
except for those who worked in houses in the medical col
lege campus. On the other hand, in some cases the salary
of the domestic workers was cut when they could not go
to work due to illness.
The health problems the domestic workers face relate
directly to the changes in the nature of housework and
the tasks defined for domestic workers.
The new dimensions of housework which in turn have
created the problem of increased workload and health are:
1. Queuing up for various essential commodities.
2. Fetching milk.
3. Taking small childrren to school and fetching them
back home.
4. Looking after infants and young children.
5. Fetching water from public taps.
6. Due to the advent of mass consumption—clothing,
many middle class families have stopped or reduced
their outside laundry and prefer to give almost all the
clothes to the domestic worker for washing.
7. The special washing powders are harmful to the skin:
the incidence of skin diseases on the domestic
workers’ hand and feet has gone up following the
advent of detergent powders.
8. Dusting furniture, cleaning glass panes, cleaning televi
sion sets, etc.
9. Often, the domestic workers are asked to wash basins
and toilets with acid, causing severe burns on the
hands.
10. Storing water, fetching flour from the mill, fetching
bread, .vegetables, groceries as required, extra washing
when guests arrive, looking after a child, cleaning the
employers’s vehicle, drying vessels and crockery.
According to the Pune study, “working in water all the
time, the women develop chronic body aches; chills and
cold. When they scrub utensils, the salt and spices inflame
these bruises”. Constant exposure to dust is also a pro
blem faced by the women domestic workers.3 The other
health problems faced by the women domestic workers
BURSITIS* is usually caused by prolonged and repeated
pressure or by repeated jolts to joints.
Symptoms*. Pain and swelling in the knee or elbow with
bursitis of the shoulder, the pain is usually widespread,
but swelling may not be apparent. One of the classical
types of bursitis is the “housemaids’ knee”.
* Bursa—a sac or a cavity especially one containing a fluid
that reduces friction as in between a tendon and a bone.
were amenorrhea, postural problems and bursitis—
housemaids’ knee (see box).
According to a study of female Tamil domestic workers,
who have migrated to Delhi, the extent of child mortality
is very high. “On an average, the women have three
children. On an average, they lose one child. When the
number of children born is five, the death toll 'is three...
Most children died between six months and two years of
birth. A few died of chicken-pox. By and large, parents
did not know what had caused the children’s deaths. Pattu, says “I gave birth to nine children. All but three
died”.6
A study of women domestics in Delhi indicates that
women do not go to the hospital due to fear of the
hospital and the time delays which waste a lot of their
time. Most of the women hold a number of jobs and time
is of great value to them.7
According to the 1975 report on the status of women,
“Domestic service, for cooking, cleaning, sweeping,
washing and looking after children is a major avenue for
wage employment of women, particularly in the urban
areas. Considering the large numbers in this occupation,
it is unfortunate that no effort has so far been made to
collect data on their numbers, wages and conditions of
work. They are not protected by any laws or regulations
and even the modicum of protection that the Minimum
Wages Act provides, is not applicable to this group”.8
The Status of women committee report had as early
as 1975. suggested, “A comprehensive investigation of this
group of workers is an imperative necessity, with provi
sion of at least the basic services for the protection and
welfare of their children”.
There has been no move in this direction for the last
decade. Almost three decades ago in 1959, a bill called
“Domestic Workers (conditions of employment) Bill “was
introduced in the Indian Parliament. But it was allowed
to lapse.
Even the recent attempts at introducing such a bill on
ly cover full-time domestic workers and completely leave
out the vast majority of “half-time” domestic workers,
who though work half-time in a particular household, are
full-time workers nevertheless.
It is now urgent that new thinking goes into framing
some comprehensive legislative measures which take into
account the conditions of women domestic workers
outlined above and take concrete steps to change the
situation.
References
1. Pawar, Amarja, The Pune domestic servant's revolt, institute of Social
Research and Education, 1982.
2. Roshni Nilaya, Research Department, School of Social Work,
Mangalore. A national socio-economic survey of domestic workers.
Catholic Bishops' Conference of India.
3. Bhise, Lata and Bhonsle, Leela, A sign of things to come, Manushi,
May-June 1980.
4. Manohar, Murali K, Socio-economic status of Indian women, Seema
Publications, Delhi, 1983.
5. Nirmala Niketan, Women domestic workers with emphasis on their
situation in Bombay (undated).
6. Prabha Rani, Kaul, Poonam. For two meals a day: A report on Tamil
domestic maids, Manushi, No 35, July-August 1986.
7. Dasgupta, Aparna, Domestic workers—profile of eight women dwell
ing in the slums of New Delhi, PIDIT.
8. Towards Equality, Status of Women Committee Report, 1975.
Psychological Aspects of Health
“Occupational health should aim at the promotion and
maintenance of the highest degree of physical, mental and
social well-being of workers in all occupations..
—Definition of Occupational Health by the Joint ILO
—
WHO Committee*.
An important aspect of a person’s mental health is the
feeling of security or insecurity vis-a-vis her own being.
The very unorganised nature of the “informal sector” and
the women working in it, exposes them to various forms
of oppression, including sexual oppression. The forms of
sexual oppression experienced by the women are
numerous: they vary from rape, forced prostitution and
sexual harassment to wife-beating, the sexual division of
labour at home and at work and restrictions on the
freedom to move around as they please. On the other
hand, women face the cruel side of "freedom"
contraceptives, which are dangerous and to be ex
perimented, repeated abortions, all dumped on them.
Rape and sexual harassment are almost universally
feared, not only by those who have experienced them, but
also by those who have not. It is a recurrent theme, and
seems to determine many aspects of women’s ‘lives: the
decision whether or not to take up a job; the kinds of
jobs available, the kind of work they train for, the place
of work, their participation in social activities, etc. Most
importantly,-it determines their self-perception, their feel
ing of ease, their feeling of security and general well-being.
The physiological effects of constant strain and tension
due to sexual or other harassment on women have yet to
be documented. But the personal experiences of women
in the informal sector is a living document of the effects
as they face them everyday.
Women workers suffer a peculiar form of oppression
in the workplace, in the home and in society at large. At
the workplace they often suffer sexual harassment.
The experiences of nurses, auxiliary nurse midwives
(ANMs), community health volunteers (CHVs), and the
female medical profession have been documented—the
fear of sexual attacks from village politicians, doctors,
wardboys and patients.
The death of Shobha Gonge at Risod village at Akola
district in Maharashtra2, the attempted rape and maim
ing for life of Aruna Shanbaug in KEM hospital, Bom
bay, are only a few glaring examples. The recent pressure
to meet family planning targets, which led to the suicide
by Manda Padwal3, an ANM, only add to the hazar
dousness of the profession.
Various studies4 have documented the constant threat
of sexual harassment for women domestic workers, their
vulnerability as their place of work is the place of
residence of the master of the house, his home-ground
and she is totally unprotected, in more ways than one. Also
various incidents of false theft-charges5 have been
reported, which have caused immense tension6 and feel
ings of worthlessness and humiliation.
Women sweepers in Patna city7, women ragpickers in
Bombay8 have also reported sexual harassment.
Prostitution is one of the most sexually hazardous
occupations9. Many have talked about being harassed—
by non-customers, who know her profession and feel they
can get away with anything; and by customers who often
come to prostitutes to satisfy their “perverse sexual
curiosities”.10
A study of the prostitute women in Bombay10 reveals
that extremely cruel methods of torture are used in order
to break the initial resistance of the girls and women.
“They were beaten up and had go without food for days,
but during that time, were forced to accept clients”.
According to a case-study of a prostitute, “in order to
prepare them to accept clients, they were kept hungry,
locked in a room or even gang-raped... They were brain
washed and told thdt society would no longer accept
them.”*0
All these pressures give rise to hypertension which is
very common among many women. A feeling of depres
sion and anger is constantly experienced due to both
helplessness and resentment towards a situation which
they have not caused, but have been trapped into.
If not sexually harassed, most women experience ac- g
tive or passive discrimination at the workplace.-They are W
given the least skilled, the most monotonous and often
the more hazardous jobs as well as often being paid less
than men for the same or similar work. Certain opera
tions in agriculture like weeding are “reserved” for women.
This operation involves constantly bending for all the eight
hours that women work. They are also paid less. In the
beedi industry, men often work in factories and women
at home, doing the same work and getting very different
wages and benefits. In the electronics industry, women
do the assembly work and men do the supervision.
At home, women are kept in a subordinate position,
denied any decisive say in family matters, and often beaten
or otherwise ill treated. Women are the last priority even
in the family—the last to eat and the last to get medical
treatment. Even when they work outside and are econo
mically productive, the work at home is her responsibility
alone—from getting water from long distances to fodder
gathering to household chores. Besides this social produc
tivity, the entire responsibility of reproduction and child
bearing is on women. This is also true about contraception. 0
Another aspect of harassment that almost all women
talk about is the harassment at home due to drunkard
husbands. As one pheriwali in Bombay said “When my
husband died, I felt I was better off. Even if I eat dry
bread, at least I ‘eat it in peace. What did I get from mar
riage but scoldings and beatings?”11 Women vendors in
Madras12 had a similar experience. A fruit vendor in
Madras says, “At night, I bear the brunt of a different
harassment”.
In personal interviews and conversations, women ven
dors as well as sweepers and domestics talked about how
they have absolutely no control over what they earn.
“After slogging for the whole month, my husband just
snatches away forcibly whatever I earn”.
And in society at large women are subjected to an op
pression not suffered by men—for example, a male worker
returning home late at night does not have to face the
danger and the fear and tension of the possibility of being
raped on the way.
There are other aspects to the oppression by society and
by the state which affects the mental well-being of a large
section of women—dalit or ‘harijan’ women. A large
number of the attacks and “atrocities against harijans" would render better prospects—all these concerns have
consists of rape and other forms of attacks on women.13 to be foreign to women. The result simply is that women
A tradition which exists in the major part of the country are not allowed to advance in their field.14
Yet the pressure is there for women to peform, to.be
gives upper caste men of rich farmer or landlord families
the “right” to make use of lower caste .women. Poor good workers, to be efficient. If they don’t, it is because
women, working daily in the fields or in the forests are “they are women”. How women cope up with these myriad
extremely vulnerable to the attacks from the police, the contradictory pressures and tensions and what toll in
terms of their mental and physical health that takes, has
forest guards and the landed rich.
Besides, in most Indian villages, dalits have seperate not as yet been a subject of research. This dimension is
wells from caste hindus. The problem of getting water, not merely an “additional element” in the health and well
the availability of drinking water is particularly impor being of women workers, but the basis on which one can
tant for women because it is a crucial part of the daily even begin to understand the “purely physiological”
labour of maintaining the household.13 Caste oppression ailments and problems of the vast majority of labouring
here implies that women have to walk great distances in women in this country.search of drinking water, despite its availability in the
village itself. This discrimination goes further in the lack
References
of opportunities for dalit girls to be educated and then
1. ILO, Encyclopaedia of Occupational health and safety, ILO, 1983.
in the type of work available to them.
2. Baija Magazine (Marathi), 1983.
The Status of Women Committee Report showed that
3. Gupte, Manisha and Duggal, Ravi, Did Manda Padval die in vain?
the majority of working women in India are in the
Indian Express.
4. Manohar* Murali, K, Socio-economic status of Indian women,
unorganised rural and urban sectors (fifty per cent were
Seema publications, Delhi, 1983.
agricultural labourers, thirty per cent peasant cultivators,
6. Pawar, Amarja, The Pune domestic servants revolt, Institute of Social
fourteen per cent in unorganised sector jobs, including
Research and Education, .1982.
casual labour, contract work, domestic service, etc). This
7. Chaudhury, Pratima, Women sweepers of Patna, Social Welfare, May
is even more true of dalit women. In 1961, the work par
1986.
8. Shah, Nandita, Women rag-pickers, Nirmala Niketan, College of
ticipation rate for women in general was 27.95 per cent
Social Work, 1983.
and for dalit women, it was 35.3 per cent. Dalits were 33
9. Bandopadhyaya, Bela, A woman’s last resort, Manushi. No. 23 (Vol.
per cent of all agricultural labourers in that year, and
4, No. 5) July-August 1984.
adivasis 10.5 per cent. The percentage of agricultural 10 Joshi, Sulabha, A study of psycho-physical conditions of prostitutes,
Nirmala Niketan, College of Social Work, February 1987.
labourers has grown since 1961; so has unemployment.
Both factors affect women more severely, and dalit women 11. Alaka, Chetna, Struggling at every step, Manushi, No. 27, MarchApril 1984.
most of all. Women are nearly 40 per cent of all 12. Azad,
Nandini, Empowering women workers, Working Women’s
agricultural labourers now, and a significant proportion
Forum, Madras, 1986.
of these are dalits. Dalit women who are not agricultural
13. Omvedt, Gail, Dalit women—point of no return, Manushi.
labourers usually work as casual daily labourers, as
14. Lessinger, Johanna, Caught between work and modesty, Manushi,
No. 28, May-June 1985.
migrants on road building and other building projects,
and in various petty, miserably paid jobs that are not even
counted as “work” by census criteria.13
Another aspect of harassment and atrocities on women
is the custom of female seclusion. Though avowedly prac
Abrasive cleaners are also known as scouring powders
ticed to “protect” women, it has extremely negative im and are widely used.for the household cleaning of hard
plications for women’s self-image, women’s ability to par metal, porcelain or enamel surfaces.
ticipate in the labour market and also directly on women’s
Due to the abrasion of the horny layer and the alkali
health.
neutralization of the acid, the protective mantle of the
The custom cuts across religious lines and is found skin may be damaged and in the long run, result in der
among, both hindus and muslims all over India. The matitis with swelling and roughness of the skin and may
manifestations of this custom differ from one region to contribute to the causation of housewife’s eczema.
another, ranging from women who are not allowed to leave Detergents, soaps, acids may cause contact dermatitis or
the household and are often veiled, to women who work eczema.
outside, but do their utmost to avoid contact with ‘out
Thorough rinsing and drying of the hand and the
sider’ men. .
application of an emollient after the use of an abrasive
The custom and ideology supporting female seclusion cleaner are to be recommended. The common occupa
support also its reverse—the idea of exposing or punishing tional diseases noticed in domestic workers are skin
a woman if she has “crossed her limits”. This punishment diseases, chronic paronchia and rheumatic complaints,
has often come in the form of systematic rapes of due to prolonged and repeated immersion of the hands
in water while washing clothes or utensils or working in
women.14
For women who have to work outside, the ideology of hot work places, causing perspiration.
female seclusion is in direct conflict with daily reality.
Domestic workers are also prone to catch any con
Often women’s work outside is portrayed as sacrifice she tagious diseases which the employers may be affected by.
has to make in order to fulfill her role in the family better,
Compiled by Vijay Kanhere from the ILO Encycloand hence any notion of self-fulfillment or self-advance paedia on occupational health and safety, ILO, Geneva,
ment is not in keeping with the role. Hence involvement 1983.
in the work, travelling often to sell wares in order to get
a better price, trying to see what area of work or trade
Home-Based Workers
Home-based workers include workers involved in a very
wide range of activities and occupations in their own
homes—house-wives, chikan workers, beedi workers, lace
makers, agarbatti workers, paper bag makers, zari and zardozi workers, garment workers and many other categories.
Homeworkers are one of the most exploited groups in
the workforce. They receive low wages, work long hours,
receive no protection against unfair conditions, dismissals
or health hazards. They have to provide their own facilities
for work—the space, the equipment and also meet costs
such as oil for papads, electricity etc. At the same time
they are at risk from a number of health and safety pro
blems associated with their work. Their children too are
exposed to these—either because the children too have to
work or because of their mere presence in the ‘work-area’.
Stress is a major cause of work-related illness, and is
both biological and psychological. All aspects of
homework—wages, monotonous and unrewarding work,
lack of security and isolated or crowded working condi
tions,—combine to make homeworkers vulnerable to stress
and stress-related diseases like ulcers, heart ailments,
blood pressure. Job satisfaction, a feeling of self-esteem
and a decent wage are some important protectors against
stress.1
The major problems faced by homeworkers are:
1. Very low earnings.
2. No protection.
3. No benefits as workers.
4. Very bad working conditions.
5. Very long hours of work.
6. Problems of availability of raw materials at reasonable
prices.
7. Competition for markets.
8. Lack of credit facilities.
9. Lack of space to work.
10. Limited or no access to new technology for facilitating
work and improving productivity.
11. Lack of skills and training facilities.
12. Absence of protective legislation.
13. No social security e.g., insurance, health benefits, old
age benefits.
14. Health problems like postural problems, problems due
to lack of facilities, e.g., eye-strain due to the non
availability of electricity, etc.
One such occupation in the state of Uttar Pradesh is
Chikan-work. Out of the 50,000—odd workers engaged
in this industry in Uttar Pradesh, about 97 per cent are
women2. As the workers are predominantly muslim
women, who observe purdah, they have no direct links
with the consumers. Work has to be obtained through
middlemen. A majority of the workers live below the
poverty line and according to the 1975 status of women
committee report, earned less than Rs 40 per head per
month.2
A large number of the women are widowed or deserted
women who support the family by their own earnings.
Since production and marketing are mostly in the hands
of intermediaries who are traditional money-lenders, this
results in a high degree of exploitation. Deductions are
made from wages on various pretexts e.g. delay in com
pleting work, bad craftsman-ship, damage to material eta
This was reported by 64% of the contract workers, 87.8%
of the self-employed-cum-contract workers and all the
wage employees. In all, 38% complained of deduction in
wages and 38% reported disputes due to low wage rates.2
TENNOSYNOVITIS —^he free movement of a tendon is
restricted usually by a swelling of the tendon or its sheath.
It is caused by very rapid, repetitive finger and hand
movements like while manipulating small work-pieces.
Such movements are present in work which is put out,
or in industries doing the assembling of small electrical
parts as well as in large-scale cooking.
Compiled by Vijay Kanhere from the ILO Encyclopaedia
on occupational health and safety, ILO, Geneva, 1983.
According to one study,3 weak eyesight, spondylitis
and TB were the major complaints. The first due to the
extreme fine work they have to do, spondylitis because
of their constant posture and TB because they live and
work in extremely closed and congested surroundings and
sit very close to each other while working.3 There were
no doctors around the area where the chikan workers live
and also work. Hence they have often to go to quacks,
who just give the women workers positive lenses, or
whatever they have at that moment.3
The other health problems noted by a study conducted
by the National Institute of Occupational Health (NIOH)
were lung function disorders and various allergic effects.4
A recent study by the Self-Employed Women’s Associa
tion states that besides postural problems and eye pro- .
blems, women suffer from tiredness due to the very long •)
hours of work, anaemia, goitre and vitamin-D-deficiency,
due to being at home all the time and due to the fact that
the women had to wear black robes.5
The rate of exploitation was extremely high and most
women felt that they would like to be provided with alter
native employment and training.
References
1. Women and work hazards group. Home working, Women and work
hazards group, London, 1983.
2. Status of women committee report, 1975.
3. Mitra, Nirmal, The chikan workers of Lucknow, Sunday special,
Sunday, 10th March, 1985.
4. National Institute of Occupational Health, Occupational health pro
blems of women workers, NIOH, Ahmedabad, 1983.
5. Self-employed Women’s Association, A studyof the health staus of
chikan workers (untitled). (unpublished).
Cooking Fuel
Latest evidence shows that air pollution within homes
may be an acute problem, an underlying cause of millions
of deaths every year. The burning of cooking fuel envelops
the indoor environment with heavy smoke and women
who have to do all the cooking may be daily exposed to
more pollutants than even industrial workers in extreme
ly polluted environments on extremely polluted days...
As firewood becomes scarce, they have to put in more
energy to collect fuel and then they have to face the
dangers of wood smoke everday.
Over 90 per cent of households use wood, dung, crop
residues as fuels. Especially during winter, but also* at
other times, when a temperature inversion prevents the
smoke from rising, houses are filled with smoke.
Though biomass smoke is a complicated mixture of
thousands of pollutants, and its impact may be more than
the sum of the impact of individual pollutants, indirect
evidence of the ill-effects of smoke can also be gathered
from studies that have been done on individual pollutants.
Other than particulates and compounds like Benzo(a)
pyrene (BaP), two major pollutants in biomass smoke are
carbon monoxide (CO) and formaldehyde.
There is a growing body of evidence that points to a
stong link between chronic CO exposures and both heart
disease and impaired foetal development. While CO has
not itself been found to be carcinogenic, there is concern
that it may act to increase the carcinogenic effects of other
air pollutants by inhibiting the ability of the lungs to clear
themselves.
Any condition which results in reducing the blood’s
capability to carry oxygen to the tissues, like anaemia, will
also make a person more susceptible to carbon monox
ide toxicity. This is particularly bad for Indian women
who are anaemic in large numbers. It is estimated that
in India 40 per cent to 60 per cent of preschool children,
25 per cent to 30 per cent of women in reproductive age
and almost 50 per cent of pregnant women in third
trimester (more than 24 weeks of pregnancy) are anaemic.
Chronic lung diseases will further reduce the capability
of the blood to rid itself of carbon monoxide during
periods of low or no exposure.
Estimated annual doses of respirable suspended particulates
(milligrammes per individual)
Gujarat villages
Cooks
Non-cooks
Traffic-police in Ahmedabad
Ahmedabad city
Delhi
Bombay
WHO recommended level
21,000
3,700
2,600
2,100
1,400
1,100
210
Source: Kirk Smith. East West Centre.
There are several factors that make women particular
ly susceptible to CO exposure. Women generally have less
haemoglobin reserves than men, which makes them more
prone to anaemia, which also makes them more vulnerable
to lower doses of CO than men. During pregnancy there
is additional demand on haemoglobin, further lowering
their reserves and making them more sensitive to CO. This
exposure can also affect the unborn child leading to reduc
ed birth weight and increased perinatal death rates.
Respiratory diseases are a leading cause of death among
girls and women over the age of five in India.
Compiled from: The State of India’s Environment—a
citizens’ report by the Centre for Science and Environ
ment, New Delhi, 1982
Agriculture
An unpublished study in Maharashtra revealed a pat
tern of seasonal mortality among children and infants.
There was a very strong clustering of child deaths in the
months of June to September. The trend was even stronger
in the 0-1 age group. 75-80 per cent of the.annual infant
deaths had occured in these 3-4 months. However, no
skewed distribution in the deliveries was found. A
majority of these 0-1 year deaths were neo-natal deaths,
between 0-4 weeks. An even larger number were between
0-7 days. 90 per cent of these were due to premature
deliveries and still births.
An obvious reason for this intriguing pattern was the
type of work women did during these specific months.
This was a ricegrowing area and the months of July and
August, which was where the cluster had occured, were
the months of the transplanting operation. This is the time
of the year when there is maximum employment in the
villages, especially for women.
During transplanting operations, women have to work
in the squatting position for 8-10 hours a day. There seems
to be a close correlation between that position, the
pressure on the uterus and early delivery. Most of the in
fants were not small in terms of the size, but were early,
deliveries, between 6% and 7 months. Thus these were
women who were in the third trimester and had gone for
transplanting work.
This unpublished study was conducted by Srilatha
Batliwala and Mona Daswani for the FRCH in 1982 and
1983.
Some of the obvious implications of this small study are:
* It is necessary and urgent to tackle the isue of ap
propriate, effort-saving, but non—labour-displacing
technology. e.g., developing devices whereby women
can sit on low stools or stand and do the work or alter
nate between these, as is comfortable. This is absolutely
essential, considering the vast numbers of women
engaged in agriculture, season after season, for almost
their entire working lives.
* It is necessary to extend and to make obligatory the
granting of paid maternity leave to all women and to
ensure that women are not discriminated against in
employment.
* It is necessary .to provide alternate employment to
women, especially during pregnancy.
* Organisations of or self-organising by agricultural
women workers is the most sustained way of achiev
ing this.
* Further research Will have to be taken up to establish
the link between women’s work and women’s health
in the agricultural sector.
Women Workers in Heavy, Manual Work
According to the Encyclopaedia of Occupational health
and safety of the ILO, “the capacity of women for sus
tained heavy physical work is substantially lower than that
of men
*
“If women carry excessive loads, their intra-abdominal
pressure may rise suddenly and cause disturbances of the
blood circulation in the pelvic organs and lower limbs,
menstrual disorders, prolapse, miscarriage or still birth.
These disorders are more common if a woman has been
carrying heavy loads from an early age. Unfavourable ef
fects on the normal formation of the pelvic bones,
resulting in a flat and narrow pelvis, have also been
observed”.
Besides, careless manual load handling is not only the
biggest single cause of industrial accidents, but there is
also a considerable risk of injury to the spinal column
and adjacent muscles, particularly in the lumbar region.
The circulatory organs may also be affected, the pulse rate
and blood pressure may rise and brain haemorrhage has
also been reported.
The constant strain and stress on muscles, joints,
ligaments and bones also cause deformities. Constant
pressure on the skin, muscles or nerves leads to callosities,
neuritic pains and paralysis.
In children and adolescents, strenuous work may af
fect bodily growth, especially skeletal growth. Deformities
of the spinal column, pelvis and thorax may occur. As
the growth' of the musculatory and circulatory systems is
often unequal, stress on these systems during childhood
and adolescence may have permanent sequelae.1
Many countries have introduced legislation covering the
manual lifting and carrying of heavy loads by at least cer
tain categories of workers, in particular women and young
persons. There are often special provisions for pregnant
women.
In Madras e.g. the maximum limit for men is 75. kg.
Maharashtra has prescribed a limit of 55 kg. in accordance
with the ILO’s Maximum Weight Recommendation, 1967
(No. 128). This recommendation does not lay down a
maximum weight for women, but suggests that it should
be substantially less than that permitted for adult male
workers (about 50 per cent less), that women should not
be assigned to regular transport of loads etc. In principle
it also prohibits the employment of women on load
transport during pregnancy and for the 10 weeks follow
ing confinement.
However as with most “well-meaning” legislation in our
country, this piece has also remained on paper and is
violated with impunity. In fact, for more than 96 per cent
of the women in this country there is only a choice bet
ween death or morbidity due to heavy work or the same
due to starvation. The provision for paid maternity leave
for every woman is an absolute must if even some of the
precautions for women’s health have to be taken serious
ly. As most women doing hard labour said “we have to
work till the last day of pregnancy in order to be able to
eat to live”.
Women and children however, continue to do extreme
* The discrimination against women for centuries in terms of nutri
tion, opportunities, health care etc., seems to have resulted in a lower
ing for their capacity for heavy work.
ly heavy and strenous work, without any precautions to
offset the bad effect on their health and general wellbeing. Women are employed as head-loaders, as workers
in brick-kilns, in the construction industry and as hand
cart pullers... Women have to walk long distances car
rying loads of wood-fuel and water.
Here we will look at one industry in some detail—the
construction industry.
The 1981 census recorded a substantial increase in
employment in this sector—a 60 per cent increase over
1971. The share of women workers rose from 9 to 11.16
per cent. According to a comparative study of women con
struction workers in Patna and Delhi,2 women were
employed mostly as unskilled labourers for carrying earth,
mortar or bricks, crushing bricks and working hand
pumps. Recruitment was mostly done either directly by
the contractor or the sub-contractor (jamadar). Wage pay
ment was on a daily or weekly basis. The Bihar study
reported that the sub-contractors obtain a contract for the
job on a piece rate basis but paid their workers on a daily
basis, ensuring a higher margin of profit for themselves.
Workers complained of short payment and unexplained
deductions. The system of deferred wage payment and un
justified fines and deductions were reported in both the
studies. The Bihar study reported that in the case of tribal
women, part of their wages were kept back to be paid at
the time of termination of their employment. The Delhi
group reported that apart from fines, the jamadar
deducted 25-50 paise per day from their wages without
giving any reasons. The existence of these intermediaries
invariably depressed the wage rates. Women from all the
three Bihar projects reported wage differentials between
men and women.
Another important factor experienced by women con
struction workers all over, but verbalised by the women
workers from Madras is that not only were women made
to do work which was considered “unskilled”, but they
were given no opportunities to learn any skill like masonry
or carpentry and hence had to continue to remain in the
same “unskilled” work till the end of their working lives.
As one of them put it, “we have no raises or dearness
allowance. At least the men can hope to become masons
or supervisors. But we women remain as sitthals (‘sitthals’
implies small people or people who do the “little”
work).7
The household incomes of nearly 80 per cent of the
workers interviewed in Delhi was between Rs 200 and
Rs 300. The per capita monthly income was below Rs 75
for 45 per cent and below Rs 50 for a little over 20 per
cent. For the Bihar group, the average household income
ranged from Rs 194.4 to Rs 334.45, the per capita monthly
income ranged from Rs 38.88 to Rs 66.6. For all the
families covered by these two studies, the earnings of the
women constituted the major share of the families’ income.
According to a study of work hazards in the construc
tion industry in India,4 “a high degree of risk and danger
is involved in this work. The work proceeds in the most
dangerous situations under sun, cold, heat, rain, dust. The
magnitude of accidents and occupational diseases
associated with this work is appallingly high and com
plex. It is because most of the operations are labour in
tensive with inadequate safety measures, low quality of
materials used, non-identification and non-recognition of
risky actions, non-analysis of accidents and lack of train
ing of workers on safety?"’
The causes of accidents were identified as:4
* failure or collapse of scaffolding, centering and
shuttering.
* improper guards.
* night work with improper lighting.
* fire and electrolocution.
* excessive noise.
* handling of heavy finished and semifinished materials,
like metals.
* blasting.
* underground work.
The cause of other health hazards were identified as:—
Cause
Effect
Cement Dust
— Irritation to lungs, cancer and
skin disease.
Plaster
— Irritation to lungs, eyes, and
skin lung cancer.
Wood burning
— Asthma and nasal cancer.
Sand
— Silicosis.
Asbestos
— Asbestosis.
Work at high places
— Blood pressure.
Sound
— Loss of hearing, stress, blood
pressure.
Heat
— Heat cramps and sun burns.
Vibration
— Numbness of hands and
fingers.
Repetitive work
— Sprain, rheumatism.
In the Warangal study,5 it was found that canal
workers had one day off for every fifteen days of work.
Paid holidays were not given during the festivals. Most
of the workers complained that they were entrusted with
some work even on holidays. The labour welfare officers
and public works engineers seldom took interest in en
suring facilities like first aid, drinking water, washing and
bathing places, latrines, urinals and other sanitary ar
rangements. Shelters, creches, canteens, sheds, etc. as men
tioned in the contract regulations were never provided by
the contractor. The material provided by the contractor
for the construction of huts was sufficient, to construct
only a 4' wide 5' long and S' high hut, with no ventila
tion. Due to the lack of accommodation in the hut, the
parents slept outside. Their huts were ill-suited for rainy
seasons. With regard to the women workers, no single ad
ditional amenity was provided despite the fact that in
several cases their workspots came under the public works
rules and other regulations.
‘Health’
Of the Delhi group, 30 who had suffered from some
illness lasting more than 1 week, had received treatment
in government dispensaries and hospitals and 22 had been
compelled to discontinue work for periods ranging from
4 days to 6 months. They did not receive any wages dur
ing such absence. The other 8 continued to work during
illness.
In the Warangal study, it was also found that most of
the women workers were in poor health. Around 40 per
cent were sick during the last two years and were in bed
for more than a week each time. Only two per cent of
them had gone to private hospitals; but even in a govern-
ment hospital, they had to pay for medicine. Some could
not get admission in a government hospital because they
could not pay bribes. The canal workers5 complained
that due to excessive use of tamarind water supplied along
with rice, they had diarrhoea, muscular pain, intestinal
troubles and gastro-enterities amongst other illnesses.
Since the contractor gave only tamarind water along with
the rice they could not escape from such diseases.
Medical facilities at the construction sites were minimal.
No trained doctor was available and no medicine was sup
plied. Patients were asked to go to government hospitals
and their wages were invariably cut during their absence
from work. Many among the workers, who had reported
long illnesses, said that they had to stop working for
periods ranging from three days to two and half months.
They felt that visiting a doctor was a luxury which they
could not afford.
More than half of the women workers worked till the
last day of their delivery and resumed work after three
or four weeks. Just as in the case of sickness, there was
no paid leave during pregnancy. Contract labour regula
tion and other relevant laws are conspicuously silent about
maternity leave for women in the construction industry.
This has an adverse effect on their health and on the
health of the new-born infants. Almost all the women had
delivered their children at home with the assistance of
elders or neighbours.
Absence of minimum health protection during pregnan
cy as well as continuous malnutrition has resulted in high
infant mortality. In the Delhi study it was found that 645
children has been born to the women but at the time of
the survey only 389 of them were alive. For the Bihar
group out of 233 children born to the women 67 were
dead; 29 of them had died before reaching the age of 1
year.
A recent report of the NIOSH (USA) an institute with
authority in this field states that women in the construc
tion industry are fairly susceptible to occupational stress.
In India, women in the construction industry have a highly
strenous job of rock and brick crushing and transporting
head-loads up improvised ladders. Apart from postural
defects and backache and muscular pains due to physical
factors and fatigue, the tropical heat could also lead to
trauma, cramps, exhaustion and stroke.
The paper by the National Institute of Occupational
Health6 also outlines some of the health problems of the
construction women workers as: Physical stress and strain,
skeletal defects, dust effects on lung function, postural
defects and. muscular fatigue.
Referenes
1. International Labour Office, Encyclopaedia of occupational health
and safety, ILO, Geneva, 1983.
2. Sinha, G.P., and Ranade, S.N. Women construction workers—reports
of two surveys, ICSSR, New Delhi, 1975.
3, Mallia, Women construction workers of Madras, Indian Women, Sth
August 1985.
4. Society for participatory research in Asia (PRIA), Beyond bricks and
stones—the voice of construction workers, PRIA, New Delhi, 1986.
5. Manohar, Murali, K., Sociq-economic conditions of women workers,
Seema Publications, 1983.
6. National Institute of Occupational Health, Occupational health pro
blems of women workers, NIOH, Ahmedabad, 1983.
Some Directions...
Very simply put, any rational health system aims at
making all the people it is responsible for, healthy—
providing the minimum health care as well as the other
conditions for a healthy life. A look at the chaos in the
health system in our own country as well as in the more
“prosperous” countries of the West, indicates that there
are certain serious obstacles in attaining this seemingly
simple goal. These obstacles are even greater where the
health of poor, labouring women is concerned.
It has been observed and studies of hospital records
show that the medical profession is both, occupation-blind
as well as women-blind. Both these blindnesses affect the
vast section of poor women adversely and grind them
down even further.
The situation is not only complex, but has been
perpetuated over decades, if not centuries. Hence a multi
faceted approach is necessary to radically change it, in
order to respond to the health needs of this disadvantaged
section:
A. An important underlying thrust of any approach has
to be the re-ordering of our national priorities.
The decisions of what our national priorities are, are
not based on the needs of the vast numbers of the labour
ing poor, especially women, but on considerations alien
to and usually opposed to these. Basic, essential drugs are
not available in dispensaries and PHCs, but IUDs and
condoms flood them. On the one hand are sophisticated
hospitals over-drugging certain sections of people, while
basic health care is not available to the vast majority.
The same situation rules in terms of housing, in terms
of the industries put up, in terms of the basic commodities
in the market. These are important, as the socio-economic
situation very much determines the choices open for
women, including the work available and the health care
facilities available, especially nutrition.
d Insurance benefits.
e Maternity benefits.
f Sick and other leave facilities, including a weekly off.
g Regulation of working hours.
h Old-age benefits/pension schemes.
i Health education—general and occupational.
j Provision of safety equipment.
At the level of the medical profession, some concrete
changes can be worked out. In the formal sector, some
industries appoint doctors trained in occupational
medicine. Here, workers have also won certain benefits.
However, poor women have no access to these. A beginn
ing may be made by developing courses for doctors about
the occupational "health problems of these sections of
women. These courses could be made a regular part of
the curriculum and the degree course. It is also necessary
to sensitise the doctors to the multi-faceted problems that
the poor labouring women face, which cannot be looked
at in isolation from their life situation as a whole. In coun
tries like England and America, doctors were in the
forefront of the movement for occupational health and
played a crucial role in the area of campaigning for the
recognition of pneumoconosis as an occupational disease
of the coal-miners.
Developing and campaigning for special health schemes
for poor, labouring women may be another area that the
medical profession can address itself to.
C. It needs to be ensured that the introduction or use
of technology is geared to the needs of women. This itself
has various aspects to it.
a More research and development needs to go into devic
ing effort-saving but non-labour displacing
technologies. For example, the broom-stick transplan
ting as opposed to the present-day squatting and
transplanting operation or the handcart study of the
B. It is also necessary to ensure that the health system
NIOH. Simple devices using pulleys and levers have to
responds to the health needs of women directly and
be deviced.
immediately.
In fact, a whole range of occupations engaging
It is first necessary to provide alternatives and choices
women have not been looked at at all. These need to
for women to choose from, rather than some system of
be recognised and made hazard-free.
health care, or lack of it, being imposed on them. It is
necessary to critically evaluate the present health care b It is also necessary to device technology which reduces
the health hazards due to occupations such as postural
system and pin-point the anti-women, anti-poor bias in it.
problems.
While demanding better choices for women, including
c It is necessary however to involve women in devicing
women’s access to safe delivery, safe and free abortions,
these at the earliest level of conceptualisation of the
it is necessary to stress the immediate abolition of the op
new methods would create additional problems.
pression that comes directly from the government—
enforced sterilisation, injectable contraceptives... In fact, d It is necessary however to ban all technology which
directly or indirectly harms women. e.g. Sex-determi
the entire emphasis on “family planning” to the detriment
nation tests, injectable contraceptives, E.P. drugs, etc.
of access to other health care facilities needs to be strongly
opposed.
e Often the choice that women are given is jobs versus
health. This is a false and heartless choice, especially
Some of the specific needs of women in this sector are:in a situation where there are such few options open.
a Nutritious and sufficient food. Specific nutritional pro
Also when jobs are made; less strenous or backgrammes which include calcium, proteins, and iron,
breaking, as by introducing mechanisation, women tend
need to be initiated through the government health care
to lose out and tend to be thrown in other jobs which
are as strenous and hazardous, while men take over the
system.
better-protected jobs. This has to stop and mechanisms
b Regular work and livable wages.
have to be created to retain women in their jobs.
c Day-to-day health care facilities.
These are some books and reprints on the topic women,
work and health, which the FRCH is gradually trying to
acquire.
Stellman, Jeanne Mager, “Women’s work, women’s
health—myths and realities”, New York: Pantheon
Books, 1977, p 262.
Bingham, Eula (Ed.), /‘Proceedings—conference on
women and the work place”, Washington, D.C: Society
for occupational and environmental health, 1976, p
364.
Ahmedabad, 1986, Gandhi Labour. Institute.
Prasad, Anuradha and Prasad, K.V. Eswara Prasad,
“Home-working in India: A review”, New Delhi, 1987,
National Labour .Institute.
Society for Participatory Research in Asia (PRIA):
“Ghatak Dhool-Mandsaur ki slate pencil udyog” (hindi), New Delhi, 1984.
Reprints
Chatterjee, Mirai, “Occupational health of self-employed
women: some issues and experiences”, New Delhi:
Leacock, Eleanor, Safa, Helen and Contributors,
Society for participatory research in Asia, 1987.
“Women’s work—development and the division of
labour by gender”, Massachussets: Bergin and Garvey Nag, Anjali, et al, “Occupational stresses on women
engaged in making beedies”, Ahmedabad: National
publishers, Inc, 1986, p 300.
Institute of Occupational Health (NIOH), 1984.
Brown, Marie, “Sweated labour—a study of homework”, Tripathi, G.C. et al, “Study of some health problems of
London, Low Pay Unit, 1974, p 30.
bidi workers’, Indian Journal of Occupational Health,
Jhabvala, Renana, Dhawan, Reva and Mahajan, Krishna,
Volume 29, No. 4, October to December 1986.
“Women who roll bidis: two studies in Gujarat”, Kalpagam, U, “Women and Urban poverty—issues from
Ahmedabd, 1985, Self Employed Women’s Association
case studies of three families”, Calcutta, ICSSR,
(SEWA), p 141.
Eastern Regional Centre and Centre for Studies in
Gandhi Labour Institute, “National workshop on pro
Social Sciences, Workshop on women and poverty,
blems of home-based workers in India, Vol. I and II,
1983.
What is New?
BOOKS
Wolf, Edward C, “Beyond the green revolution: New ap
proaches for third world agriculture” - Washington:
World Watch Institute; 1986, p 46.
Economic and social commission for Asia and the Pacific
(ESCAP), “Directory of Population Periodicals of the
ESCAP Regional Population Information Centre"
New York: United Nations; 1986, p 173!
Treichel Joan Arehart, “Biotypes” — London: W.H.
Allen; 1980, p 245.
American Medical Association, “Family medical guide"
New York: AMA; 1987, p 832.
Bhopal Group for Information and Action, “Byssinosis”
— Bhopal: BGIA; 1987, p 25.
World Health Organisation, “Health research strategy”
— Geneva: WHO; 1986, p 89.
Vickery, D.M, and Fries, J.F, "Take care of yourself: con
sumers’ guide to medical care” — Massachussetts:
Addison-Wesley; 1986, p 400.
Rao Amita (Dr.), “Health curriculum for schools” — New
Delhi: VHAI; 1986, p 24.
Reprints
Mehrotra N.N., “Indian Patents Act: Paris convention and
self-reliance” — EPW; 1461-1465, 22nd August, 1987.
Gotzsche Peter C., “Reference bias in reports of drug
trials” — British Medical Journal; 295, 654-656, 12th
September, 1987.
Thurow Lester C., “A surge in inequality” — Scientific
American; 256(5), 26-33, May 1987.
Ryan Michael, “Illegal abortions and Soviet health ser
vice” — British Medical Journal; 294, 425-426, 14th
February, 1987.
Johnson Anne M., “ABC of AIDS: strategies for preven
tion” — British Medical Journal; 295, 373-376, Sth
August, 1987.
Fulop Tamas, “Health personnel for health for All: pro
gress or stagnation? (part 2)” — WHO Chronicle; 40(6)
222-225, 1986.
Lancet, “Risk of unexplained stillbirth at different gesta
tional ages” — Lancet; 1(8543), 1192-1194, 23rd May,
1987.
World Health Forum, “The expanded programme on
immunisation” — WHF; 8, 208-215, 1987.
New England Journal of Medicine, “Comparisons of
national cesarean—section rates” — NEJM; 316(7)
386-389, 12th February, 1987.
Lancet, “Future hunger” — Lancet; 8528, 309-313, 7th
February, 1987.
The Following Publications are available at the FRCH
Bang, Abhay and Patel Ashwin (Eds.), “Health care:
which way to go, examination of issues and alter
natives”—Medico Friend Circle; p 256, Rs. 15.00.
Jayarao, Kamala S and Patel, Ashwin (Eds.), “Under the
lens: health and medicine’—Medico Friend Circle; p
326, Rs. 15.00.
Voluntary Health Association of India, “Banned and ban
nable drugs” — VHAI; p 67, Rs. 15.00.
Balasubramanyan Vimal, “Contraception: as if women
mattered’— CED; p 94, Rs. 20.00.
Radical Journal of Health; Rs. 8.00 per copy; Rs. 30.00
(Individual) and Rs. 45.00 (Institution) - yearly
subscription.
Books in Brief
Manish Mankad
1. Vickery, D.M. and Fries, J.F., “Take care of yourself: ment and when to call or see a doctor.
consumers guide to medical care" Massachussets: 2. Treichel, Joan Arehart, “Biotypes” — London: W.H.
Addison-Wesley; 1986, p 400.
Allen and Co: 1984, p 245.
For those who believe in self care in health, this book
The book tries to explore a link between one’s personali
will be a useful addition. This is the third edition of the
ty
and health. Medical and behavioural studies reveal that
book, the first being brought out almost a decade ago.
there
are particular personality types—biotypes—which
The book is divided into 3 sections viz. skills for the
in
times
of stress breakdown in specifies predictable ways.
medical consumer, the patient and the common com
plaints and family records. The first and the last sections
The author has explained major diseases’ biotypes and
are descriptive in nature. However, the strong point of this some preventive measures. The only drawback is that the
book is the 2nd section, which contains diagnostic charts socio-economic background against which disease
and helps the readers to decide when to use home treat biotypes are explained in the book is largely from the west.
Dear readers,
With this issue, we will be completing one year of our
association with you. Hope you have enjoyed reading our
newsletter and have found it useful in your work.
We would like to continue this effort, and have felt en
couraged by the response we have received from you all.
However, we do expect more participation from you in
terms of:
* Sending us more material/articles about your work,
about events and happening relating to health...
* Suggestions about how the newsletter could change or
respond better to the needs of groups and individuals
in their work.
* By contributing monetarily to the newsletter.
Hope to hear from you soon.
Yours
The FRCH collective.
Firewood Collection
The collection of firewood and fodder are some other
areas of womens’ work. These are extremely difficult and
back-breaking tasks, especially for those women who live
far away from forests and forests are getting scarcer by
the day.
In a study of women’s work in the Garhwal hills, it was
revealed than in 86.3 per cent of the households, only the
women went out to collect firewood. On an average, the
load of wood carried per trip was 24.5 kilos with- a range
from 18 to 40 kilos. Women had to begin heavy work 15
to 20 days after childbirth and continue to carry loads
even when they grew old. In 51 per cent of the households,
the women had to spend three to four hours in collection
and travel a distance of 3 kilometres; 27.5 per cent had
to spend five to six hours, travelling a distance of four
kilometres. In more than 50 per cent of the households,
a daily trip was made to collect the wood.
Besides, in this area, most of the men go out to work
as migrant labour and the predominantly agricultural
economy is seen mainly on the strength of the women.
Another severe problem faced by women all over the
country, especially in the drought-affected areas, is the
necessity to walk for as long as 6 to 7 hours.to get fodder
for the animals. The trip to fetch water is a different story.
In parts of Gujarat, women are up at 2.30 am to begin
this search and as fodder gets scarcer day by day, the
women sleep lesser hours each day. The effect this hard
labour has on already mal-nourished bodies is a mattei
of grave concern.
References
1 Swaminathan, Madura, Eight hours a day for fuel
collection—women’s survival tasks in Garhwal hills,
Manushi, No. 21, 1984.
This issue has been written and edited by Sujata Gothoskar with the co-operation of Manish Mankad and secretarial assistance from Anuradha
Naik and Eleuterio Fernandes. The material for this issue is based on the work done for the National Commission on Self-Employed Women
(and women workers in the informal sector) and especially on the workshop organised by the Health Task Force of the National Commission
in September 1987 in Bombay. Produced by the Foundation for Research in Community Health, 84-A, R.G. Thadani Marg, Worli, Bombay 400 018.
Telephone 493 86 01. Typeset by Economic and Political Weekly. Printed by Modern Arts and Industries, A-Z Industrial Estate, Lower Parel, Bombay.
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