FRCH NEWSLETTER VOL.7-No. 2-5-MARCH-AUGUST-1993
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- FRCH NEWSLETTER VOL.7-No. 2-5-MARCH-AUGUST-1993
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Vol. VIL No.2
Mar. - Apr. 1993
FUNCTIONAL CLASSIFICATION OF DISEASES
N.H. Antia
Classification of diseases is necessary for diagnosis as well as
treatment While diagnosis must theoretically precede treatment, in the
practitioner and much more expensive hospital and specialist services.
Expensive investigations and services are also rationed.
majority of cases when the patient first presents her / himself, treatment is
Such an appropriately graded form of health care is not only cost-
chiefly on a symptomatic basis after eliminating any serious condition
effective, but is generally more acceptable to the patient. This is because
posing an immediate threat to life or limb. Else the diagnosis is self-
it is more readily available and permits intimate interaction and caring,
evident and can be treated on the basis of simple clinical examination.
so often lost in the increasingly technologically oriented medicine. While
This approach is not only cost effective in time and expense for both
desirable in a country like Britain, there is no alternative to such a
the patient as well as the doctor, but it also avoids unnecessary
graded system of care in a country like India, if health care is to reach
investigation. What most patients need at this stage is assurance and
the majority of our people who are dispersed in the 600,000 villages.
information, as to when and how to seek additional advice and/or
The proliferation of allopathic doctors from 59,338 to over 3,00,000
treatment, in the unlikely event of this being a prodromal symptom or
since 1947 has failed to solve the problem of the control of communi
sign of a more significant disease. In actual practice, waiting and
cable diseases. These are still responsible for the major mortality and
watching is one of the most important tools in the medical
morbidity load on our people. We have a plethora of public and private
medical practitioners and specialists in the cities and towns. But 70% of
armamentarium.
the population which lives in rural areas does not have access even to
Graded Facilities: optimising health care
The degree of confidence with which an ailment can and should be
diagnosed or managed depends not only on the skill of the physician but
also on the disease itself t also depends on the individual and national
resources, which may be the predominant factor in countries where the
overall health manpower, the public and the personal resources are
limited or scarce. This constraint also operates among the poor sections
in affluent countries where health services in the public sector are
restricted. Even in a country like Britain, with a tradition of good health
care in the public sector which is available to all its citizens, the
burgeoning cost of health care necessitates that the utilization of
available medical manpower and resources be optimized. This has
been achieved by encouraging self-care arid the use of paramedics and
nurses, for help in the home as well as in general practice and in
hospitals. This relieves the load on the more expensive general
the most elementary form of health care. The current medical education,
which has tried to imitate the latest technology trends of the West, is
steeped in the diagnostic approach, based on pathology. In actual
practice, because of the absence of even the elementary facilities for
investigation in most situations, a dangerous blunderbuss type of
symptomatic medicine is the rule.
It is hence necessary to evolve a more functional classification
whereby diseases are classified hot according to their pathology, but
according to the varying levels of skills and facilities needed for their
diagnosis, management and care. Experience in health care projects,
such as our own at Mandwa, has demonstrated the advantages of
differentiating diseases by utilizing a more practical and functional
approach. In this approach diseases are classified not according to
pathology but also more according to the knowledge, skills and facilities
required for their diagnosis, treatment, prevention and control.
The Categories of Diseases
Dr. N. H. Antia is the Director, .Foundation for Research in
Community Health, Bombay and Pune.
Broadly speaking, diseases can be grouped in the following five
categories:
FOR PRIVATE CIRCULATION ONLY
Category A:— A PNC study by the National Institute of Mental
Health and Neuroscience revealed that 25% of all the attendance at a
PHC comprised of psychosomatic problems which needed under
standing and explanation rather than a pill or an injection.
bureaucratised health system in both the public as well as the private
sectors.
Four decades of experience under the prevailing conditions dictates
that this can only be attained through the community's own efforts
Category B:— These comprise of simple, self-limiting diseases
closely supported by community-based paramedical workers, who, in
which can be adequately handled by the individual and/or the family, eg.
turn, must be taught and supported by the medical profession and the
minor coughs, colds, diarrhoeas, bodyaches, headaches, cuts, bruises,
health services. Withholding this simple and readily available knowledge
boils, minor allergies and a host of everyday conditions. Both the
and technology merely because of the dangerous consequences of
diagnostic as well as the treatment skills are known to most families and
these diseases (especially if not diagnosed and treated in the early
the community, who can manage by utilizing home and folk remedies
stages) and a few untoward reactions to drugs, has proved counter
and/or some cheap and safe over-the-counter drug like aspirin.
productive.
Category C:— These are diseases which are not life threatening
Many of these diseases can be prevented by attending to nutrition,
but are nevertheless responsible for a substantial part of the
environment, water and sanitation besides the immunization of the high
community's morbidity load, such as scabies, worms, moderately severe
risk groups within the community. Even diseases like tuberculosis and
diarrhoea, dysentery, acute tracheo-bronchitis, moderately severe cuts,
leprosy can be readily suspected by trained community health workers
bruises, abdominal colic, osteoarthritis, chronic dermatosis, common
and paramedics and referred to the doctor for confirmation of diagnosis.
fever and chronic obstructive pulmonary disease. They can be
The prescribed treatment regimen can be given and supervised by the
adequately diagnosed and looked after by a properly trained
local workers. The patient can then be referred back only for an
paramedical worker with a modest repertoire of safe but effective drugs.
occasional check-up, or if any of the well-known complications of the
Even more important than the drugs is the advice for the management
disease or untoward effects of treatment arise. Others, especially in
of diseases eg. ORT, steam inhalation, application of sulphur ointment
situations where medical help is not available, can be treated by trained
or benzyl benzoate. Such advice would be more appropriate than that
community workers with short courses of drugs like chloroquine,
by a doctor, because of the physical and cultural proximity of those
enteroquinone, sulphonamides, metronidazole, aminophylline or oral
workers to the people, as well as the low cost of such an approach.
penicillin and can be referred only if the seriousness of the condition so
Category D:— This category comprises of diseases like severe
warrants. The role of the medical profession must be of a guiding,
gastroenteritis and dysentery, acute respiratory tract infection,
encouraging and supportive nature not appropriative. Professionals,
tuberculosis, tetanus, leprosy, malaria, poliomyelitis, measles,
however highly trained, have clearly demonstrated their inability to
pneumonitis, rheumatic heart disease and sexually transmitted
achieve the desired result. It is often difficult for the profession to
diseases.
understand this in view of the impersonalized and curative nature of
They are the major killers and maimers in the tropics today despite
present day medical education and practice.
the fact that, we have effective knowledge and means for their
Category E:— Comprises of those high profile but relatively few
prevention, treatment and control. The knowledge and technology for
conditions which need skills and facilities that can be provided only by
this is remarkably simple, cheap, effective, and safe. Yet the medical
the medical profession and the hospital. These include major medical
profession has revealed its inability to control these diseases despite
and surgical problems and emergencies which are beyond the scope of
monopolizing health care services. Experiments such as at Mandwa,
the paramedical worker who can nevertheless be taught to provide
Banaswari and Jamkhed have revealed that even these diseases can
adequate first aid before referral, follow-up and after care. Early
be effectively tackled by the people themselves in conjunction with their
diagnosis by such workers, as for cancer, tuberculosis and leprosy, can
paramedical workers. The problem therefore lies not in the inadequacy
greatly reduce the load and expenses for the treatment of an advanced
or non-availability of medical science and technology, but in the inability
disease as often seen in our hospitals. This would also be far more
to reach it to the people through the over-professionalized and over-
humane, as far as the patient is concerned.
It is understood that in a few cases in each category, the severity of
Some Issues in the Community
Participation in Health Care Services
the diseases may increase and upgrade it to the next higher category or
categories. A holding period of 48 or 72 hours is generally indicated
following which, persistence or exaggeration of symptoms indicates
referral to the next level of care. The paramedical workers can be taught
A Review Paper Prepared for the
ICSSR-ICMR Joint Panel on Health, Dec. 1990.
the signs and symptoms of a few diseases / problems like meningitis
Dr. Amar Jesani with Ms Shilpi Ganguly.
and abdominal pain or injury where immediate referral is necessary,
Pages: 30, Price: Rs. 25/-, Postage: Rs. 8/-
This Paper examines in detail the concept of Community
Participation (CP). CP is now thought to be a pre-condition for
succesful provision of primary health care as the government
health system has failed to reach a large proportion of the
population. Innovative experimentation by NGOs and the role of
the Panchayatsin the promotion of CP are discussed. Finally the
when in doubt.
The Rationale for this Classification
Such a classification may seem to smack of over-simplication and
even dangerous practice to those who work in countries where quality
medical services are readily available to all. Yet a similar attitude by the
medical profession in countries where even elementary medical
services are inaccessible to most has been extremely counter-
report stresses that the participatory process remains an empty
shell if it does not bring about redistribution of power and
nology to the majority of the people. This approach also leaves relatively
resources.
few problems requiring greater knowledge, skills and facilities for the
productive because it denies available medical knowledge and tech-
contd. on page 8
FRCH NEWSLETTER, VOL VII, NO. 2. MAR. - APR. 93
2
CANADA
Sonya Gill
Th is is the sixth article in the series, "Health Financing and
Costs: comparative perspectives". (No. 1 -Japan; No.2 - Zambia;
No.3 - China; No.4 - Brazil; No.5 - Sri Lanka).
Medicare : A federal - provincial system of public
reimbursement
A series of separate, provincially administered, insurance plans
form the core of the Canadian Health System. These are operated or
Canada's system of universal medical and hospital insurance,
supervised by the provincial health departments. The role of the federal
known as Medicare, has guaranteed every Canadian equal access to
government, however, has been substantial, as it sets certain terms and
high quality health care. The Canadian model of national insurance
conditions which provinces have to comply with in order to qualify for
departs from both the National Health System of Britain and the social
federal funds. These national standards have ensured that health care
insurance systems of other OECD countries. Medical care in Canada is
is available to all as a right and there are no income-related barriers to
provided by private (though not-for-profit) facilities which are paid from
access. The provincial plans must be universal rather than selectively
general tax revenues by department of Health of the different provinces.
covering certain groups as in the USA; comprehensive (covering all
This model is uniquely adapted to the loose federal policy of Canada
"medically necessary procedures"); accessible, which in the 1984
wherein the provision of health services is the responsibility of the
Canada Health Act was classified to mean the prohibition of direct
provincial governments but funding is shared by the centre, which also
charges to patients; portable, to enable coverage any where in Canada;
enforces a uniform health policy framework.
publicly administered, thereby limiting the role of expensive private
Health Status
of the programme.
insurers; and, providing access to information regarding implementation
Canada, with a population of 26 million (1989) has achieved
favourable levels of health status. It ranks after Japan and Sweden in its
life expectancy rate at birth (72 years and 80 years, for males and
females respectively) and infant mortality rate (8 per 1000 live births)
(Table 1). Maternal mortality has declined from 45 per 100,000 live
births in 1960 to 1/100,000 in 1986. As in other industrialised countries,
ischaemic heart diseases, cancers and accidents account for 60% of
adult mortality. Similarly Canada is also experiencing a general ageing
of its population. However the birth rate of 15 per 1000 population in
Medicare developed incrementally in the two decades after World
War II. Two legislations, passed in 1957 and 1966 respectively, com
mitted federal funding for the existing voluntary programmes of hospital
and medical care insurance. Medicare was fully established in all
provinces by 1971. These legislations were replaced in 1984 by the
Canada Health Act which sought to financially penalise provinces
imposing hospital user-fees or direct charges on patients. Having one
insurer per province rather than multiple plans has made the adminis
tration of medical insurance efficient and low cost.
1985 is high for a western society, and coupled with low IMR, the rate of
Health Care Services
natural increase is substantial.
The Canadian Health Care System is a mix of public funding and
TABLE 1
HEALTH STATUS
private provision. Private medical practitioners, both generalists and
specialists, and not-for-profit private hospitals constitute the country's
health delivery system. Office-based private practitioners are contracted
YEAR
MORTALITY
RATE
to the provincial insurance plans and are paid by the latter according to
CRUDE
CRUDE
BIRTH
DEATH
INFANT
MATERNAL
EXPECTANCY
a fee-for-service arrangement. A common province-wide fee schedule
RATE
RATE
PER
PER
AT BIRTH
for each item of medical service or procedure, is established through
1000
100000
(years)
BIRTHS
BIRTHS
(per 1000 population)
UFE
negotiations conducted at regular intervals by the respective medical
associations and insurance plans of the provinces.
Private practice wherein the doctors set their own fees is
1960
26.7
7.8
27.3
45.0
71
permissible, but in sharp contrast to the British NHS, it is prohibited for
1985
15.0
7.0
8.0
1.0
76
This prevents the development of a two-tier health care system and
doctors and hospitals which have a contract with the insurance plans.
protects all citizens against the economic costs of illness. As Evans
Source: United Nations, World Tables Vol. II, 1983 and 1989-90 editions.
points out: "The British private consultant can use his dual role to select
and steer patients according to their resources and the nature of their
problems. He can even use his position within the NHS to manipulate
The author was co-researcher in the above FRCH study. She
is presently involved in revising and editing the forthcoming
updated volume of "Health Status of the Indian People".
3
waiting lists and other aspects of access to ensure that private care will
be preferable to those who can afford it. The Canadian physician who
decides to "go private" must go all the way. He cannot use a strategic
COMMUNITY HEALTH CELA
326, V Main, 1 Block
Koramangela
Bangalore-560034
FRCH NEWSLETTER, VOL VII, NO. 2, MAR. - APR. 93
position within the public system to cream off only the profitable patients
patterns of the two countries began to diverge. Unlike the multiple
for his private services."
insurance plans in the USA, which are administratively expensive,
Canada had 209 active physicians per 100,000 population by 1986.
inequitious in coverage and loading the costs of health care on the
Slightly over 50 percent are general practitioners. Medical education
manufacturing sector, medicare is funded by a combination of federal
policy has attempted to control the growth of physician supply and the
and provincial general revenues. This spreads the costs across the
relative proportions of generalists and specialists. The provinces have
economy as well as centralises the disbursement of funds in a single
used various methods to overcome the maldistribution of health
public agency, the provincial ministries of health.
personnel, such as higher reimbursements for practicing in under
The monopoly of funding has “served as a powerful, if indirect, form
doctored areas, the rotation of residents to outpost hospitals, cottage
of regulation" (Evans). The administrative costs of the insurance plans
hospital systems, and systems of nurse practitioners or frontier-nurses.
are just 2.5 to 3 percent of total health expenditures as against the US
The common fee schedule is another incentive for physicians to relocate
spending of 8.2 to 15 percent. Raising additional funds through taxation
in underserved and poorer areas which would have a lower physicians -
is much cheaper than collecting premiums, and the process of claims
population ratio than more developed areas.
payment handled by a single agency is far more efficient.
Almost 90 percent of the 1,298 Canadian hospitals (1986) are
The inflationary potential of the fee-for-service reimbursement
voluntary, non-profit institutions, called “public" hospitals, which were
system is to some extent offset by the uniform fee-schedules. These
developed by local communities to meet perceived needs for care.
have restrained the escalation in physicians' fees to 15% of total costs
These are managed by independent boards of trustees drawn from the
as against over 20% in USA. Fee-schedules control fee levels but do
local area, and are funded on a prospective budget basis by the plans.
not attempt to change or control practice patterns as the highly intrusive
Investor owned hospitals have, generally, been prohibited after 1967,
prospective payment system in the USA does. It is the medical licensing
and private insurance companies have been restricted to supplementary
body in each province, and not the reimbursement agency, which
benefits that are not fully covered by public programmes.
controls the quality of service and deals with cases of malpractice.
Alternative models of health delivery are increasingly being
suggested in the context of an ageing population, the increasing
An important feature of the funding process is the separation of
Hospital care consumes the largest chunk of expenditures (40%).
proportion of chronic and degenerative diseases and rising costs. The
operational and capital costs. The provincial plans provide each hospital
financial coverage for all medically necessary services has skewed the
with an annual, inflation-adjusted global budget, negotiated in advance
delivery system towards intensive hospital and physician care. With
with the respective ministries, to meet operational costs. Capital costs
rapid technological developments this leads to the increasing use of
are met mainly from government grants, but require prior scrutiny and
medical interventions and hospitalisation for the chronic illness among
approval from provincial ministries. In the absence of approval, the
elderly population which has sharply increased the costs. The health
insurance plans can deny the institutions the necessary operating funds
delivery reforms are advocating the expansion of community-based
to implement the new activity. The public investment approach based
services such as home care services, paramedical services based on
on the province's needs for institutional care, rather than as profitable
visiting nurses, day surgery and preventive and promotive care as more
ventures, successfully constrains hospital investments.
cost-effective services for the 1990s. These modifications in delivery
Some pressures and conflicts have arisen on the issue of "rationing"
pattern would be complemented by increased planning of resources
and the devolution of planning and some financial responsibility to
of health care, which limits access to sophisticated technology and
increases the waiting time for hospital admissions. As compared to USA
regional councils within each province.
or Germany, Canada has a much lower rate of diffusion and utilisation
of the “state-of-the-art" technology. Most major technologies are
TABLE 2
HEALTH DELIVERY
restricted to teaching hospitals only and provinces deliberately
regionalise high-technology units to ensure optimal use. Studies,
however, indicate that the number of beneficial procedures for elderly
YEAR
PHYSICIANS
NURSES
DENTISTS
BEDS
(per 100,000 r OPULATION)
1960
117
...
1986
209
935
*
citizens, barring coronary bypass surgery, is not less than that in the
USA.
32
1,057
52
1,628
Source : OECD, Health Care Systems in Transition, 1990.
TABLE 3
NATIONAL HEALTH EXPENDITURES 1960-86
YEAR
TOTAL
PUBLIC EXPENSE
TOTAL EXPENSE
EXPENSE
TO TOTAL EXPENSE
TO GDP
$MILLIONS
%
%
1960
2142
43.1
5.5
1970
6256
70.3
712
1980
22658
75.0
7.4
1986
44276
76.0
8.5 A
Health Expenditures & Cost Containment
Canada, with a per capita medical care expenditure of US $ 1,4983
and 8.6 % of GDP devoted to medical care, ranks as one of the higher
spending health care systems. It has, however, had a lower rate of
growth of health expenditures than other OECD countries in the period
1975-87, and its national health expenditures are far below those of the
USA.
Until 1971, the two countries had similar health delivery systems
and spent the same proportion of their respective GDPs on health. With
the establishment of universal medicare in 1971, the health expenditure
FRCH NEWSLETTER, VOL VII, NO. 2, MAR. - APR. 93
Source:--UL, fiedl -de V/SE5 " ‘‘dPu0‘, ‘P>-
contd. on page 6
4
DROUGHT OF HEALTH IN DROUGHT AREAS
Bharat Patankar
It was 1971-72 in Maharashtra. Groups of interns from Government
drought still remained a dominant aspect of Maharashtrian rural life. The
Medical College, Miraj, were given the duty to visit drought affected
number of the drought prone talukasot Maharashtra went on increasing.
people labouring on drought relief works. In this very severe drought
In 1973 the government had been compelled to enact a law which led to
year every village in Maharashtra was affected. Hundreds of men and
the formulation of Employment Guarantee Scheme (EGS). Under this
women were working on drought relief works, forcibly, because nothing
scheme, under drought conditions the State was obligated to provide
could grow on their lands. They were toiling peasants, landless
employment on development works to toiling peasants and labourers,
labourers and even well to do middle class farmers.
so that they could subsist inspite of partial or total failure of agricultural
operations. Provision for medicines and visits by a doctor from the
Home Truths for a Young Doctor
Interns were supposed to take a kit of medicines with them in a
jeep, visit various sites, examine patients and give them required
treatment Their kit included vitamins and iron tablets, anti-bacterial and
anti-amoebic drugs, etc. One of these groups was giving doses of
medicines according to what they had been taught in the course of their
medical education. They finished their stock soon and went to the Zilla
Parishad to refill their stock. The person responsible for supplying
medicines was not ready to give any more because a team was
supposed to pull through a whole week with the help of the limited stock
of medicines given to them. But these interns were not willing to go by
such a rule. They went to visit the DHO (District Health Officer) and
demanded that they be given more medicines. The DHO who was used
to behaving in a dictatorial and arrogant manner said, “You kids do not
understand that this programme is not really for treating these patients.
You are supposed to give some medicines to those people only for their
psychological satisfaction!" But the interns were not ready to listen.
They said, "We will give medicine according to the people’s
requirements. If a patient is having severe anaemia we will give them
the tablets stock for one month because nobody is going to visit them
nearby centre at the site of EGS work were compulsory facilities to be
provided in this scheme. Still, the problem of ill health of the drought
affected people remained unsolved.
Our conception about the relation of health with poverty in general
and drought in particular, changed radically during all these years. The
experience of people's struggles for a better life told us many things. We
learned that poverty is not the only reason for ill health. Factors like
pollution, condition of drainage systems, type of irrigation, cropping
pattern and food habits can and do cause ill health in the affected
population. Curative and medicine-oriented business approach can and
does create problems in the field of health. We realised then, that
eradication of poverty or drought will not automatically solve the
problems of health. It would require a new approach to health and, on
this basis, a new approach even towards the way in which drought
would be eradicated. This new approach consisted of looking towards
the problem of drought in a different way. Drought of clean water, of
clean air, of vegetables and pulses may be included in 'drought' related
to health. Drought which is generally understood as a situation where
crops fail and scarcity of drinking water is created should also include
the above aspects.
again for a month". But the DHO would not relent. In the end, these
interns threatened to report the matter to the press. Only then did he
agree to give the required medicines!
This experience gave me a big shock. I started thinking that
hospitals and doctors were useless for poor people. The existence of
medicines in the market does not mean anything to them because they
cannot buy these medicines. Their vitamin and iron deficiency
syndromes arise due to their poor living conditions. The main reason for
ill health is poverty. Unless it is eradicated; medical knowledge, hospitals
and health programmes cannot help majority of Indian people who are
poor. The conclusion was to work for creating a society without
exploitation, without poverty. One cannot do much by merely working in
the field of health, to help poor people remain healthy.
Drought Related Health Problems
The first and generalised effect of drought is on mental health. The
feeling of insecurity about one’s own and the family's existence creates
mental irritability in drought affected populations. In spite of the
existence of the EGS law one is not sure of getting employment
continuously during the period of drought. Once the work at one site is
complete one does not know whether another work would start
immediately. So one is faced with the prospect of not having something
to eat from the very next day. People are forced to sell their land, trees
and similar assets for the mere existence of the family. Quarrels in the
family go on increasing. Many times drinking and wife-beating are forms
taken for coping with mental instability in this male-dominated society.
There are cases where women are sexually abused by the employees
Experiencing Drought: changing perceptions
Years went by. Many more irrigation schemes were completed but
who control the guarantee of work at the immediate work-site. There
are rare but definite incidences of suicides because of mental tension.
Landless labourers and women in general are the worst affected in all
The author is a doctor by training, who has been a social
drought situations.
political activist since two decades. He is involved in the
Unhealthy drinking water is also a common problem in droughts.
mobilisation of the rural masses in Sangli district in Maharashtra.
Water is either provided from tankers directly or poured into dried-up
5
FRCH NEWSLETTER, VOL VII. NO. 2. MAR. - APR. 93
wells in the villages. This water is brought by tankers' owners from any
Private Sector and Privatisation in the
Health Care Services
source which would be at the shortest distance. Because, for tanker
owners it is always an opportunity to earn a lot of money. They are not
bothered about providing clean water. This results in repeated dysen
teries and diarrhoea further reducing resistance to other infections.
A Review Paper For The ICSSR-ICMR Joint Panel on Health,
August,. 1990
Food intake is also repeatedly reduced. Along with decreased quantity
Dr. Amar Jesani with Saraswathy Anantharam
of food intake, quality of the food available creates ill health in such
situations. Failing of the crops makes import of the food materials from
Pages: 97, Price: Rs. 50/-, Postage: Rs. 8.50
outside the market inevitable. With limited cash in hand, the main food
intake remains restricted to jowar or wheat and a very small quantity of
This Paper was among those commissioned by the Joint Panel on
'dal if possible. Generally jowar or wheat roti are eaten with just onion
Health to review the achievements of the decade 1978-88. We
and chilly powder and a very small amount of oil. This results in various
know almost nothing about the private health care sector in India
kinds of vitamin deficiency syndromes, anaemia, protein deficiency
to which 80% of doctors, from all the systems, belong. The authors
syndromes, etc. In such situations incidence of infections like
narrate: the State involvement in Health Care in India and abroad;
tuberculosis also increases.
the growth of the public and private sectors in India and the nature
As it becomes difficult to get even drinking water, it becomes almost.
of medical practice therein. In India, making health care services
impossible to have a bath everyday or even once in a week. Spread of
accessible to all, without financial barriers, is the central problem.
skin diseases becomes rampant because of this. Under such conditions
But the private sector and the market mechanism have not shown
curative approach towards health leads only to temporary relief, but
access-consciousness.
repeated occurrence of ill health cannot be prevented. In fact preventive
approach can easily help in keeping people healthy. It is not very difficult
to provide healthy drinking water with very simple measures. It is also
possible to provide food components, which could be bought within the
range of people's wages, thus preventing deficiency syndromes and the
possibility of other infections. People could be advised to keep their skin
clean with simple methods requiring small amounts of water.
contd. from page 4
Conclusion
Medicate remains the most popular public programme in the
country. The Canadian system is unique in the virtual absence of private
sector involvement in health insurance, and the unwillingness of policy
makers to seek private finances to ease the financial pressures on its
Drought Eradication and Health
tax-financed programme. It continues to uphold the principle of equal
At this point one would think that eradication of drought is the real
solution to all these health problems. But unfortunately it is not true.
access to health care and has so far refused to raise additional finances
through patient-based direct charges.
Today's method of drought eradication consists of providing water for
Nevertheless, the public insurance system is facing new pressures
agriculture, that is, providing water to a small area with mono-crop
from the wider economy. High unemployment and inflation rates and a
domination and mainly to the lands of the elite section of rural society.
massive budget deficit (6% of GDP in 1986-87) have reduced the
This results in cash crop (such as sugarcane) production in a small area
contribution of the federal government to the plans. The cutbacks in
and paucity of necessary food components. People from the remaining
federal finances come at a time when utilisation of medical services is
non-irrigated drought affected areas become migrant workers at nearby
growing, and health care costs are exceeding the growth in provincial
irrigated areas or agricultural labourers on the lands of those who have
revenues. Economic forces have thus placed pressure on the provinces
control over water resources. Over-use of water, accumulation of water
to find innovative approaches. Between 1987 and 1991 at least 6
in low level lands, etc. create new health problems. Even if there is
provinces have reviewed their health systems and made broad policy
plenty of water available for drinking in some of the irrigated areas it is
recommendations for the 1990s. Having achieved equitable access to
polluted either because of contamination from over-use (or wrong use)
health care, Canadian medicare is now grappling with the wider issue of
of chemical fertilizers and pesticides or because of the effluents coming
equitable access to health. The emerging policy directions point towards
out of sugar factories, liquor factories or paper mills. New kinds of skin
greater community-based care, consumer participation, improved
diseases are also induced by the use of such water.
efficiency and effectiveness, and a modification of the organisational
Hence it is neccessary that the perspective on health should be
structure.
integrated to a new approach and should include strategies for drought
The success of medicare has provided the conditions for Canada to
eradication. This would encompass — a) Water utilisation based on
consider these options. At the same time, its US neighbours across the
principles of equitable distribution, thus ensuring water availability to
border are weighing the option of the Canadian model to create a uni
wider areas; this would mean water-shed development and
versal health system for themselves.
redistribution of waters from big dams in the valleys, b) Bio-mass based,
sustainable
agriculture primarily providing all necessary food
components to each family, c) Establishment of cropping pattern cycles
to make this possible, d) Decentralised industry based on renewable
Select References
1)
EvansR.G., Public Health Insurance: the collective purchase of individual care, Health
2)
Evans R.G. et. al; Controlling Health Expenditures: the Canadian reality, New England
3)
Journal of Medicine, Vol. 320 (9), 1989.
Iglehart J.K., Health Policy Report: Canada's health care system (three parts), NEJM,
4)
Iglehart J.K., Canada's Health Care System Faces its Problems, NEJM, Vol. 332 (8),
5)
Mhatre S.L and Deber R.B., From Equal Access to Health Care to Equitable Access to
Policy, (7), 1987
materials and energy, whereby pollution could be minimised and
controlled.
While my focus has been to pinpoint the links between drought and
1986.
health, it goes without saying that all these are part of a broader vision of
development which sees a society free from social and economic
exploitation where human beings live in harmony with nature.
FRCH NEWSLETTER, VOL VII. MO. 2, MAR. - APR. 93
•
1990.
Health: a review of Canadian provincial health commissions and reports, International
Journal of Health Services, Vol. 22 (4), 1992.
•_
6
UPDATE ON FRCH PROJECTS
School Health Education Project: This project sponsored by the
determine the steps involved in eliciting participation of the community
Ministry of Human Resource Development has been completed now. It
b) Developing training methods/material for that purpose c) Assessing
started with the aims of imparting knowledge of health and disease to
its effectiveness and studying its macro implication.
teachers and students and developing simple teaching means and
The Study of Social & Operational Constraints in Tuberculosis
methods. The manuals for teachers and children are ready and will be
Control Programme: The objective is to find out the constraints
responsible for the persistence of the TB problem. This study is
published soon.
Health Status of the Indian People: The second volume
undertaken in urban and rural areas of Pune district. The project started
consisting of two parts is being prepared. The first part will have three
with the orientation of the researchers and planning and preparing the
theme papers which will deal with public and private sectors in health
research tools. The data was collected from the households, patients,
care in India and health research and information system in India. The
medical officers in PHCs and other health workers. This data was coded
second part will give the statistical information and a brief write-up about
and analyzed. The next phase includes private practitioners in addition
health status of Indian people updating the information in first volume.
to the other sources in the first phase. Now this data is being compiled.
Manual of Primary Health Care: The hospital-oriented training
Public Information: This project aims at information dissemination
that the doctors receive in urban-based medical colleges does not equip
about Government schemes for poverty alleviation as well as other
them to perform the curative and preventive health care activities in a
social issues. This is done through various methods of communication
Primary Health Centre (PHC) covering about 25,000 population. This
like pamphlets, group meetings, posters, films etc. This work is going on
manual covers the common clinical problems as well as the common
in fifteen villages of Purandar taluka, fifteen villages of Parner taluka-
administrative procedures and problems that a medical officer may
and fifteen villages in the surrounding area of Ralegan Siddhi. The
encounter. It will be published soon.
pamphlets produced so far have been: a) Government health services,
Leprosy Footwear: FRCH in conjunction with the plastic shoe
b) IRDP, c) EGS, d) Gram Panchayat and e) Schemes for SC-STs.
industry of Bombay/Thane has devised footwear to suit the anaesthetic
Those in the pipeline are: a) Women and law, b) Rural-urban disparities,
feet of leprosy patients. Two thousand pairs have already been provided
c) Corruption and d) Water management.
to the Government of India for trial in five leprosy institutions. A new
Village Library Movement: The target group of this activity is: neo
form of neuro-vascular surgery has been devised at our sister
literates, young school and college goers and literate adults in villages.
organisation the Foundation for Medical Research.
Through reading material like books, magazines, and newspapers on
&
various subjects the aim is to create social awareness, change feudal
Pharmaceuticals: This project has completed its first phase where
thinking' and initiate development. This work is supplemented by
Study of the Supply,
Use
and
Cost of Drugs
data regarding supply, use and cost of drugs and pharmaceuticals was
Balwadis and Adult Education which involve the.enthusiastic support of
collected at nine PHCs, three Rural Hospitals, one Cottage and one
the locals.
Civil Hospital in Satara district. The second phase, now attempts to
IDS Kasare: Kasare self-help project was developed on the model
make an estimate of the volume of drugs and pharmaceuticals in the
of Ralegan-Siddhi. It has mobilised residents of the village and
private sector. Interviews of providers to study prescribing and
organised them into village development committees. Various
dispensing behavior and analysis of prescriptions to determine degree
informative and action oriented programmes such as animal husbandry,
of irrationality are also planned.
water-shed development, road-repairs, horticulture, libraries, procuring
The ‘Health Investment & Expenditure* in a District: This study
IRDP loans are being carried out.
is being conducted in Ahmednagar district. In the first phase of the
Stree-Dhan: This is a women's savings and Credit group tin the
study, an inventory of all health resources in the district has been made.
lines of Grameen-Bank of Bangladesh in Malshiras ^taluka Purandar,
It includes medical practitioners belonging to all systems of medicines,
District Pune). Here women are disbursed loans upto 1000 Rupees for
small and large hospitals, dispensaries, consulting rooms, medical
household expenditure, repaying old loans, buying sheep, without any
stores, pathological laboratories etc.; from both the private and the
collateral. Since these are neighbourhood saving groups, the repayment
public health sectors. In the second phase, detailed investment and
is 100%. This savings and credit group has initiated women's
expenditure patterns of a few health establishments from the aboye
empowerment in the three villages where this work is carried out and
inventories are being studied.
given the motivation to expand to more villages.
•
Community Health Care Model Project: This will be a six year
project The Government and the Zilla Parishad have shown their
willingness to hand over Parinche PHC (Purandar taluka, Maharashtra)
This gives a brief idea about FRCH projects.Detailed report
to FRCH for that duration. The objectives of the project will be:
of each project can be found in the Annual Report 1992, to be
a) Developing a community based health care system with a view to
7
published soon.
FRCH NEWSLETTER, VOL VII, NO. 2, MAR. - APR. 93
LIBRARY NEWS
Books
1)
11)
Bridahl H. and Court J., Diabetes, A.H. Wheeler and Co. Pvt. Ltd.,
Programme: a proposal for effective action, I.I.H.M.R., Jaipur,
Allahabad, 1987, pgs. 66.
1991, pgs. 20.
2)
Brown Y. and Crack D., Your Children's Teeth, A.H. Wheeler and Co.
3)
Buchanan N., Childhood Epilepsy, A.H. Wheeler and Co. Pvt. Ltd.,
12)
Pvt. Ltd., Allahabad, 1985, pgs. 45.
Coleman V., Health Scandal, Mandarin, London, 1989, pgs. 245.
5)
Coovadia H.M. and Benatar S.R., Century of Tuberculosis: South
pgs. 26.
14)
Krishna V. etc., Collaborative Study on High Risk Pregnancies and
15)
Montgomery B., Coping with Stress, A.H. Wheeler and Co. Pvt Ltd.,
16)
Mustaph J., Backpain, A.H. Wheeler and Co. Pvt. Ltd., Allahabad,
17)
Norton L, Preventing Heart Disease, A.H. Wheeler and Co. Pvt. Ltd.,
African perspectives, Oxford University Press, Oxford, 1991, pgs.
319.
Allahabad, 1987, pgs. 56.
Gopalan C., Science and Nutrition in the Future, International
Congress of Nutrition, Seoul, 1989, pgs. 21.
1987, pgs. 68.
Jain A.K., Managing Quality of Care in Population Programmes,
Kumarian Press, U.S.A., 1992, pgs. 162.
9)
Maternal Mortality, I.C.M.R., New Delhi, 1990, pgs. 214.
Gopalakrishnan S. and Mahendru B., Growth Monitoring : an
annotated bibliography, N.I.P.C.C.D., New Delhi, 1992,pgs. 74.
8)
Allahabad, 1988, pgs. 77.
18)
PrashantS., Drug Abuse and Society, Ashish Publishing House, New
19)
Selected Chapters From the Sth Five Year Plan Document of the
Jesani A., and Ganguly S., Some Issues in the Community
Participation in Health Care: a review paper prepared for the ICSSR-
Delhi, 1993, pgs. 219.
Government of India, Voluntary Health Association of India, New
ICMR joint panel on health, FRCH, Bombay, March 1993, pgs. 30.
10)
Kothari D. and Gulati A., Recent Government Policies and Strategies
to Control Population Growth: a critique, I.I.H.M.R., Jaipur, 1992,
4)
7)
Kothari D., Family Welfare Programme in India: an alternative
approach, I.I.H.M.R., Jaipur, 1991, pgs. 20.
13)
Allahabad, 1985, pgs. 66.
6)
Kothari D. and Gulati A., District Level Approach to Family Welfare
Kothari D. and Gulati A., An Inter-Sectoral Coordinating Mechanism
for the Indian Population Programme : a framework, I.I.H.M.R.,
Delhi, 1993, pgs. 61.
20)
Subrahmanyan S., Status of Women and Children in Andhra
Pradesh, UNICEF, South East India Off., Hyderabad, 1991, pgs.208.
Jaipur, 1992, pgs.24.
contd. from page2
medical professionals. They can then devote much more of their time as
technically and culturally to be operated most cost-effectively in a
well as the limited expensive resources for secondary and tertiary care
decentralised system as conceived under Panchayati Raj. This is
for which they are specifically trained. The risk of not utilizing the
possible provided the public health and illness approaches are graded
available knowledge and technology far outweighs the danger of
and operated according to the skills and facilities, as indicated by the
withholding it, certainly under the prevailing circumstances, and even
categories described above.
when the socio-economic conditions improve.
Such an approach would involve the people in their own health care
The present approach has succeeded only in mystifying health and
and would help release them from the clutches of the health industry. It
medical care and placing it within reach only of the affluent minority who
would also establish the rapport and confidence between the people
can afford to pay for services or, through influence, monopolize
and their most important first level contact, the paramedical workers,
whatever effective services are provided in the public sector. The
without whom no programme can succeed. This will require the
medical professionals, who increasingly perceive medicine as a lucrative
provision of more knowledge and availability of essential drugs with
business, have also mesmerized themselves into believing that 'West is
Community Health Workers and other paramedical workers.
Best*. They have alienated themselves from the masses as well as from
A vast country like India with so much diversity, calls for a modified
their socio-economic problems and culture. The result is that they firmly
approach to suit the prevailing epidemiological arid social realities which
believe that there is no alternative to the present system, despite its
vary from urban to rural areas, from region to region and often from
proving to be increasingly counter-productive. The pharmaceutical and
village to village.
medical instrumentation industry, whose sole motive is profit, has spared
no effort in reinforcing the belief among the professionals and the public
References
that modem health care must follow the latest Western pattern however
1)
expensive and inappropriate it may have proved to be even in the
Antia N.H., The Mandwa Experiment: an alternative strategy, British Medical Journal,
pp. 292; 1986.
countries of their origin.
/
An Alternative Approach —
FREE ABSTRACTING
The alternative model, as proposed in the ICSSR/ICMR report
The contents of this newsletter may be abstracted
"Health For All - An Alternative Strategy, envisaged that the vast
without prior permission. However, we would welcome
majority of all preventive, promotive and curative health care would be
acknowledgement of the source and copies of any
undertaken by and within the Gram Panchayat and Panchayat Samitiat
abstractions.
one lakh level. It was based on the principle that health lends itself both
Edited by Rohini Lele & Nagmani Rao, with secretarial assistance from Joyeeta Sinha & Lucy Dias. Produced by the Foundation for Research in
Community Health, 84-A, R.G. Thadani Marg, Worli, Bombay 18. Registered under the Bombay Public Trusts Act. Printed at Printext Offset, Pune 30.
May - June 1993
Vol. VII, No.3
MALSHIRAS : THE STRUGGLE CONTINUES
Sadhana Natu
FRCH believes that health as an issue is not unidimensional. It is
spend three to four hours every day to fill enough water just to satisfy
influenced by socio-economic factors. Hence if the health status of the
household needs. While the natural sources of water have dried up, the
people is to be improved then their socio-economic problems should
other sources like bore-wells and wells with electric motors and hand
also be addressed.
pumps belong to the rich farmers. Hence the women from Below
This perspective was the backbone of the five year action research
project at Malshiras in Purandar taluka (district Pune, Maharashtra)
crucial to achievement of good health — having access to water and
from 1987 to 1992. A team of senior researchers imparted health
having enough of water.
Poverty Line (BPL) families are left bereft of two water related criteria
education to the people of eighteen villages through close interaction.
Being witness to this recurring scenario, from the initial funds that it
This was possible because they resided in the village. Also their
had received, MASUM advanced substantial amount towards getting a
personal involvement with the wider movement and diverse social
pipeline into the village. But the work remained incomplete and some of
issues made them sensitive to respond to the issues articulated by the
the money unutilised. Accounts were not settled, nor was the pipeline
people. Hence during the course of five years a strong bond had been
completed even after constant reminders. In those places where the
established with the villagers of Malshiras and surrounding areas. Using
pipes had been installed on certain wells, on the understanding that
health as a starting point the work evolved to include relevant socio
there would be open access to drinking water, the women were still
economic issues like drought, alcoholism and women's oppression.
denied their right to fill water.
An offshoot of this was the formation of a Mahila Mandal called
The situation had become very grim. On one hand the money given
Jagrut Mahila Mandalwhere these diverse and crucial issues concerning
for a specific purpose was not utilised properly. On the other hand the
women could be addressed. Also the need for income generation arose
women were left with dubious choices : spend three-four hours to get
and to carry out these activities; a trust: Mahila Sarvangeen Utkarsh
just one potful of water or pay three rupees per kavad (tin)! (those who
Mandal (MASUM) was formed. MASUM has championed the cause of
could afford it that is — and these were abysmally few). A meeting of
oppressed women; whether it was in the struggle for prohibition or in
Jagrut Mahila Mandal, MASUM members, and the village women was
case of the gruesome murder of a daughter of Malshiras village or in a
molestation attempt on a minor girl by a high-caste villager. It has taken
therefore called. In the meeting the women articulated their thoughts:
they were exhausted with their mile long treks for water, saddened at
up cudgels on behalf of the exploited time and again.
the numerous accidents that took place when women slipped and fell
Drought, Women and Mobilisation
this perilous task. But they were ready to fight it out. Ready to demand
into steep wells and inconsolable at the deaths that took place during
Ever since the massive drought of 1972 the area has not received
adequate rainfall. In fact the whole of Purandartaluka lies in the scarcity
answers to the question regarding the pipeline and MASUM money.
Two of the trustees of MASUM declared that since they had given
zone; receiving an annual rainfall ranging between 600 mm to 700 mm.
money to the villagers and had received no answers for two years they
In this drought prone area, women are the worst hit as they have to
felt morally responsible for the situation. Hence they would write to the
village elders and issue an ultimatum — if the accounts were not settled
and the issue of water not discussed in a Gram Sabha (village-meeting)
by Sth of March then they would go on a hunger-strike till these two
The author is a researcher at FRCH, involved in the Public
Information Project and MASUM work. She has a post
demands were met. The women supported this proposal unanimously
graduate degree in Clinical Psychology.
and were ready to join in the hunger-strike too.
FOR PRIVATE CIRCULATION ONLY
So the stage was set..........
The Hunger-Strike
International Women's Day was celebrated with its usual gaiety in
The hunger-strike began in the morning and the women rallied
the village. But a solemnity underlined all the celebration : every song,
round in substantial numbers. By mid-afternoon the village elders had
speech, presentation had the theme of drought and water-scarcity finely
conferred. The fact that the women were present in large numbers, the
interwoven into it. The programme also provided an effective platform to
people from neighbouring villages had heard about the hunger-strike
clear out all the cob-webs from the minds of the few doubting villagers
and some had visited Malshiras, the outside support that the MASUM
about the role of MASUM in the village, and to allay their fears about the
activists had, made a dent; private had become public.
hunger-strike being a political gimmick. They were convinced that
political power or alignment with any political party has never been or
never will be the mainstay of MASUM or MASUM activists.
The clarion call for mobilization was given and the women dispersed
vowing to turn up in large numbers from wadis and vastis to support the
hunger-strike. The local political big-wigs started feeling uneasy and
their Machiavellian machinations began. They tried to negotiate with
MASUM trustees about clearing up the accounts that very night. But the
trustees flatly refused. Everything had to be discussed in the open in the
Gram Sabha.
Under such pressure the village elders were finally compelled to call
a Gram Sabha. It was a day of 'many firsts': — it was the first time that
accounts of public money were given to the community. For the first
time it was acknowledged that nobody had a monopoly over water and
that drinking water would be given priority over water for irrigation.
It was for the first time that a Water Committee was formed
consisting of MASUM members, one MASUM trustee and two villagers
representing two different political parties.
The Water Committee was to fulfill the following duties —
1)
See to it that the women were allowed to fill water from wells
2)
Take a physical stock of the pipes and motors which were
3)
See that the fields were not irrigated till the drinking water
where pipes had been installed with MASUM money.
A series of environmental tragedies over the last decade —
Minamata, Chernobyl, Bhopal, the contamination of the Rhine
with toxic effluents from Roche, the oil spill in the Gulf, etc.—have
focussed attention on the increasing ‘chemicalisation’ of the
environment; more or less at the same time, the Thalidomide,
SMON (subacute myelo-optic neuropathy) and DES (diethyl
stilbaestrol) tragedies and, more recently, the increasing
incidence of iatrogenic diseases and pesticide poisoning have
dramatically illustrated the growing ‘chemicalisation’ of the body;
Both developments have forced us to realise that health and
environmental issues cannot be dealt with in isolation, not only are
they intrinsically linked to each other, but neither can be easily
solved by a quick technological fix. For pollution today is not only
chemical, it is also biological, social and psychological.... To my
mind, the problem may be articulated as one of extreme
deprivation on the one hand, and of irrational excess on the other.
The deprivation is that of 'essentials’ such as food, clean and
adequate water, air, health care, and safe living and working
conditions. The excess consists of bombarding our beings, over
lives, and our environment with hazardous gases, chemical and
biological contamination, i.e., irrational and 'inessential'
toxification.... It did not require the study of social and preventive
medicine to demonstrate the great importance of adequate and
clean drinking water in ensuring good health, and of the nature of
water borne diseases. Medical books have informed us that 70 %
of all diseases are water-borne and therefore preventable, and
that one-third of all paediatric hospitalizations are due to
diarrhoea..... History has shown that laws can act as a deterrent
whereby social conscience and responsibility take precedence
over individual profiteering. But where vested interests have
ensured an accumulation of power and money, the silence of the
tormented is enforced, and that of law enforcers bought Legal
loopholes are given precedence over morality and ethics, and
unjust laws are passed, while attempts to enforce controls are
scuttled whether they related to Bhopal gas tragedy, the violation
of the Baby Food Code, drug dumping or the indiscriminate use of
toxic pesticides. Ecological and health hazards cannot be
prevented or dealt with unless a collective consciousness is built
up among those who are willing to make sacrifices and to live
without destroying and exploiting; It is only when enough people
have cared and dared that changes have been enforced.
Source: Mira Shiva, ‘Environmental Degradation and Subversion of Health*
'Development Dialogue'. (1.2), 1992.
bought with MASUM money.
problem was solved.
4)
Discuss various workable solutions to find a permanent
answer to the perennial issue of drought.
In the entire proceedings of the Gram sabha the local politicians all
stood together in the rocking boat and supported one another. But this
was a mere face-saving tactic since the villagers already knew who the
culprit was and also the exact nature of the irregular actions. But on the
part of those on the hunger strike, there were no recriminations or
scape-goating. The aim had been to highlight the issue of water-scarcity
and this was certainly achieved. Despite the fact that there would be
many more struggles ahead before the issue is entirely resolved, the
strength and resilience of the women came out forcefully during the
experience of this hunger strike. In their own words: "We have to make
do with one handa (pot) of water for three days" says it all.
The Backlash: lessons learned
Shalantai, a fiery MASUM worker, was a recipient of many threats.
Fields were irrigated at night, so that in the morning less drinking water
was left. The women were in a combative mood: they wanted to drag
out the pipes, which they understood were theirs and hence they had a
right to water. All separate events, but all direct results of the hungerstrike. So though social pressure had worked in the Gram Sabha a tew
loose ends still remained.
The Water Committee intervened; some villagers also pitched in
and a new pipeline was dug. Through it the water was collected in a
tank from where the women could fill water for two hours (in the morning
as well as in the evening). The gushing water told its own story.
A dialogue has now begun and various alternatives to solve the
water-scarcity are being discussed. But unresolved questions remain:
the well from which the water is being brought by the pipeline is to be
cleansed of impurities. Who will pay for the task? Will the villagers unite
and contribute collectively? What will happen when this source dries up
or the water level is reduced? If a percolation tank or an underground
dam is to be worked on as a viable alternative, once again where will the
economic resources come from?
The struggle for Water and the following hunger-strike led to many
contd. on page 6
FRCH NEWSLETTER, VOL VII, NO: 3. MAY - JUNE 93
2
STAKES OF MEDICAL PRACTICE
Maya Nirmala
In the past there have been a few articles in FRCH Newsletter
the cost of modern medical education and considering the increased
focussing on various dimensions of the financing of health care services
cost of setting up a medical unit, taking loans is an indispensable factor
in India. One of the current studies in FRCH is looking into health
except for those who inherit fortunes. Agencies like Maharashtra State
investment and expenditure patterns in Ahmednagar district of
Financial Corporation (MSFC) reflectthe same discriminatory attitude in
Maharashtra.
favour of allopaths. Doctors with M.B.B.S. or M.D. degrees can avail of
In the first phase of this study we had prepared an inventory of all
the'Medical Practioners Scheme' but non-allopaths have to enter into a
health-care resources including medical personnel and establishments.
contract with the allopaths for getting loans from MSFC. Hospital
This inventory only confirmed the well-known urban bias in the
standards sanctioned by MSFC are difficult to achieve in the rural set-up
geographical distribution of health-care-services. This disparity between
having inadequate water and electric supply, inadequate sanitation and
rural and urban concentration of doctors (1885:1 and 343:1 population
scarce qualified paramedical staff. Whether these standards should be
to doctor ratio respectively) is also stratified by trends among doctors
relaxable as suggested by some doctors is a much complex issue to
trained in different systems of medicine. For example, about 60%
settle. Incidently, those who have availed of loans are also supposed to
allopaths and more than 90% dentists and specialists practice in the
give an undertaking that their practice will grow every year, enabling a
urban centres of the district. The reasons are obviously located in the
faster repayment of loans, indeed, doctors exercise all rational,
socio-economic conditions available for medical practices and institu
professional and irrational means to keep up the promise even after the
tionalisation of those practices operating in our society.
During July-August 1992, FRCH had organised three one-day
workshops — two in Ahmednagar and one in Shrirampur — with the
repayment of loans. Everyday at least five X-Rays or three
sonographies have to be conducted on the respective instruments not
for any less obvious reasons.
doctors from Ahmednagar district, focussing on some regularities
The private health sector offers a wide range of medical services
evident in the field of medical practices. Participants came from all over
and specialities. The specialists and pathological laboratories are visited
the district, representing medical practitioners of all pathies. There were
even for illnesses like minor ophthalmic or skin diseases. The status of
also RMPs, and those who were part of the public health sector. The
the doctor as a family physician is fading away. About 50% patients
deliberations during these workshops mainly revolved around the
move from doctor to doctor. Doctors beginning private practice face
economic dimensions of medical education as well as setting up and
acute competition. The competition takes bizarre shapes among GPs
continuing medical practice; competition among doctors; role of the
and specialists, and among modern and traditional medical
drug industry and patterns of charging fees. Doctors also raised the
practitioners. Fifty years ago, superstitions and faith in 'unscientific'
issue of consumer movement and talked keenly about their impressions
rituals had an adverse effect on allopathic practice. Now that the taste
regarding that. The following brief account is an attempt to skim through
and desire for modern medicine has already been created, doctors no
some aspects of these exchanges between our doctor-friends from
longer compete to retain monopoly, but to provide most advanced
Ahmednagar district and some colleagues in FRCH, in the context of
treatment, thus paving the way for new 'scientific' biases.
some ongoing debates concerning community health.
Unfortunately, with every specialized technique, the subtle intuitions
supporting a therapy and its simple remedies are being forgotten. Many
Initial Determinants
State discrimination at the level of financing the training and
research facilities, and at the level of health-care provisions and
recruitment in the public sector, influence the status and scope of
different medical practices. Priorities of the medical industry and the
social images of various therapies have a strong hold on their relative
marketability, despite a high degree of cultural advancement in the
district. In fact, with the booming sugar economy and growing
urbanization, the contrast between the hegemonic allopaths and the
young doctors follow a certain 'pathy' without having sound faith in it.
Medical colleges function as incidental launching pads into the
profession. Even those doctors who carry the necessary conviction for
practicing Homeopathy, Ayurveda or any other traditional system, resort
to Allopathy dictated by patients' expectations or by the medical market.
Only a minute stratum among the urban middle class, which respects
the traditional medical knowledge, has the patience and luxury to await
the recovery offered by these systems, against the backdrop of irrational
allopathic treatment.
under-privileged non-allopaths is growing wider with each passing day.
When we consider the high profile therapy, allopaths have a better
Cross-practice and CME
choice in deciding location, raising finances from institutional sources
Cross-practice, mainly by non-allopaths has therefore become one
and repaying loans, etc. After paying an exorbitantly high price towards
of the major concerns of the state. With the recent legitimization of
The author is a researcher at FRCH, involved in the study,
was still under consideration at the time of the workshops, ayurvedic
'Health Investment and Expenditure in a District',
doctors strongly advocated re-introduction of integrated approach in
cross-practice, in Maharahtra (drily for the ayurvedic practioners) which
3
FRCH NEWSLETTER, VOL. VII, NO. 3, MAY - JUNE 93
medicine, hoping to overcome limitations involved in following any one
therapy exclusively. But the idea of multi-system short courses in
medicine proposed by some doctors sounds problematic. Doctors fear
that the idea of complementary therapies would be exploited by some of
their fraternity merely to expand their practice. More compounders and
nurses than those already practicing might want to treat people
independently, on the basis of some working knowledge of medicines.
At the same time we are also familiar with the image of a bare-footdoctor or that of a village-health-guide. The attempts at demystifying
medical knowledge and devices for assuring a rational medical practice
should then be monitored in the same vein. Similarly the 'propriety' of
continuing medical education (CME) per se is not being questioned.
Doctors certainly need orientation programmes in order to acquaint
Role of the Drug Industry
Despite the Hathi Committee recommendations many ready-made
combinations, non-essential tonics and protein preparations are
flooding the market. Apart from the routine queries from the FDA there
is no controlling mechanism. Drugs which are patented abroad escape
the critical gaze of 'Central Drug Research Laboratory', Lucknow. This
laboratory, the only national institute of its kind, scrutinizes the new
Indian pharmaceutical products, most of which are ayurvedic
preparations. Competition among pharmaceutical companies and the
continuous flow of new medical products is mentally strenuous for the
doctors. They have to choose the combinations and brands on the basis
of a plethora of ready-made information. There is every possibility that
the chosen drug would look dangerous or backward with the ever
themselves with new developments in medicine. But apart from lectures
exploding new researches and higher drugs. However, these untimely
organised by local medical associations, most of the rural doctors rely
basically on the literature distributed by pharmaceutical companies.
professional scruples are eventually sobered up when about 40% of the
This literature is designed for propaganda purposes rather than for the
altruistic goal of educating doctors. Likewise, as Andrew Wear writes,
druggists and distributors, as doctors themselves admit. Despite the
"Cries for scientific medicine, for better medical education, more
conscious of the irrationality in their practice, medical professionals are,
rigorous examination etc., (have) their altruistic side, but (are) also
mixed with social and financial considerations". Pharmaceutical
companies, being the pivotal forces operating in the medical market,
influence the present day medical practice, determining the nature of
annual turnover of the drug industry is distributed among doctors,
fact that there are doctors who practice rationally or those who are
to a great extent, instrumental in further victimization of patients.
Physician samples are tested out on poor patients in the name of
charity. Patients are sent to specific drug stores with loaded
prescriptions. And chemists push forward their pet substitute brands.
diagnosis, treatment and charging pattern.
contd. on page 7
Capitation Fee and the Right to Education
Maharashtra: Till the current academic year, 80 % of the seats in
The Supreme Court issued the landmark directive in February that
There shall be no quota — reserved for the managements or for any
private medical colleges used to be filled on the basis of merit, the
family, caste or community which may have established the institution**. As
remaining 20 % constituting the ‘management quota’. Henceforth the
per the directive, all professional colleges will have at least 50 % of seats
filled by the nominees of the government or university as ‘free seats’. The
Director of Medical Education and Research will allot seats in all medical
colleges. With legal experts asserting that the dual fee structure violates
remaining 50 %, called ‘payment seats', shall be for those candidates who
are prepared to pay the fee prescribed by a committee consisting of a ViceChancellor, the Secretary (or Jt. Secy.) for Education, and the Director of
the fundamental right to equality, the system is likely to be challenged in
Medical or Technical Education as the case may be. The seats in both
outright, have asked that since market forces were being encouraged,
categories will have to be filled up on the basis of merit, or, in its absence,
consumer rights of students must be protected by making local public
inquiry committee reports on all private colleges affiliated to the university.
such criteria as may be determined by the competent authority—the state
government or the university. Where the institutions have constitutionally
valid social objectives and obligations to certain sections of society, as in
the case of minority institutions, the state shall decide how much of this the
managements are free to fulfil and under what criteria, again determined
court. The Akhil Bharatiya Vidyarthi Parishad along with several senate
members of Bombay University, while not condemning the fee hike
Tamil Nadu: Interestingly, Tamil Nadu's education Secretary V.
Sankarasubbaiyan corroborates the sentiment in Karnataka, when he
points out that one positive feature of the Supreme Court directive is that it
ensures that merit is built into the system of admission to professional
on the basis of merit.
Karnataka: The managements of private professional institutions in
courses. The other feature, he points out, is that it recognises the heavy
Karnataka are up in arms against the State Government implementing the
Supreme Court directive on admission norms. But the Karnataka
it. Professor Peer Muhammed, director, Crescent Engineering College,
Vandalur, explains that Article 30 of the Constitution provides for the right
Government is in no mood to relent. In the 1960s Karnataka encouraged
capitation fee-based colleges. Today it has 15 privately-managed medical
of minorities to establish and administer educational institutions of their
choice. “In our college, about 30 percent of the total strength comprises
colleges. With successive Chief Ministers sanctioning colleges, most of
Muslims....
that is our aim, to serve the cause of education in our
community. With the new ruling, however, we would hardly get about four
them on caste lines, today major communities like Vokkaligas and
Lingayats, including the Backward and the Scheduled classes and
Brahmins, own capitation fee colleges. This has resulted in strong ties
between politicians and the college managements. In this background,
enforcement of the law to curb the capitation fee menace remains difficult.
Another sore point is the Supreme Court’s decision under Article 30(1) of
the Constitution to permit minority institutions to admit not more than 50 %
investment made by the institution on the student and the need to recover
or five students a year".
— in the course of liberalization, while there is a probability that
education will be looked at, more and more, as a commodity, the Supreme
Court's directive comes as a hope for the deserving students from the poor
and middle classes. But considering the vested interests, one cannot
expect that it will curb the commercialization of education.
of the candidates. This has caused much heartburn among other
managements. This may prompt more colleges to clamour for minority
Sources: 1) Times of Indian Ju^6,1993.
2) Frontline: July 2,1993.
status, either linguistic or religious. Interestingly, some minority institutions
have appealed to the Supreme Court to allow them to fill up all seats.
FRCH NEWSLETTER. VOL VII, NO. 3, MAY - JUNE 93
4
DOCTORS ‘COPE’ WITH RISING DRUG PRICES
Audrey Fernandes
As a part of the New Economic Policy, the government has removed
medical store has given, very few insist on the prescribed drug, and still
the price control on a large number of drugs. Consequently, last couple
fewer check that the drugs are not 'Bombay Market'ones. Most of them
of years have seen a sharp rise in drug prices. This has been
do not bother at all. The general feeling is, "what can we do?". One
documented by Dr. Wishwas Rane's study 'Rising Drug Prices' in the
doctor said that twenty-five percent of the patients take the prescriptions
Economic and Political Weekly, April 17,1993. It is noteworthy that not
but do not buy anything because they do not have the money. Fifty
only consumers but even the doctors have been affected by this price
percent buy only a part of those prescribed, and ninety percent take the
rise. This was revealed to us recently during our interviews with doctors
prescription to the medical store only the next day. Though the doctors
in both the private and the public sectors in rural areas of Satara district.
are concerned with the implications of patients taking only a partial
The interviews were a part of the study called ‘The Supply, Cost and
course of medicine, e.g. resistance to certain antibiotics, they know that
Use of Drugs and Pharmaceuticals in a District', being conducted by the
often a large part of what they prescribe might be irrational.
FRCH. One part of the second phase of this study consists of analysing
prescriptions of doctors in both the public and the private sectors to
determine the degree of irrationality,and the other consists of in-depth
interviews of doctors to probe into factors that influence their prescribing
behavior.
Drug Companies: marketing strategies
Most doctors when asked the reason for the increase in drug prices,
attributed it to the marketing strategies of drug companies. Detailed
explanations were given as to how the expenses on the visiting Medical
Representatives, and particularly the large number of samples that they
The ‘Family Doctor’: an obsolete concept
The general impression of the interviewers was: the nature of the
•
leave behind, increase the cost of drugs finally available in the market. A
doctor showed us a set of five Ciplafloxacin injections that a
doctors' practice (especially those practicing for a number of years) has
representative had left with him that day. He said, “Each of these vials is
been changing over a period of time. The concept of 'family doctor' who
sold for Rs. 60 to Rs. 70 at the Drug Store. I am only a small doctor
dispensed medicines seems to be fading out. When asked about the
practicing in a rural area. If they leave so many samples with me, can
reason, the almost unanimous answer was: cost of drugs. Most doctors
you imagine how many they would leave with a consultant practicing in
said that it is now a common practice for a doctor to prescribe rather
Satara?" That this was done at patients' cost was a view expressed by
than dispense drugs from his own stock. There are many reasons for
many, and some doctors felt that this was bad ethics.
this. When a doctor dispenses drugs, patients are reluctant to pay for
Perhaps drug companies are also finding it difficult to maintain a
both — the drugs as well as the consultancy. Some doctors said
force of Medical Representatives to promote their products. Companies
therefore that the only drugs they dispense are the samples left with
such as Cipla, do not hire representatives anymore (at least in Satara
them by the Medical Representatives. Earlier, a patient insisted that a
doctor gave some medicine alongwith consultancy, but now patients are
district). They depend almost entirely on what doctors call 'Cipla Courier*
not so insistent. Just an injection is enough. The doctors say that a
doctors. This is often the only printed ‘continuing medical education* that
for their promotion. This is sent to all private doctors as well as PHC
patient does not question the contents of a prescription, being under the
a doctor receives. To quote an example, ‘Cipflox’- the anti-typhoid drug
impression that the more expensive the drug, the more powerful and
from Cipla, is to most of the doctors, the ‘Wonder Drug*which is the
hence better the drug. In the same logic the doctor who precribes such
result of the ‘pioneering research that Cipla did in Thane district'. Some
'better'drugs is the better doctor. Some doctors on the other hand felt
refrain from prescribing it only because it costs Rs. 24/- per tablet. At the
that not dispensing made patients lose faith in them — "Doctor only
time of interviewing most doctors were happy to convey that the latest
writes, does not give anything in hand". Doctors feel that it is not worth
courier from Cipla had announced a reduction in the price to Rs. 12/-
their while to dispense drugs though most of them know that patients,
per tablet.
many times, have to travel to the nearest drug store to buy the drugs
Companies like Medicare dp not approach doctors at all. They
prescribed. This often means the nearest taluka town and in some
operate entirely through medical stores. A discussion with Medical
cases even the district headquarters. There too the drugs prescribed
Representatives revealed that they offered certain schemes to dealers,
are often substituted by the drug store. This occurs more often if it is the
only store in the village (though this is not very common anymore, as
such as a percentage on the goods sold,, or an offer like, "stock up Rs
40,000 of ‘A* drug and we will send a washing machine to your house".
most PHC villages have at least three drug stores and eight to ten
Some companies still concentrate on doctors, giving incentives such as
private doctors operating). The substitute drug is generally more
a trip to Singapore, after having prescribed a certain amount of a
expensive; While some doctors ask the patients to show them what the
particular drug. A senior doctor in Medha PHC, in Javali taluka, which is
a remote, under-developed, hilly and drought-prone area, said that at
least three to four doctors had gone abroad on such trips in the last four
The author is a researcher at FRCH, involved in the study,
years. He expressed alarm concerning the growing trend of this
‘Supply and Cost of Drugs & Pharmaceuticals in a District'.
5
FRCH NEWSLETTER, VOL. VII, NO. 3, MAY- JUNE 93
unethical practice. He further added, "The new doctors entering practice
Some doctors rationalize this by saying, “anyway PHCs are not meant
fall prey to such unfair means because now, being in practice means
for curative care, our job is preventive care and the drug supply we get
being in competition with other doctors".
is adequate for that purpose". But others felt that this perpetual
The Public Sector
esteem as doctors. But, most of them felt that when the drug budget
inadequate supply of drugs was an insult to their training and their
Doctors in the public sector find their own way to deal with drug
shortages, which, according to them, are the result of a stagnant drug
budget on one hand and rising prices on the other. Not revising rate
contract prices since 1988 has resulted in refusal by many companies to
supply drugs, procrastination of delivery, etc. At one PHC, we were
shown tubes of an antiseptic cream packed in cartons. Except for the
needed to be increased, there were threats of it being slashed. The
Medical Superintendent of one Cottage Hospital told us that the drug
budget had been halved in the last year and they had received a GR
again for another 25% cut. This was also accompanied with the threat
that if he did not manage with the reduced budget, the extra expenses
would be cut from his salary.
tubes in the first layer all the rest were filled with air. This was perhaps
the drug companies' way of retaliation against the low contract prices. In
Time for Intervention
practice, this means long periods of time being spent without many
While rising drug prices were ultimately always directed at hapless
essential drugs, and almost always, an acute shortage. For Primary
patients, the recent liberalization trend has also alarmed the doctors.
Health Centre doctors this is a way of life and they do not expect any
They find their esteem as healers being questioned by patients who
better, knowing that in the past they have many a time requested for a
cannot afford what they prescribe. It is well-known that doctors fall prey
larger quota, but to no avail. Many doctors hold the view that the drugs
to the hard sell tactics of the drug companies, this being the largest
available through the public sector are of sub-standard quality. Most of
influence on their prescribing habits. They are aware that drugs are
them cope by giving prescriptions for drugs to be bought in the open
increasingly being promoted, not necessarily for what they are worth,
market In larger hospitals, like Civil and Cottage Hospitals, samples left
but only for profit. The rural doctors whom we met were well aware that
by Medical Representatives are collected even from private doctors, a
most of their clientele was not able to afford prescribed drugs.
'drug bank' is maintained, over-prescription for rich patients is done and
the surplus medicines are used for poor patients.
In one PHC, a doctor showed us with pride how he stamped every
The problem of cost of drugs can be addressed on different planes.
One of these is to convince doctors of a more rational practice e.g.
prescribing less tonics / placebos etc. Of course this is very difficult. It
case paper at the top right hand corner. When any patient came to the
has been tried time and again by the rational drug movement activists
OPD he / she was asked whether he / she had undergone a sterilisation
with partial success. Today, the country is facing the threat of the
operation, and if yes, after how many children. Patients who had
Dunkel proposals. This would result in an increase in drug prices on a
undergone the operation were given Septran; or a more potent
much larger scale. It is possible that the impression of some doctors that
antibiotic, if the surgery was done after two or less children. These
the smaller doctors would be pushed out of business, might come true.
antibiotics are not available in large numbers. Those who had not
This is perhaps the right time for intervention. In such a situation the
undergone the operation were to be content with Aspirin, which was the
doctors, particularly those practicing in rural areas, might pay more
only tablet available in plenty in all PHCs.
attention to the fact that ‘rising drug prices' is an adverse effect of the
Usually, drugs required for National Programmes, particularly the
immunization programme and sterilisation operations, were in adequate
liberalization policy and the globilization phenomenon may have frightful
consequences on their lives.
6
supply. But drugs for TB and Leprosy were sometimes not available.
contd. from page 2
But if these gains are to be consolidated then sustained efforts on
positive repurcussions.
Firstly it focussed on the issue of drought and water-scarcity from a
women's perspective. Drought is inevitably linked with hunger, poverty,
the part of the people of Malshiras along with MASUM will have to
,
continue. So the struggle is not over yet........
hazards for agriculture. But the lack of drinking water - a basic necessity
- and the immeasurable hardships that the rural women undergo while
An Appeal to our Readers
filling this water get sidelined. This was sharply focussed on and the
women narrated their experiences in detail. Also they became aware
that the pipes were fixed for their benefit by MASUM. As the pipes
belonged to MASUM and, by the same measure, to all the women, hey
could demand their right to draw water.
Secondly MASUM as an organisation succeeded in giving
'accountability', which is no longer a buzz-word in the day and age of
stock-market scams, its rightful place of pride. MASUM, itself, displays
its annual statement of accounts on the village notice board. Hence the
expenditure of MASUM funds by the village should also have been
explained to the community. Only when this was done was the fast
broken.
Thirdly the formation of a Water Committee meant that the issue of
water would be discussed democratically by the ordinary citizens who
During the last few months, we have been receiving letters /
messages from our readers, informing us that they have not
been receiving their copies of the "FRCH Newsletter" regularly.
If you or any of your friends, have been facing the same
problem, please write to us so that it will be possible for us to
follow up the matter with the Post Ofice. Please check that you
have received the following issues:
1) Six issues for the year 1992:
Four general Issues
Two Special issues:
Special Issue on the Handicapable
Special Issue on Children
2) Two issues for the year 1993:
Jan.-Feb. issue:Special issue on AIDS
Mar.-Apr. issue: A General Issue
were members of the committee and the hegemony over water of the
rich and landed members of the community would be questioned.
FRCH NEWSLETTER, VOL. VII, NO. 3 , MAY - JUNE 93
<
Editor
a
6
LIBERATION FROM LIQUOR
a way to development
Abhay Bang
Dr. Bang, a friend of FRCH from 'SEARCH' (Society for
Education, Action and Research in Community Health, district
Gadchiroli, Maharashtra), shares his experiences of the
movementfor liberation from Honor with us, which we would
like to share with our readers.
2.
The power to control alcohol should be given to the village.
In the last five years, 600 villages, 334 organisations and 40,000
people in Gadchiroli district participated in the movement forcing the
state government to declare the district dry from 2nd October *92. A stay
by the high court prevented the government from implementing the
‘prohibition’. But, in a gathering of 10,000 representatives from 300
All liquor shops in Gadchiroli district were closed down on 29th
March *93 effectively putting stop to the annual alcohol trade of Rs. 200
<
million. People, especially the women and children, are experiencing
tremendous gains in their lives. This has further strengthened our
conviction that liberation from liquor is a way to development.
When we faced the widespread problems of alcoholism in
Gadchiroli on our arrival here in 1986, our first response was medical
de-addiction. Twenty men were de-addicted in one year out of which
fifteen relapsed into the addiction. And there were thousands of addicts
in the district! Obviously the medical approach was extremely
inadequate. So we decided to turn to people for the solution.
In the pilot work emerged a social model to control the availability
and consumption of alcohol in the villages. Very rapidly the small public
health work became a massive 'Liberation from Liquor Movement'
which, in 1988, made two demands to the state government:
1.
Stop the trade of alcohol in the district by cancelling the
villages, the movement declared the programme of 'people's liberation
from liquor'. In the subsequent six months 200 villages put effective
community ban on the consumption and sale of alcohol using a wide
variety of creative social and political techniques. Thus people have
taken control of their lives with regard to an issue they considered very
vital.
After a legal battle of six months, the highcourt finally declared the
prohibition order valid resulting in closure of the licensed alcohol shops
in the district. One goal has been achieved. The movement shall
hereafter concentrate on the community control of alcohol, on
preventive education of the individuals vulnerable to alcohol and on
providing de-addiction services to the addicts.
The movement has already spread to the adjacent Chandrapur
district. Women in Andhra Pradesh have successfully forced the state
government to declare prohibition. The tide is definitely turning against
alcohol in India. This heralds emergence of new frontier of public health
©
and action — Action Against Alcohol I
licenses.
contd. from page 4
The issue of 'Bombay Market Drugs* is a different story altogether.
accomplices to the drug merchants. Doctors are divided over fixed or
These sub-standard allopathic drugs which are provided in bulk at
flexible charging system. Despite the tension between the professional
extremely low costs, seem to be the saviours of the GPs. Ayurvedic and
commitment and cost of giving standard medical treatment and the
homeopathic drugs have also not escaped the cutting edges of
humanitarian ideals about charging consessional fees, the conviction
competition. Ready-made operations and steroids are commonly used
against charity towards patients remains unscarred. Nevertheless, in
for large-scale production of traditional medicines. There is no
practice, rural doctors are forced to forego their charges in many cases.
standardization for these products. Simple powders and potions
Patients too have contradictory feelings about paying charges. Rural
prepared from locally available herbs being comparatively expensive;
patients, not necessarily poor, invariably expect concessions, credit, or
cannot really stand the competition of modern medicines. Certainly, the
free treatment. Yet, they would doubt the healing powers of a system or
healing practices and their allied agencies are governed by a larger
the knowledge of a doctor if inexpensive treatment is offered. Homeo-
capitalist scheme.
paths are forced to charge more tor the same reason, only to experience
yet another disillusionment People try Homeopathy only after all other
Charging Patterns
therapies have failed. And they are not willing to pay even half of the
charges that they pay elsewhere.
Medical practitioners in Ahmednagar district unanimously claim that
cut-practice and feed-back mechanism have not yet infiltrated into their
towns so far. But there is a definite shift of focus from consultation to
Impressions about Consumer Protection Act (CPA)
diagnostic tests and medication. Relevance of sharing pain and that of
It is difficult to refer poor rural patients to specialists in the cities.
giving professional opinion / advice as an essential part of therapy is
very often neglected. If the patients are made to realize this and also to
Rural doctors have to therefore take greater risks and all important
decisions for handling difficult cases with inadequate facilities. The
pay for consultation, even by the GPs, the demand for injections and
issues of non-maintainable hospital standards, mistaken self-
medicines would automatically come down. In this way, doctors would
assessment of the doctor and that of medical negligence are closely
resume their legitimate professional function rather than being
contd. overleaf
7
FRCH NEWSLETTER, VOL VII, NO. 3 , MAY - JUNE
93
LIBRARY NEWS
Books
Buck C. and Llopis A, The Challenge of Epidemiology: issues and
1.
11.
Isaac M.K. and Chandrashekar C.R., Manual of Mental Health for
12.
Jain A.K. and Visaria P., Infant Mortality in India: differentials and
13.
Jarman H. and Scrivener B., Sardar Sarovar, Narmada Bachao
Medical Officers, NIMHANS, Bangalore, 1985, pgs. 210.
selected readings, Pan American Health Organization, Washington,
1989, pgs. 989.
determinants, Sage Publications, New Delhi, 1988, pgs. 398.
Channabasavanna S.M.and Shah S.A., Affective Disorders: recent
2.
research and related development, NIMHANS, Bangalore, 1987,
Ahdolan Bombay and others, 1992, pgs. 363.
pgs. 239.
DANIDA, Essential Drugs Project Bangladesh: final report (1986-
3.
14.
Mascarenhas M.M., The Population Trap, C.R.E.S.T., Bangalore,
15.
Misquith D., System Analysis of Health Care Delivery in Plantations
1990, pgs. 41.
1990), DANIDA, Dhaka, 1991, pgs. 248.
4.
Dasgupta S. and Murty L.S.N., Panchayati Ra) Institutions in West
Bengal, NIPCCD, New Delhi, pgs.72.
under United Planters Association of Southern India, 1993, pgs.
5.
Dunstan G.R. and Seller M.J., Consent in Medicine, King Edward’s
16.
303.
Rose G. and Barker D.J.P., Epidemiology for the Uninitiated,
6.
Ghai O.P., Understanding and Managing Acute Diarrhoea in
17.
Sriram T.G. and Chandrashekar C.R., Manual of Psychotherapy for
18.
Thimmayamma B.V.S. and Menon K., Use of Food Products in
Hospital Fund, London, 1983, pgs. 128.
Infants and Young Children, AllMS, New Delhi, pgs. 25.
7.
B.M.J., London, 1983, pgs. 59.
Medical Officers, NIMHANS, Bangalore, 1990, pgs. 60.
Ghosh R. and Zachariah M., Education and the Process of Change,
Sage Publications, Nev/ Delhi, 1987, pgs. 301.
8.
Supplementary Feeding Programmes in Andhra Pradesh, NIN,
Govt, of India - Ministry of I. and B., India 1992: a reference annual,
Hyderabad, 1987, pgs. 76.
Publication Division GDI, New Delhi, 1993, pgs. 930.
9.
Morris F.R. and Wilkins R.W., Quiet Riots: race and poverty in the
10.
ICMR Reporton Research Activities During 1990, ICMR, New Delhi,
19.
World Bank, World Development Report 1992, OUP, Oxford, 1992,
pgs. 308.
United States, Pantheon Books, U.S.A., 1988, pgs. 223.
20.
Partners in Health: the role of NGOs in health development,
WHO, New Delhi, 1988, pgs. 13.
1990, pgs. 1'62.
contd. from page 7
intermingled. Doctors argue that the fault does not always lie entirely
The issues emerging from the discussions dwelt upon here have
with the doctor. Patients make very little attempt to understand the
served as guidelines for the second phase of the present study. This
treatment and to participate consciously in the medical decision. But as
phase would focus on the actual investment and expenditure patterns of
Dr. Arun Bal of ACASH points out; “even the most uneducated,
a selected sample of health establishments in both, the private and
backward.... person can be communicated the facts of his I her illness if
public sectors.
the will to do so is present in the doctor. At present such a will is
conspicuously absent". The patients litigate doctors when things go
References
wrong. In many instances doctors feel they are unjustifiably litigated.
1,
Bal Arun, Consumer Protection Act and Medical Profession, Economic And Political
2.
Indian Express, 27th December, 1992.
3.
Wear Andrew (Ed.), Medicine in Society: historical essays, Cambridge University Press,
Unnecessary litigations can certainly be minimized if, as Dr. Bal
suggests, "Informal reconciliation machinery (is) formed with the help of
consumer organizations". Instead, doctors are panicking over the issue
Weekly, Vol. 28 (11), March 1993, pp.435.
Cambridge, 1992, pp.7.
i
of medical malpractices surfacing with the growing consumer
interventions in this field. It is difficult to convince doctors about the
usefulness of the CPA. Consumer movements are neither painting the
doctor-patient relationship in black and white, nor limiting the scope of
their action to just doctors and patients. They are aiming at medical
malpractices in general, including offensive behaviour towards the
doctors by insurance companies, dealers of medical equipments, big
hospitals employing young doctors, etc. Consumer movements are
looking forward to doctors' co-operation because even if the latter are
trapped in the logic of the medical-market, they are better equipped to
break out of it Doctors are in a privileged position and hence capable of
comprehending the socio-economic reality and also of exercising self-
FREE ABSTRACTING
The contents of this newsletter may be
abstracted without prior permission.
However, we would welcome acknowledge
ment of the source and copies of any
abstractions.
regulation.
Edited by Rohini Lele & Nagmani Rao, with secretarial assistance from Joyeeta Sinha & Anita Nair. Produced by the Foundation for Research in
Community Health, B4-A, R.G. Thadani Marg, Worli, Bombay 18. Registered under the Bombay Public Trusts Act Printed at Printext Offset, Pune 30.
COMMUNITY HEALTH CEU
326, V Mein, 1 Block
Koramangala
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India
NEWSLETTER
Vol. VII, No.4
Jul.-Aug. 1993
HEALTH FOR ALL IN INDIA
A Long Way to Go
Ravi Duggal and Sonya Gill
diseases. These overall figures hide, however, very large variations in
This is the seventh and the last article in the series, "Health
Financing and Costs: comparative perspectives”. (No. 1 - Japan;
No.2 - Zambia;No.3 - China;No.4 - Brazil;No.5 - Sri Lanka;No.6
- Canada). We invite our readers to write to us regarding their
impressions about this series. It will help us in planning our
future series'.
health status across regions, between rural and urban areas and
different socio-economic groups. Almost 39 % of all deaths are among
children aged 0-4 years. The infant mortality rate crosses 120 per 1000
live births in rural Orissa, Madhya Pradesh and Uttar Pradesh, and is
above 100 per 1000 births in rural areas of Bihar and Rajasthan. The
excess female deaths in age groups upto 35 years and a persisting
adverse sex ratio is another feature of health conditions. The poor
Multiple medical systems, the fast growing private medical services,
grossly inadequate public services, enormous differences in the
availability and quality of services in urban and rural areas, and the
neglect of public health and epidemiology are the central features of the
Indian health care system. It is one of the largest health care delivery
systems in the world and has grown at a remarkable pace in the forty
five years since Independence. But as a result of the wide disparities
female health resulting from widespread anaemia and malnourishment
combined with very poor availability of maternity services manifests
itself in a high maternal mortality of 500 per 100,000 live births, that rises
to 800/100,000 live births in many rural regions. In sharp contrast to this
mortality pattern is the experience of Kerala where all health indicators,
including birth rate, have long surpassed even the targets India hopes to
achieve by the year 2000 AD.
India has made slow progress in meeting the health needs of its people
and compares poorly with those Asian countries such as China and Sri
TABLE 1
HEALTH STATUS
Lanka that started at the same level of development.
Health Status
Crude
Crude
Mortality Rate
Life
Literacy
Birth
Death
Infant
Maternal
Expect.
Rate
dependent on agriculture for its livelihood. Indians as a whole have
Rate
Rate
PER
PER
At Birth
experienced a major improvement in survival chances, with life
(per 1000 pop.)
1000
100,000
(years)
(%)
BIRTHS
BIRTHS
State
Year
India’s population of 844 millions is three-quarters rural and highly
expectancy rising from 31 years in 1947 to 60 years at present and
general death rates falling from 27 per 1000 population to 10 per 1000
India
(Table 1). The decline in the rate of infant deaths (from 146/1000 births
1951
...
16.7
1989
39.0
30.5
27.4
10.2
146
91
500
31
60
52.1
...
70
90.6
54
41.7
in 1951 to 91/1000 in 1989) and child deaths (currently 33 per 1000 in
the 0-4 years age group) has contributed to the longer life span of the
Kerala
1989
19.8
5.9
22
people, and itself reflects the small improvements in living standards,
U.P.
1989
37.0
12.6
118
reduction in severe malnutrition and efforts to control communicable
Source: GOI, CBHI, Health Information of India (Respective years)
Sonya Gill was a co-researcher in the above FRCH study. She
has written this article in collaboration with Ravi Duggal who
The highest toll of mortality and morbidity is from preventable and
was a senior researcher at FRCH, and contributed to this
easily curable communicable diseases, amongst which pulmonary
study.
tuberculosis continues to be the most severe and widespread public
FOR PRIVATE CIRCULATION ONLY
health problem (9 million cases in the country and four lakh deaths
urban areas and the private sector. Viewed historically, the inequalities
every year). Tuberculosis, pneumonia, anaemia, gastroenteritis,
and imbalances in health care services have continued to grow over the
dysentery and typhoid together account for nearly 20 % of all deaths.
past forty five years as a result of policy support and subsidies to the
Since 1971 malaria has shown a resurgence, while filariasis,
production of doctors for the private sector as well as subsidies for
encephalitis and meningitis are currently on the rise. Along with
setting up private practice and private hospitals, the disproportionate
communicable diseases, the chronic and degenerative problems
concentration of medical services in urban areas, and granting
particularly cardio-vascular diseases and cancers, associated with
permission for the large-scale migration of medical professionals and
developed societies, are also rising as a proportion of all
health personnel. The poor coverage of public services and the long
deaths.Underlying this public health situation are the large-scale poverty
term under-funding of this sector has encouraged a rapid growth of the
(40% below the poverty line), malnourishment and chronic hunger
commercial health sector. Its accelerated growth since 1976, has
among the lower income groups, illiteracy, and the lack of environmental
occurred in the very period when the community health model was
sanitation and clean drinking water supply for most of rural India. It is
being projected as an alternative method for strengthening the public
this failure to provide social inputs on a wide scale that is responsible for
services and making them accessible to the underprivileged and rural
such modest achievements as against the significant improvements
majority with the help of paramedic staff and non-professional village
achieved by an average income state like Kerala.
health workers. This model, incorporated into the National Health Policy
of 1983, has made little difference to the poor state of the public services
in the rural areas.
Health Policy
There are thus two sub-systems in health care, the smaller public
At Independence, India inherited a very limited infrastructure of
health care system and the dominant private health care system. The
public health and organised health care services. Allopathic medical
public services are constitutionally the responsibility of the state
care and preventive and environmental measures were narrowly
governments, but the Central government has played the more
concentrated in centres of commercial activity and colonial military and
significant role by defining policy and influencing the choices in the
civil administration. Ayurveda and other indigenous medical systems
health programmes through allocations of funds and grants. The private
were the only available services for the mass of people, again largely in
sector is estimated to control 70 % of all health resources but it has
urban areas, while caste-based herbalists and healers were the main
never been planned or regulated, and no policy document has ever
providers in rural areas. The nationalist vision of a new India responsive
looked at the private sector in order to arrive at a holistic picture of the
to the rural majority, the increased role for the State in social security
Indian health care system.
and welfare in Western countries after World War II, and the ‘right to
health* approach of the USSR, all influenced two remarkable pre
independence policy documents — the Sokhey (1942) and the Shore
Health Care Services
Around three-fourths of all routine illnesses, both in urban and rural
(1946) Committee reports. The Shore Committee made a detailed
survey of health conditions at that time and recommended an integrated
national health service organised on a 3-tier model, which was to
provide complete medical and curative care as close to the people as
possible. It gave a detailed plan for developing the infrastructure for the
primary and district levels which was highly suited to provide preventive
and rural services, the time frame of 30 to 40 years for achieving this,
and the resource burden that would fall on the government. It estimated
that the State would need to increase its health expenditure by three
times, from the existing 4.5% to 15% of the total government
expenditure. The conceptual framework of the Shore plan became the
blue print for developing the public (government) health services sector
in India but its specific recommendations were only selectively and
minimally implemented. India’s chosen path of development gave
areas, are treated by self-employed private practitioners. On the other
hand public facilities are used for 60 % of all inpatient care. The private
practitioners, who form the largest component of the private health
services, are extremely diverse in their qualifications, practice patterns
and the quality of care they provide. Almost 69% of qualified allopaths
and 90% of non-allopaths work privately. A major policy concern should
be the large numbers of unqualified practitioners among them,
particularly in the rural areas. During a nation-wide survey of diarrhoea
in rural India, it was found that 62% of practitioners had no medical
qualification and 61% did cross-practice between different systems of
medicine. In the absence of regulation and licensing of providers in
India, a large number of helpers, compounders and assistants to other
doctors have set up practice and dispense medicines.
priority, in investment, to creating the socio-economic infrastructure
TABLE 2
HEALTH DELIVERY
necessary for the growth of private capital, and neglected and under
funded the social sectors. Initially two concepts from the Shore plan
were picked up for implementation — the primary health units and the
State
Year
PHYSICIANS
programmes to control communicable diseases. The former, as it exists
Nurses
Beds
(Allopaths)
today, consisting of a 4-bed health centre with two doctors and some
per 100,000 POPULATION
paramedic staff to cover a population of 30,000 is not even an apology
U
R
R
U
R
U
of what was originally outlined. The latter, implemented as separate
vertical top-down campaigns showed some initial success, particularly
the malaria control programme. In the absence of basic health services
Shore Recommendations*
576.0
150.8
62.3
India
1981
11.3
93.8
7.2
65.9
17.6
239.7**
Kerala
1981
18.8
81.5
48.7
107.4
192.4
425.9"
U.P.
1981
12.9
83.8
1 0.1
54.7
7.6
191.6**
in the rural areas, however, the impact of these programmes could not
be consolidated and these too were increasingly marginalised within the
government health services as increasing priority was given to the
family planning activities and. targets. The only target of the Shore
Committee plan to be achieved is the production of doctors, but this has
only accentuated the imbalances, by concentrating health services in
FRCH NEWSLETTER, VOL VII, NO. 4 , JUL - AUG. 93
Note:
* Uniform provision for the whole country
* 1989 data
Source:
GOI, Census of India, 1981;GOI Helath Information of India, 1990.
2
According to the 1981 census data, 41% of all doctors (indigenous
systems and allopathy) were in rural areas, but the actual proportion of
qualified allopaths, serving approximately 76% of the total population
residing in rural areas, was just 27%. Medical education, largely
subsidised and provided by the government has grown rapidly from an
annual out-turn of 2000 doctors in 1950 to around 20,000 at present.
This includes around 15,000 MBBS graduates from 128 recognised
colleges and the rest from the increasing number of private, unrecog
nised colleges. Additionally the admission capacity in other systems of
medicine is approximately 10,000. The availability of doctors has as a
result, increased markedly from 17 allopaths (43 doctors of all systems)
for 100,000 population in 1950 to 43 allopaths/100,000 population (106
doctors of all systems) today. These are increasingly becoming
concentrated in the urban private health care sector, with the result that
the proportion of doctors working in rural areas has actually declined in
the past 40 years or at best improved marginally in certain states. The
weightage in public policy to developing highly trained doctors and
Health Financing
Health expenditure in India amounts to an estimated 6% of GDP
which is fairly high spending for a low-income country. The public share
of this spending is however, just 1.6 % of GDP, while 4.5 % of GDP is
spent privately. This ratio of public to private expenditure is contrary to
the trend in health spending in countries with more efficient,
comprehensive and better quality health care systems. The trend world
wide is towards publicly controlled or publicly regulated health financing
methods which ensures that health care is accessible to individuals
when they need it irrespective of their capacity to pay. In sharp contrast,
in India, the private expenditures not only constitute 75 to 78 % of total
health spending, but three-fourths of this private spending itself is the
direct expenditure made by households. This large volume of private
health expenditure and its rapid growth in the past 15 years has hardly
been documented, but constitutes an enormous burden on lower
income groups. Various household surveys have shown that per capita
health care spending ranges between 7 to 9 % of total consumption
specialist skills has meant that the rural (and even urban) public sector
expenditure and on an average the per capita annual health spending
primary medical and preventive services have suffered acute shortages
could be Rs. 178/- (Kerala), or Rs. 183/- (Maharashtra) or as high as
of both medical and paramedical staff. A further distortion of the health
services is the low priority given to paramedical education and the
training of nurses. In most states, barring Kerala, the number of doctors
exceeds the number of nurses, and even the proportion of paramedics,
especially nurses, in rural areas has declined between 1961 and 1981.
The public services are organised differently in rural and urban areas,
almost constituting two separate delivery systems. For the country as a
whole, in 1989, there were 10,172 hospitals (31% rural), 28,304
dispensaries (45% rural) and 625,418 beds (17% rural). The distribution
of inpatient facilities available to the rural population has hardly changed
since 1956. From a mere 10.9 beds per 100,000 rural population the
availibility has increased to 17.4/100,000 today, whereas in the urban
areas it has increased from 165 to 239.6 per 100,000 urban population.
Despite the greater severity of health problems in rural areas, good
curative care in the public sector is concentrated in urban areas in the
form of city civil, specialist and teaching hospitals. This urban concen
tration is further accentuated by the huge private sector consisting of
diagnostic centres, nursing homes and super specialist corporate and
trust hospitals. Rural areas on the other hand are served by a rural
hospital for 500,000 population, primary health centres for 30,000 pop
ulation and paramedic-staffed sub-centres for 5000 to 6000 population.
These rural public sector institutions have selective focus on certain
preventive and promotive services such as detection and treatment of
communicable diseases, immunisations and family planning.
The Minimum Needs Programme launched in 1974 within the Fifth
Five Year Plan gave a thrust to the expansion of rural health services.
Subsequently, the new population-based norms for developing primary
health care infrastructure laid down in the National Health Policy of
1983, led to a rapid expansion of a network of public facilities. Yet while
the coverage at the lowest level — the sub-centre, has physically
expanded, the referral and support services needed to ensure good
curative care have not kept pace. On an average no state has met the
norm of having a CMC or small rural hospital for 80,000 to 120,000
population. A large number of vacancies for posts of doctors and
supervisory paramedic staff exists and the quality of care suffers from
acute shortages of crucial inputs, especially drugs. Despite a large
physical infrastructure PHCs are not meeting the demand for curative
services and are hence underutilised in the majority of states. Since
70% of the time of paramedical staff is spent on identifying and motiva
ting eligible cases for family planning, the rural population is not motiva
ted to utilise the primary health centres.
3
Rs. 299/- (Madhya Pradesh). It is obvious that almost half the country’s
population which lacks sufficient resources to meet even its food
requirements, is not going to utilise health services or only take
intermittent treatment due to the costs involved. The costs of travelling
to distant public health centres in rural areas and the out-of-pocket
expenditure on drugs in short supply as well as poor quality of care,
means that public services are free only on paper.
The latest estimate for government (both Central & State) health
expenditure is about Rs. 60/- per capita per annum, (Rs. 80/-, if
expenditure on water supply and sanitation that does not come under
the perview of the Ministry of Health and Family Welfare is included).
The public expenditure on health has declined from 4% of total
government expenditure in the First Plan period to 3.8% in the Seventh
Plan. The Bhore Committee had recommended raising it to 15% by the
early '80s. The developed states like Goa, Maharashtra, Punjab,
Haryana and Gujarat have higher per capita public expenditures than
the backward states of Bihar, Orissa, UP and Rajasthan. Low-income
Kerala is once again the exception.
The spending on curative (medical) care, though still the single
largest component of public expenditure, has declined from 43% in
1951 to 37% in 1985. Given the growing demand for medical care, the
vacuum has been filled by private services. Much of the curative care
expenditure is on urban hospitals and dispensaries. The rural health
system, such as PHCs and sub-centres, is funded by the other
components of the government budget, namely Communicable
Diseases Control Programmes (between 12 to 13% of total public
health spending) and Family Planning (16% of the total). The latter
programmes indicate the bias towards preventive services for rural
areas, while curative care is better available in urban areas. The urban
areas also gain from public spending on teaching hospitals (10% of total
spending is for medical education), statutory insurance for organised
workers, and municipal services.
The acute under-funding of rural health services is evident from the
fact that just 25% of total, curative care expenditure is spent on rural
facilitates, i.e Rs.9/- per rural inhabitant as against Rs. 65/- per urban
dweller. Salaries have absorbed an increasing share of this small budget
(between 66 to 80%) leaving just 25% of the funds for medical supplies
and material inputs. The under-supply of drugs has reached such a
crisis point that 58% of PHCs and 80% of sub-centres were found to be
contd. on page 8
FRCH NEWSLETTER, VOL. VII, NO. 4 , JUL. - AUG. 93
LESSONS FROM LEPROSY FOR AIDS
N.H. Antia
The present unrealistic fear of contracting AIDS is nothing new to
While none should underestimate the consequences of AIDS to the
those who have worked with leprosy patients for the past three decades.
‘need based’ countries, it must be realized that while AIDS may be a
Even when leprosy was no longer an incurable disease due to the
major consideration in the Western society, it is only one more major
availability of Dapsone, and though it is not contractable through casual
hazard to the health of the poor of the world where millions die annually
contact, the stigma attached to leprosy was as intense as it is at present
from diseases like gastroenteritis, acute respiratory infection, malaria
to AIDS. This stigma was reinforced by the medical profession who
and tuberculosis—for which we have knowledge as well as simple and
continued to treat it as a disease apart from all other diseases. Leprosy
cheap technology for their prevention, cure and control. Tuberculosis
patients were not admitted to general hospitals and the sufferers were
affects nine million people in India at any one time, of whom, 4,00,000
confined to distant leprasoria generally run by missionaries. It was
have died annually for the past three decades. Western media, through
hardly fair to expect the public to accept cured patients, when the
channels like Star TV choose to ignore this while blowing up the danger
of its spread via AIDS, relying chiefly on the testimony of Western
doctors, even in leprosy institutions, sat behind barriers and refused to
handle the certificates of cure and rehabilitation once issued by
themselves.
•)
experts which is based on poor epidemiological data.
The $100 million loan given to India by the World Bank to combat
No amount of health education can succeed in the presence of such
AIDS, is further distorting the approach to this disease which should be
an attitude of the profession to whom the people look for advice and
based on detailed countrywide epidemiologic data and scientific
opinion regarding all their health and disease problems. And yet it is the
information about this disease, and not on a knee-jerk response. The
changed attitude of the same profession which has brought about a
almost entirely urban approach of the World Bank based on urban data
transformation in the attitude towards leprosy patients during the past
collected by urban doctors and urban social workers seems to ignore
three decades. The first leprosy patient was admitted to the plastic
the fact that 70% of our population is rural. As a result of the urban-rural
surgery department of the J.J. Hospital in 1959 for correction of a
nexus there will soon be a larger problem of rural AIDS as predicted by
deformity of the face. It proved to be a myth that this would lead to
the epidemiologist Roy Anderson, a WHO consultant epidemiologist on
refusal by doctors, nurses and wardboys to work and other patients to
AIDS. The injection of vast sums of money is leading to a ‘run’ on this
be treated in the same department, for not a single objection was raised
new Bank account with everyone wanting a piece of the cake.
by anyone. Those who had propagated this myth had now to accept this
as a fait accompli. Thousands of patients have since been accepted in
various departments of general hospitals all over the country and
researchers handle live germs of this disease like any other pathogenic
microbe. The stigma could not have been reduced by mere slogans like
‘Leprosy is Curable', without actual demonstration by the professionals.
Strange as it may seem the integration of leprosy into medicine and
health services has been opposed by leprologists themselves who have
a vested interest in this disease. This is true of specialists in almost all
fields.
Changing Attitudes: an uphill task
The chief method for containing its spread lies in changing the
sexual habits rather than devoting excessive attention to blood
transfusion or protection of the doctors. This needs a predominantly
anthropological and sociological rather than a medical approach for
both understanding the problem as well as solving it It is unfortunate
that the role of the social scientist is seldom adequately appreciated in
the field of health and disease and is generally converted into a techno-
managerial one by the medical profession and the health bureaucracy.
Lack of understanding of social, economic and cultural factors, generally
The AIDS Stigma and the Western Media
leads to a failure in achieving the desired results. Social workers cannot
The stigma attached to AIDS is following a very similar pattern even
replace sensitive social scientists who are prepared to live with the
though it is a relatively new disease. Unfortunately being a disease
people they study. These are unfortunately a rare breed, some as
which has originated and spread from the Western societies, it has
epidemiologists.
received media coverage more in conformity, with the needs of Western
The study of the problems of sexuality among the rural population
media, than with its medical and epidemiological reality in this country.
needs attention, as revealed by the high rate of promiscuity and
Within a decade this has led to stigmatization of the disease of an extent
prevalance of sexual diseases in a study by Dr. Rani Bang, of the tribals
which has taken centuries for leprosy. The power of Western media to
of Gadchiroli. It is rare to find such urban trained researchers living for
influence human behaviour is revealed by the way it has instilled this
prolonged periods in rural communities, without which little can be
unrealistic fear even in the medical profession, for it needs a Shabana
gained in a subject requiring both intense personal and cultural rapport
Azmi to bring sanity to the scene.
as well as high technical and analytical skills.
Dr. N. H. Antia is the Director, Foundation for Research in
Changing of attitudes and practices in such a highly private and
personalized subject cannot be achieved merely through the use of
Community Health, Bombay and Pune.
mass media which in any case are not the media of the majority,
FRCH NEWSLETTER, VOL VII, NO. 4 , JUL - AUG. 93
4
0))
especially the rural population. For them, meaningful communication is
the oral communication - through interpersonal and small group
discussions.
The Need for the Right Approach
Leprosy also teaches us that fear leads to concealment and delay in
early detection of the disease, which in turn helps the spread of infection.
Deeply ingrained cultural practices cannot be changed in a subject
Early voluntary reporting and treatment compliance showed a marked
like sex, merely through television, radio or even through health
improvement with the decrease of stigma. As in the case of leprosy, the
education, that is, lectures or group meetings. The professionalised
control of AIDS will require a prolonged massive effort at the grass root
techniques of social marketing for goods and commodities have not
level where the problem like most other health problems lies. A
proved effective, even when employed extensively, as in Family
hysterical response, dictated by Western advisors who provide loans
Planning.
and termed aid will not do, because it leads to further indebtedness and
The high illiteracy rate especially in the BIMARU states is also a
there is a failure to understand the entirely different culture and ethos of
handicap in using many of the mass media.While changing the attitudes
the majority of our people who are at the greatest risk. Urban
and practises may pose difficulty, mass media can be more effective in
industrialization dictated by imported Western models of development is
creating fear. Unfortunately, as in the case of drug addiction, it may not
not only responsible for creating the conditions for prostitution and
only prove of limited value in AIDS but its association with tuberculosis
spread of sexually transmitted diseases (besides many others) but is
may revive the stigma to the latter disease.
also responsible for its spread to rural areas when urban workers visit
the families left behind in the villages.
g
THE NEEM CAMPAIGN
This is an appeal made by the following organisations, to join the campaign against the theft of common intellectual property
of the Third World People by Transnational Corporations, which is being given international legal sanction by the GATT
Agreement.
* The Research Foundation for Science, Technology and Natural Resources Policy,
* Karnataka Rajya Rai tha Sangha,
* Azadi Bachao Andolan,
* All India Drug Action Network, &
* People's Health Network
It has come to our notice that the bio-pesticidal properties of the Neem have been patented by one Robert (Tony) Larson from the US
(Patent No. 4,556,562). The claim for the patent wilfully ignores the fact that Larson has patented and made his private property what is the
common natural/cultural and intellectual heritage of the people of India who have selected and used the neem's biopesticidal properties for
millennia. Larson has further sold his patent to W.R. Grace & Co., USA for a sum of $150,000 cash, 5% of the royalties and 50% of the
foreign license fees. Larson however has taken W.R. Grace to the court for breaking the agreement. The neem has also been patented by
Dr. James Klocke in the U.S. (Patent No. 5,047,242) in 1991. This patent too may be owned by W.R. Grace. W.R. Grace is setting up a
plant in Antarasanahalli, Tumkur Dist., Karnataka, in collaboration with P.J. Margo Pvt. Ltd. The plant will initially process 20 tonnes of seed
per day for export to the US. W.R. Grace is producing and marketing the neem pesticide internationally under the names MARGOSAN-O
and BIONEEM. The latter is marketed by their subsidiary, Ringer. W.R. Grace & Co. claim that their Tumkur plant is the world's first
commercial scale facility specially designed and built for producing neem-based pesticides. This claim is totally false. Neem based
pesticides have been commercially produced and marketed in India by the small-scale sector under various brand names.
Patenting the active principle of the neem is:
—
-
a direct attack on the intellectual contribution of a Third World country;
—
open theft of common intellectual property of the people of a Third World country;
—
an arrogant statement that the intellectual contribution of a person/organisation from the First World has a hand
in developing it.
The issue of the Neem further makes clear that the individual, the community and the Third World countries have no rights of
safeguards against piracy by Transnational Corporations. This piracy is being given international legal sanction by the GATT Agreement
on Trade Related Intellectual Property Rights.Succumbing to the US Super 301 clauses, the government of India is betraying the people of
India and those of the Third World by signing the GATT Agreement in secrecy. By doing so, it is signing away the sovereignty of India and
the human and national rights of its 800 crore people.
THE NEEM CAMPAIGN demands that:
5
—
the US patents on the neem granted to Robert Larson and James Klocke be withdrawn.
—
unequivocal rejection of the US patent laws by the Indian government and other Third World countries.
—
rejection of the GATT Agreement on Trade Related Intellectual Property Rights.
—
protection of Third World Biodiversity and Third World knowledge through the effective interpretation and
—
implementation of the Biodiversity Convention.
FRCH NEWSLETTER, VOL. VII. NO. 4 . JUL. - AUG. 93
THE WORLD BANK REPORT ON HEALTH-CARE STRATEGY
A Critical Discussion
Anant Phadke
The World Bank, for its annual World Development Report (WDR)
and the privatization to which most participants were opposed. The
for the year 1993, chose ‘health care’ as its subject. This report, titled
report was criticized without inhibitions by most of the participants. The
“Investing In Health" was released in July 1993 and the World Bank
fact that such a big report was made available hardly a week before this
decided to release it in India this year.
meeting, was also criticized.
A hundred thousand copies of this report are being distributed all
The following major critical points were raised:
over the world. A series of meetings were organized by the World Bank
1. Neglect of socio-political reality: Just the pumping of more
in some of the major cities in India, to launch this report. The FRCH
money into “cost effective public health services" is not going to produce
organised one such meeting at the request of the Bank, on 10th of July
the desired results. The experience of last forty years, as to why
in Bombay. About forty prominent health workers and health
different schemes did not work, has to be analysed. The structural
researchers, mostly from Bombay, were invited to participate. The
maladies which result in the dysfunctional public health system, have to
researchers from the FRCH and the FMR were also present.
be corrected. The WDR does not talk about this important problem. The
tertiary hospitals, like the J.J. Hospital in Bombay, serve mostly the poor
The World Bank Recommendations
Prof. T. Jamison, the Staff-Director of the World Bank team which
has prepared this report, had specially come to India to launch this
report. He, along with his colleague R. Skolnik presented the
background and the chief recommendations of this report. They argued
patients and are the bases for training new doctors. If they are further
starved of funds, the poor will have nowhere to go and the standards of
medical education will decline. The tertiary hospitals in the private
sector would grow but the teaching public hospitals would be degraded.
2. Private sector not touched: “Greater reliance on private sector”
that the international experience showed that the investment in health
shows a misplaced faith in the private sector. The reality is that the
care was extremely cost-effective and hence the Bank's interest in
unregulated private sector is too costly, wasteful, substandard and
health-care.
The report argues for a three pronged strategy to improve health:
1. “Foster an environment that enables households to improve
health”: This includes growth-oriented economic policies, expansion,
investment in schooling especially for girts, and promoting rights and
status of women.
2. “Improve government spending on health”: This includes
reduction in government expenditure in tertiary care facilities, increase
in governmental spending on highly cost-effective package of Public
Health Interventions, improvement in the management of government
services through measures such as decentralisation and “contracting
out”.
3. “Promote diversity and competition in health services”: This
means that apart from the government financed “package of essential
health services” there should be social or private health insurance.
exploitative. A number of examples were quoted to illustrate the nature
of the unregulated private sector in India. The drug industry is the
biggest example of how national resources are wasted on unscientific
drug combinations. It was therefore forcefully argued that unless the
drug industry and the private sector are radically improved through strict
rational regulation, mere pumping of more resources into public health
services (if at all this is actually done) is not going to change the health
scenario in India. It was pointed out that all interventions must be seen
within the context of the ground reality in India. Only 1.3% of the GDP is
spent on Public Health Services and 4.7% is spent on Private Health
Services. Public Health intervention in the context of a major, irrational
private sector, has been ineffective,
3. Fragmented approach: There has to be a comprehensive
approach in public health interventions. Isolated vertical programmes in
the absence of basic comprehensive services are ineffective. Secondly
4. “Encourage suppliers to compete”: One of the implications of this
there has to be integration within different social sectors. increasing the
budget in education and reducing it by 20% in health shows a disjointed
policy, as the report itself further says, is that “the domestic suppliers
approach. Fears were expressed that Structural Adjustment
should not be protected from international competition”.
Programme (SAP) would affect adversely the poor and the women. In
the context of worsening socio-economic conditions, all the talk about
The Criticism of the World Development Report (WDR)
The impressive look and the sophisticated language of the report
did not seem to impress the participants. This was partly because of the
women’s empowerment and social upliftment sounds empty. What
about the degradation of environment and the consequent diseases
caused by the ‘green revolution'? What about the impact on health
image of the World Bank as the agency for promoting foreign interests
status of increased poverty due to SAP?
The author is a medical doctor, active in the Medico Friend
systems have firm roots in our tradition, are cheaper, effective and
Circle and the people's Science Movement. He is presently
associated with FRCH on the project "Supply and Cost of
decentralised. They have lagged behind partly due to their systematic
Drugs & Pharmaceuticals in a District."
offer a bio-mass based, decentralised source of medical care, which
4. No mention of non-allopathic systems: Non-allopathic
FRCH NEWSLETTER, VOL VII, NO. 4 , JUL - AUG. 93
neglect. Yet, they are very much there. Herbal medicines, in particular,
6
has a strong basis in people's culture. But the WDR does not even
thening of district level health structures. He further claimed that the
mention it and hence there is no programme to upgrade and use these
SAP had helped many countries to come out of economic chaos. These
pathies. A homeopathic doctor made a strong plea to give serious
claims would not have impressed the participants, but there was no
thought to this “modern system of medicine which is popular all over the
further discussion as the time allocated was over and the meeting
world".
concluded. Dr. Ms Armaity Desai, Director, T.i.S.S. was in the chair and
5. Absence of people’s control: It was argued that “scientific
Dr. M.W. Uplekar delivered a note of thanks on behalf of the FRCH.
interventions” at the behest of international agencies do not leave any
The WDR - 93 is not a plea for privatisation; it takes a much more
scope for indigenous, grass-root initiatives. The Bhore Committee,
balanced view of the role of the private sector. It has argued for a much
which recommended comprehensive basic health care services;
higher spending on essential health services. It does talk about the need
Gandhiji who aimed at developing decentralised, self-reliant rural
for social development, increase in the level of education, especially of
communities; the experiments like Ralegan Siddhi which show that the
women, in order to improve the health of the people. It has gathered
rural development can occur without international finance or advice —
impressive data from all over the world to estimate the global burden of
all these have been forgotten and a dependent, fragmented, centralised
diseases and has worked out a prioritized list of “cost-effective health
model of development is being fostered. This approach to development,
interventions”. Towards this end, it has brought forward a novel concept
itself, has to be basically questioned.
— DALY — Disability Adjusted Life Years — to measure the burden of
In his response to the above criticism, Prof. Jamison argued that
diseases. This concept enables us to take into account losses due to
this report does not argue for privatisation of health services; on the
morbidity and thus to go beyond mere mortality statistics by combining
contrary, it has argued for a far more expenditure on essential health
the human years lost due to both morbidity and mortality. Secondly it
services in the public sector — from the current level of $ 4 (US) per
does not measure impact of morbidity or mortality in money terms, but in
capita to $ 12 (US); and that the Bank’s lending in Public Health facilities
terms of years of human life wasted. (It is a technical concept, yet
has increased from 1% to 5% of its total lendings in the past few years.
vulnerable to ideological prejudices and hence will have to be used very
He clarified that according to the World Bank, in case of education and
carefully.) Despite these positive features, this report suffers from some
health, relying on private sector was not enough and the government
basic weaknesses and these were very well brought out in this meeting.
had to have a leading role. Prof. Jamison claimed that the World Bank
But would the decision-makers listen?
©
was not in favour of vertical programmes, but favoured the streng
Neem: The Kalpavriksha
skin diseases such as furunculosis, arsenical dermititis, eczema, scabies
and seborrhoeic dermatitis.
Dental Diseases: Nimbidine gargle and dentifrices have been found to
be effective in bleeding gums and pyorrhea, etc.
The neem, widely called Kalpavriksha (the tree of imagination),
belongs to every facet of Indian life — housekeeping, religion and
ceremony, agriculture and medicine. Its use may well be taken for granted
as a commonplace event in many Indian households. A "grows-in-my-
backyard" toothbrush; nature's very own naphthalene balls; the mosquito
repelling smoke from its burning leaves - almost every part and product-of
this tree has long found some use or the other in Indian society.
A number of neem-based products have been in the Indian market for
some years now. Among them are “Margo” soap, "Neem" toothpaste and
Piracy by the MNCs
While Indian Policy makers and a section of the press may object to
the violent mode of protest by the Karnataka Rajya Raitha Sangha, against
the seed processing complex of the US multinational subsidiary, Cargill
Seeds India, at Bellary some time ago, very few among them appear to
understand the full implications of the introduction of seed patents in Indian
agriculture at the behest of the multinationals.
industry, and neem cake is a good fertilizer. Neem extracts are known to
If the operations of Cargill Seeds at Bellary appear too distant and
esoteric to-the average Indian citizen, a similar experiment being
have anti-malarial properties.
undertaken, again by a US firm in Karnataka, should cause concern to
Pharmaceutical products •.Galakoi1
, tablets as galactogogue; ‘JK22
Tablets’: against diabetes mellitus; ‘Neembola*: Neem oil capsules
every Indian. It involves the processing of the familar 'neem' seed.
“Wellgro” pesticides. Neem oil is a widely-used raw material for the soap
against diabetes; ‘Olosyn*: soothing action on the nervous system;
'Loquin*: antimalaria tablets; ‘Neem Cure’: antiseptic bactericidal skin
ointment; ‘SensaT: a herbal medicinal liquid contraceptive.
A time may come when the seed processing firm - for its increasing
requirements for export, may encroach more and more on the the 'neem*
trees which till now have remained the common property of villagers all
over India. (Similar private commercial encroachments on common
Medicinal Uses of Neem
property have eroded the access of our people to their traditional food
resources, like fish, in the coastal areas.) Further, the MNC attempts at the
Anti-Tubercular activity: Neem oil inhibits the growth of all the three
strains of Mycobacterium. Anti-Fungal actvity: Nimbidin, Nimbin,
hybridisation of neem (for greater profits from faster and higher production
Nimbidol and Neem Oil are very effective against various fungi like Tinea
rubrum, ring worm fungus, Trichophyton interdigitale, Coccidiodes immitis
and other species of Trichophyton at comparatively very low
concentrations. Anti-Protozoal activity: Nimbidin and Sodium nimbidinate
as had happened in the case of wheat and other seeds) may lead to the
gradual decrease and final disappearance of the original 'neem' breed.
That this is no idle speculation is evident from the fact that new hybrid high
yielding varieties of wheat had driven out the numerous diverse traditional
varieties that used to grow in different parts of the world.
kill paramaecium candatum. Anti-Allergic activity: Nimbidin is reported
to be effective against eosinophilia with marked symptomatic relief.
Dermatological Diseases: Nimbidin is also effective against various
7
Sources:!. Frontline, August 13,1993.
2
.Note on Neem*, compiled from the literature on neem by C.M. Ketkar.
3
. Piracy by the MNCs. ,E.P.W., Aug. 7-14.1993.
FRCH NEWSLETTER, VOL VII, NO. 4 , JUL - AUG. 93
LIBRARY NEWS
Books
Borlaug N.E., Population: a challenge to contemporary development
1.
12.
2.
David L.H., Project as Instrument of Change: the DANLEP
13.
Desai A.V., Human Energy, Wiley Eastern Ltd., New Delhi, 1990, pgs.
139.
4.
Gopalan C. and Kaur S., Women and Nutrition in India, Nutrition
5.
Gupta R.B., Verma M.M. and Jayakrishnan B. Baseline Survey in
14.
Ruben M. and Ruben S., Diagonostic Picture Tests in Ophthal
16.
Sood M., Swaroop N. and Batra A. Voluntary Organisations
mology, Wolfe Medical Publications Ltd., London, 1987, pgs. 128.
Working for Children and Women: some profiles, N.I.P.C.C.D.,
ILO, How to Read a Balance Sheet, Universal Publishing Corporation
New Delhi, 1992, pgs. 326.
India, Bombay, 1988, pgs. 214.
7.
Jitatmananda, Holistic Science and Vedanta, Bharatiya Vidya Bhavan,
8.
Jussawalla J.M., Art of Healthy Living, Vikas Publishing House Pvt.
9.
L.S.H.T.M., An Evaluation of WHO’s Action Programmeon Essential
17.
Drugs, London School of Hygiene and Tropical Medicine, U.K., 1989,
Swaminathan M.S., Population and Environment: how to meet the
twin challenge in India, Family Planning Foundation, New Delhi,
1991, pgs. 28.
Bombay, 1991, pgs. 156.
Ltd., New Delhi, 1993, pgs. 162.
18.
Tata J. R.D., Population, Poverty and Environment, Family Planning
19.
WHO, Our Planet, Our Health: report of the WHO commission on
Foundation, New Delhi, 1992, pgs. 31.
pgs. 137.
health and environment, Oxford University Press, Delhi, 1992, pgs.
10.
Mitra A., Population Stabilisation Strategies in India: an assessment,
282.
11.
Nagi B.S., Review of Ongoing ORT Programme in India, Council for
obstetrician and gynaecologist, World Health Organisation, Geneva,
Social Development, New Delhi, 1990, pgs. 143.
1989, pgs. 22.
Family Planning Foundation, New Delhi, 1992, pgs. 36.
20.
WHO, Women’s Health and Safe Motherhood: the role of the
contd. from page 3
without antibiotics by a recent national survey. On the other hand Family
universal health coverage need urgent attention. Taking the cue from
Planning funds, almost wholly provided-by the Central government, are
worldwide trends, India too can create a single, publicly controlled
spent mostly in rural areas with the result that the entire rural health
financing mechanism such as a national health service or social
infrastructure and personnel get diverted into fulfilling family planning
insurance programme, or a combination of both, that will pool the
targets. Acute shortages of inputs and the obsession with family'
enormous private resources along with the tiny public funds. It would
planning has completely eroded the credibility of the rural public health
also create the framework for integrating the private and public systems
services. The only credible public sector facilities today are the
and ensure the regulation of the system as a whole. Given the size of
government hospitals.
the country and its uneven regional development, the organisation and
provision of services and the administration of the funds could be the j
Conclusion
responsibility of invigorated local governments and panchayat
Ensuring access to an affordable and decent level of health care
institutions.
services for the large majority of people remains the major challenge
even today. Ironically, instead of arresting the long term decline of public
Select Bibliography
1.
Antia N.H., A Disastrous Prescription, The Economic Times, August 21,1993.
2.
Duggal R, Health Care Services and Financing in India, FRCH, Bombay, 1992.
All by 2000 AD and of raising investment to ensure the effectiveness of
3.
Special Issue on Shore Committee, FRCH Newsletter, Vol IV (1-2), Jan.-Apr. 1990.
services in the rapidly expanding rural primary health infrastructure after
4.
ICMR, Evaluation of Quality of Family Welfare Services at Primary Centre Level,
5.
Jesani A. & AnantharamS., Private Sector and Privatisation in the Health Care Services,
FRCH, Bombay, 1993.
0
spending on health in response to the commitment to achieve Health for
1983, the share of government spending on health further fell during the
Seventh Plan period. The burden of cuts was borne mainly by the
New Delhi, 1991.
disease control programmes which account for 60 % of PHC funds.
With the economy undergoing the IMF and World Bank mandated
structural adjustment programmes, public spending on health will
continue at current low levels. In fact, accelerated privatisation of health
care and medical education, raising charges in public hospitals and their
eventual disinvestment, and narrowly targeting public funds on a set of
selective services and backward regions is likely to be the emerging
trend in the Indian health sector. At a point when the Indian health
sector is once again at policy crossraods, changes in the direction of
|
1992, pgs. 188.
15.
Himachal Pradesh under IPPVI and VII, IIHMR, Jaipur, 1992, pgs.
6.
College, New Delhi, 1991, pgs. 291.
Purohit B.C., Juyal R.K. and Siddiqui T.A. Socio-Economic Case-
Mix of Patients Utilising Public Health Services, IIHMR, Jaipur,
Foundation of India, New Delhi, 1989, Pgs. 378.
200.
Puri R.K. and Sachdev H.P.S., Secular Trends and Determinants of
Under-Five Mortality Components in India, Maulana Azad Medical
experience, ASCI, Hyderabad, 1992, pgs. 40.
3.
OECD, Financing and External Debt of Developing Countries
OECD, Paris, 1989, pgs. 217.
strategies, Family Planning Foundation, New Delhi, 1990, pgs.24.
FREE ABSTRACTING
The contents of this newsletter may be
abstracted without prior permission.
However, we would welcome acknowledge
ment of the source and copies of any
abstractions.
Edited by Rohini Lele, with secretarial assistance from Anita Nair. □ Produced by the Foundation for Research in Community Health,
84-A, R.G. Thadani Marg, Worli, Bombay 18. (Registered under the Bombay Public Trusts Act.) □ Printed at Printext Offset, Pune 30.
g
•
Sept. - Oct. 1993
SPECIAL ISSUE ON INDIGENOUS MEDICINE
Vol. VIL No.5
THE RELEVANCE OF HERBAL MEDICINE
Problems Encountered
Marie D'Souza
To most lay persons the word ‘Herbal1 immediately brings to mind
injections rightly or wrongly given by doctors more interested in making
the shampoos and face-packs so much advertised lately — and an
money than ‘catering to the real needs of the patient. And tablets /
import from the West. To most allopathic doctors Herbal Remedies are
capsules come in attractive colours, syrups taste so very good. Why go
associated with quacks and charlatans and they ask: “Can an allopath
back to remedies which are unattractive, bitter and take time to be
practise or promote Herbal Remedies and still be called a doctor?"
effective? Besides, the herbal remedies have to be prepared before
In the present day, I would say that Herbal Medicine, if properly
practised, is very much relevant. N.H.Antia in his article, ‘Functional
they can be used while the tablets and syrups can be bought from the
market ready-to-use. It matters little that time and money have to be
Classification of Diseases', suggests that diseases could be divided into
spent in going to town to buy them. Of course, in some villages the
five categories according to the knowledge, skills and facilities required
tablets are available with the VHWs, very well trained by NGOs arid well
for their diagnosis, treatment, etc... and I would like to say that Herbal
provided too, unlike the government VHWs poorly trained and
Medicines can be used in the categories ‘B’ and ‘C. People should be
inadequately provided in most areas. The VHWs are also trained to
able to treat themselves and should not necessarily depend on doctors
reject / forget the ‘superstitious practices* of their forbears who are
or pharmacies especially if remedies are easily available in and around
supposed not to have known better.
their homes, and the diseases are self-limiting and not life threatening.
In some cases Herbal Remedies have been misused by people not
Today, people are trained for independence and self-reliance. Why
at all trained in the preparation or correct use of the remedies. They
should this not be in the field of health? Is treatment with herbs really a
have ‘heard* about a remedy and advise it incorrectly with disastrous
new idea that we are introducing into our country? Or is it rather an old
results, thus earning a bad name for a valid tradition. Another harm
truth, done away with by vested interests, and now rejuvenated?
done to Herbal Medicine is the indiscriminate destruction of forests,
leading to the non-availability of herbs needed for treatment.
The Herbal Tradition: misconceptions
Re-introducing the idea of Herbal Remedies to the younger
In fact, the herbal tradition is a sound one, especially when practised
by persons who are properly trained and not interested in monetary
generation is a difficult task, especially in rural areas. The younger
gain. The vaidus have been chosen and they choose others because of
generation is ‘educated* or rather I would say ‘literate* and looks down
their integrity, ability and willingness to undergo a rigorous practical
on those who are not. Why should they learn from their fathers or
training under the guru. The remedies they use have proved their
grandmothers? The middle generation has experienced the ‘magic* of
effectiveness over a period of time. Also these vaidus do not limit
themselves to the old remedies alone. They learn from others and with
The author is an allopathic doctor. She moved out of a hospital
thirteen years ago because she realised that health was linked
to the social, political and economic conditions of the people.
She wanted to work with tribals and help them fight against
exploitation. She joined the Janaseva Mandal because it was
newer plants being introduced into the area they use the new remedies,
always taking at least one dose of the new remedy themselves before
giving it to a patient in order to be sure that there are no ill-effects. They
treat the diseases included in categories ‘B*, ‘C*, and some of those in
‘D* of N.H.Antia's classification. Some psycho-somatic diseases (though
working in that direction. She believes that Herbal Medicine is
the vaidus may not call them so) are also treated by them with good
effective and can help tribals to be self reliant.
results.
FOR PRIVATE CIRCULATION ONLY
%
V0
The Role of Janaseva Mandal and other NGOs
Fortunately for the Herbal Tradition, some NGOs have become
aware of the need of preserving and re-vitalising this tradition, though
this effort is very meagre considering the vast ocean of knowledge
existing in the country.
The Lok Swasthya Parampara Samvardhan Samithi (LSPSS) is an
organisation attempting to co-ordinate and encourage the activities of
various NGOs through training camps/workshops on:
a) Identification, uses and properties of medicinal plants.
An interesting development has been that the women have now started
discovering treatments on their own. The use of Aloe barbadensis for
menstrual pain and leucorrhoea was explained to them, together with its
other uses for cuts, wounds, bums, abscesses, etc. A child had parotitis
and her mother, Chamubai, decided to tie Aloes. The swelling subsided
the next day and by the third day the child was free of symptoms. The
mothers and children of two neighbouring families also went down with
the disease and Chamubai advised tying of Aloes with similar good
results. She related to me later, “It is not enough to tie it for only one day.
Even if the swelling subsides, it must be tied for at least another two
days till the symptoms disappear completely”.
b) Methods of processing, in order that medicines can be preserved
We encouraged the women to grow plants around their homes and
for a certain length of time, to be available for immediate use by the
then realized the difficulty they had in doing so. Many homes had only
patient.
rocky ground around. Others who had a little useful strip of land found
that infants, allowed to roam freely around the home, destroyed the
c) Diagnosis and treatment of common ailments.
seedlings, while bigger shrubs were destroyed by cattle. The problem
was finally solved by giving them plastic pots to hang from their roofs—
It has also taken up the task of creating village nurseries, village
herbal gardens, medicinal forests, etc.
an idea given to us by a woman. This idea has caught their fancy, for it
not only provides easy availability of a remedy, it also adds beauty to the
house.
We at Janseva Mandal, Nandurbar are attempting in a small way to
correct the wrong done in the past. Having observed the effectiveness,
Government Policy: doublespeak ?
initially of a few herbs, we came to realise the potential that indigenous
The government may speak of Health For All by 2000, a target
medicine had in developing a better self-image and a greater
which does not seem feasible. Rural India, comprising seventy percent
independence among the tribals who have been exploited for centuries.
of the population, is the area where the need is the greatest. And
Deprived of their lands and forests, marginalised by a capitalistic
however much government spends on training in allopathy, or for that
society, they are gradually being made to forget their very culture and
matter in ayurveda (on the latter the amount is relatively little), the
traditional knowledge, in the process of absorption into a money
doctors tend to gravitate towards the towns and cities, where a more
economy.
Of course, we needed to have a better base for this activity, and it
lucrative practice is available. If, however, it had made more efforts to
promote and revive this dying tradition and helped strengthen it with
was just then that a meeting was called, at Academy of Development
fresh inputs, we would, perhaps, have a healthier nation. China, with its
Sciences, Kashele, of people interested in re-vitalising the Herbal
barefoot doctors trained also in traditional medicine, is a case in point.
tradition. It was then that we discovered that vaidus in other parts of
Efforts have been made by LSPSS to help NGOs interested in
India used the same herbs for treatment of similar illnesses. Thus, an
promoting the Herbal Tradition get funding from government organi
empirical base for continuing our efforts in promoting and strengthening
sations. But it has run into difficulties. One government organisation
this tradition, was established. The vaidus from this area met and
wants all the reports submitted in English! Even Hindi, the rashtra-
exchanged information with those from other areas, through the camps
-bhasha will not do. It was difficult for NGOs existing in rural areas with
organised by LSPSS, further confirming their own knowledge and
members speaking the local / regional language to submit reports in
learning from others.
English and as a result funds were stopped. Another organisation had
This knowledge limited to vaidus alone, we felt, was not enough.
given funds for 'involvement of women in indigenous health practices’
We prepared photographs and slides of trees, shrubs and weeds of
and 'cultivation of medicinal plants'. A new director says that this organi
medicinal value. These slides are being shown by our Tribal Animators
sation is meant for research and is not willing to sanction funds to future
in the villages. The turn-out for the slide shows is very good as the
‘applicants wanting to involve women in indigenous health practices. Are
people learn the usefulness of the plants for common ailments and
only 'degree holders' capable of research and adaptation of technology?
simple methods of preparation of the remedies. The slide shows have
Is an illiterate incapable of thinking and adapting technology to her/his
also helped re-generate a respect for trees and a desire to grow a few in
needs? Or is it that adaptation of complex technologies alone is
their fields. The literate keep asking for written material about the same
acceptable?
as they say they are not able to remember all the information given. At
the moment a book is being printed in Bhili and English, to satisfy this
come from an urban background with a Westernised training. They are
expressed need. In it is recorded information, collected from the vaidus.
constantly looking to the West for guidance and norms. They find it
Most persons in government bureaucracy and in city-based NGOs
difficult to accept that any 'new technology' can come from the Indian
Women's Contribution
Recently we turned our attention to the problem of women’s health,
which is rather neglected. Meetings are organised once a month in the
villages at a time convenient for the women. Herbs which are useful
specifically for women's ailments are dealt with at these meetings and a
mention is made of the other possible uses of the plant. The women are
very happy to be able to treat themselves, where earlier they bore up
with their illnesses rather than explain their problems to a male vaidu.
FRCH NEWSLETTER, VOL VII, NO. 5 , SEPT. - OCT. 93
country-side. So also, most of the rural-based NGOs look up to the city
based ones as if they have a 'better’ education. And as long as this
attitude remains, the wealth that exists in the land, specifically with the
rural population, will be lost — to the detriment of the well-being of the
nation.
References:
1.
2.
Antia N.H., Functional Classification of Diseases, FRCH Newsletter, Vol.7(2).
LSPSS Pamphlet
O
2
SCIENTIFIC VALIDATION OF AYURVEDA
Urmila Thatte
Ayurveda, literally translated, means 'knowledge of life'. Some call it
by a shloka from Sushruta Samhita, Satyavati and Dwarkanath explored
a philosophy, some say it is a scientific description of facts, some say it
the utility of gum guggul in hyperlipidimia. Dr. G.V.Satyavati, (currently
is a way of life, while others relegate it to the class of folk medicine.
the Senior Deputy Director of the ICMR) first published in 1966, the
Amidst this confusion emerges the fact that almost eighty percent of our
hypolipidemic action of Commiphora mukul in her thesis, ‘Effect of an
population looks to ayurveda for remedies and has been staunchly loyal
indigenous drug on disorders of lipid metabolism with special reference
to this system. Because of its continuous interaction with Indian
to atherosclerosis and obesity ^medorogay, submitted to the Banaras
Ethnomedicine, the ayurvedic formulary has become rich and diverse.
Hindu University. Since then, guggul has come a long way. A complete
Over the years, ayurveda has grown and matured in the soil of India. An
phytopharmacological workup followed by exhaustive experimental and
uninterrupted contact with the folk medicine has enriched the materia
clinical studies has led to the drug now being on market as an effective
medica of ayurveda.
and safe hypocholsterolemic agent.
The primary aim of ayurveda is promotion of health, and removal of
The Central Drug Research Institute, the Indian Council of Medical
disease. The therapy is therefore directed at protection of cells from
Research and Central Council for Reasearch in Ayurveda and Siddha
endogenous and exogenous stress factors and preserving their
are actively involved in exploring the ayurvedic pharmacopoeia in order
functions. Several therapeutic approaches are advocated including
to develop new drugs.
Prakritisthapani Chikitsa, Roganashini Chikitsa, Rasayani Chikitsa and
In the Ayurveda Research Wing of the Dept, of Pharmacology
Naishthiki Chikitsa. The procedures used to achieve these aims are :
(Seth G.S.Medical College and KEM Hospital) we are engaged in the
Vyadhiharanam, diet and drugs.
study of Indian medicinal plants for different indications. Our first clues
In this paper, I shall restrict myself to drugs—especially plant drugs
are from Charaka and Sushrut Samhita. We take these hints, use the
used in ayurveda, although the horizon for research in ayurveda is far
principles of ayurveda but try to fit them into a lattice woven with modem
wider. We shall see how modem tools can be used to explore ayurvedic
technical strings.
concepts, so that useful drugs can be picked up for general use.
The Tc Story
Traditional Remedies: an unexplored treasure
Man has looked toward nature for remedies ever since the dawn of
civilization and scientists have delved into the 'grandma’s pouch' for the
magical cure. There are several examples in Western medicine that
illustrate the usefulness of this approach. In 1785, William Withering
published his famous treatise describing the usefulness of foxglove in
dropsy. His observations were based on the folk use of the plant.
Subsequent diligent research led to the identification of the active
Perhaps the most interesting story we have, is that of Tinospora
cordifolia (Tc). A plant extensively used by vaidyas and found even
more widely among the constituents of ‘over the counter* brands of
‘herbal* or the so called ayurvedic drugs marketed today, Tc is
prescribed as a rasayana, usually in fevers and post-fever convale
scence. At that time we felt it likely that this use of the drug could be
based on its effects on the immune system. And since then, the story of
Tc reads like a fairy tale.
ingredient ‘digoxin', and its use in congestive heart failure and atrial
Our initial studies showed that Tc protected animals against
fibrillation. Perhaps the story of reserpine comes closer home. The
infections induced by a variety of organisms. The animals withstood the
publication, in the British Heart Journal, of the usefulness of
onslaught of bacteria or fungi and survived. This happened in normal as
Sarpagandha in hypertension, by Dr. R.J.Vakil led to the isolation of
well as those animals whose immunity was depressed.
reserpine and validation of its efficacy in patients.
Logically the next step was to identify the mechanism of action of
Today, the National Institute of Health in Bethesda, USA, has
the drug. We looked for, but found no antibacterial activity. How, then,
launched a massive multi-million dollar programme to identify, from
was Tc working? To was proven to have immunomodulatory actions
ethnomedicines all over the world, drugs that may prove useful in AIDS
when its protective effects against the myelosuppressive effects of
and cancer. The Chinese and the Japanese have not lagged behind.
cyclophosphamide (CP) were confirmed in mice. Tc not only increased
The development of Artemisine from Quing Hou sou for malaria, and
the counts, but also stimulated immune cells to function better. This
gossypol as an antifertility drug, are fine examples of how a scientific
meant that Tc would be a useful adjuvant in patients receiving
merging of the two streams — modem and ancient — has led to the
chemotherapy for cancer. All these were experimental studies. There
discovery of useful new drugs.
was a need, at this point, to prove its efficacy in clinical situations.
The story of the development of guggulipid is an illustrative example
of how ayurveda can contribute to the modem pharmacopoeia. Inspired
The Safety Studies: a continuing debate
A very widely debated issue regarding ayurvedic herbal remedies is
The author is an Associate Professor in the Department of
Pharmacology, Seth G.S. Medical College, Bombay.
3
the need to conduct safety studies on them. Protagonists for this believe
that with the changing ecological environment, use of pesticides, new
FRCH NEWSLETTER, VOL. VII, NO. 5 , SEPT. - OCT. 93
smanufacturing techniques, modern formulations and combinations of
The protective effects of the drugs were found to be mediated through
herbs not prescribed in ayurvedic texts, there is a pressing need for
macrophages. These results prove that there is a strong scientific basis
looking at ayurvedic herbal drugs as 'new drug entities’. Opponents feel
for using these drugs in ‘anti-stress’ preparations so commonly found in
however that herbal remedies are ‘natural’ remedies and are beyond
the market.
conventional toxicity studies.
We, in our laboratory, conducted toxicity studies on the aqueous
The Need for Genuine Efforts
extract of Tc and satisfied ourselves regarding its safety. We then went
What then are the problems that face us? What has prevented us
to the clinic and evaluated Tc in patients with obstructive jaundice.
from being far ahead in the global scene vis a vis health care? One of
These patients tend to develop biliary sepsis and were found to have
the major reasons for the setback that ayurveda faced is the language.
significantly depressed immune functions. They were administered Tc
Sanskrit is a very rich language. But the stanzas, which are short and to
in a dose of 16mg / kg for 15 days before and following definitive
the point, can be interpreted in different ways. The subject tends to be
surgery. It was observed that treatment with Tc significantly reduced
looked at from different angles, without making a unified effort at
mortality and this was associated with increased immune function. We
identifying the real message. This scenario brings to mind the story of
are currently evaluating its usefulness in several clinical situations where
the men who were blindfolded and asked to identify an elephant. Are we
chronicity associated with immunosuppression is the hallmark of the
doing the same with ayurveda? Can we all not work out a policy of
disease. These conditions include tuberculosis, tropical pyomyositis,
teaching, utilising and researching ayurveda which is mutually
malaria, etc.
acceptable and above all applicable to the society at large? Can we not
Thus we see that in Tc we have a potent immunostimulant which is
all communicate freely and on a large scale?
orally effective, indigenously made and without major adverse reactions.
We have seen that a lot can be achieved by using modern
Drugs like Tc will be of great importance in conditions like AIDS, chronic
techniques to explore usefulness of ayurvedic drugs. We have a rich
infections, antibiotic therapy etc., where the immune system is at its
lowest ebb. Multicentric and large scale clinical trials are required to
tradition in ayurveda, however, ways that are well thought out have to be
evolved to incorporate its colours into the canvas of our lifestyles so that
evaluate the efficacy of this promising drug. It may prove useful as an
the picture that emerges is not confused but clear and beautiful. In
adjunct in malnourished children, in tuberculosis patients and in patients
1940, Zimmer said, 'There lurks a secret truth from which modem
with fevers of unknown origin. Still several questions remain. For
research might take its flight toward a new insight”. Let us hope, then,
example, what is the active ingredient and the exact mechanism of
that our country will take the lead in integrating new and old, in building
action of Tc? Although such questions are mainly academic.
upon the grand traditions that we already have inherited — all in an
Rasayana is a term which is used to describe rejuvenating effects.
Tc, Ar and Eo (Tinospora cordifolia, Asparagus racemosus, Emblica
(y
-"
attempt to alleviate human misery and perhaps to put India back on the
world map of medicine.
0
officinalis) have all been described as rasayanas. We studied them in a
‘cold immobilization stress model' and found that pretreatment with
these drugs protected rats against stress induced gastric damage,
If the readers want to correspond with the author, the address
increase in serum cortisol levels and inhibition of macrophage function.
is available with us. — Editor.
Private medical colleges are sprouting all over. The resultant
present collecting the data which he will analyse soon. But
imminent spread of modern health care to remote rural
the initial results are very impressive. For example, one of
areas, so far untapped by doctors, has raised several issues.
the time-tested remedies, Aloe - a fleshy xerophyte- locally
It would surely work as a death-blow to already withering
called 'Korphad', is found to be extremely effective in the
indigenous health care. In fact, it is likely to be replaced by
treatment of infected wounds. The cut-surface of the fleshy
irrational ‘modern’ health care soon, as the young doctors
leaf is tied to the woimd for two to three days. The slough
start exploiting the rural health market in order to recover
drops off and fresh healthy granulation tissue appears.
the cost of their expensive education at the earliest. With this
Powder of 'Avali' leaves is found to be useful in treatment of
new development, it is now an urgent need to think and act
fresh wounds. 'Shibeko? roasted to brown-black and then
accordingly, so as to preserve at least the time-tested
powdered and mixed with coconut oil can be used for the
indigenous remedies.
treatment of infected scabies and bacterial scalp infections.
Many of these remedies have not been systematically tested
Asafoetida when applied to the skin affected by ringworm
in the field and are likely to be shrouded with mysticism,
is quite effective.
claiming total cure and total safety. Dr.Anant Phadke, while
Similar exercise is being undertaken at the four training
training the health workers in villages near Pune, decided to
centres, where ashram - school teachers are being trained in
test some of these remedies in a more systematic manner.
health care by the FRCH team. Although there is enough
He asked the health workers to name the traditional
empirical evidence as to the efficacy of such remedies, here
medicines which according to their experience were very
is an attempt to systematically collect data from the field
effective. Then he selected a few ofthese, medicines which
were confirmed as being effective by health workers from
and re-establish the commonly available, useful and cheap
health care in a de-romanticised manner.
other villages. He encouraged the health workers to use
them and keep a record of the results. Dr. Phadke is at
FRCH NEWSLETTER, VOL. VII, NO. 5 , SEPT. - OCT. 93
— Mohan Deshpande, researcher, FRCH.
4
TRADITIONAL HEALING
A Dying Practice
Manisha Gupte and Ramesh Awasthi
Two extreme views categorize our attitude towards traditional
0)
eclipse. On that night, the guru took the young entrant to a body of water
healing: either that such healing is all hocus-pocus or that it is
(well or pond), and asked him to undress entirely. Then he whispered
sacrosanct. While some of us will believe that no such arts (or sciences)
the sacred chanting in the latter’s ears and asked him to repeat it the
exist anymore, some others will shudder at the so called superstitious
whole night, staying partially immersed in water all the time. The guru
behavior of backward rural or tribal people. Furthermore, all traditional
advised him to revise the chanting at least a thousand times in an
healers are clubbed together, often making no distinction between
overnight session each year, during an eclipse. Then he ought to bathe
ritualistic and secular healings. Overtly, or covertly, urban biases about
and change into fresh clothes; that would keep his magical strength
having to redeem the local healers surface even amongst well-meaning
intact.
individuals, the 'dangerous practices' of traditional practitioners are
Now certain taboos have to be observed by the new healer. For all
sought to be curbed and new ‘scientific methodology1 is sought to be
his life, he must not eat stale food; not even a small portion of it. He
imparted to them.
should avoid eating in large gatherings. At no cost, should he touch or
Is there a middle path in the understanding of traditional healing?
come in contact with a menstruating woman. He should never eat food
As we stayed in Malshiras area for some years, and saw that our
cooked by women during the four days of menstruation. The most
neighbours and friends practiced traditional healing in various forms, we
important taboo is the woman in the post-partum period. He cannot
thought of documenting their actual experiences and perceptions
share a roof with a woman for forty days after child-birth; if and when
without interference of our own preconditioned biases. The findings
child birth takes place in his household, he should stay elsewhere. If he
were interesting, to say the least.
is defiled, his chantings cease to have effect. Similarly, he should never
We found that though healers practise a multitude of arts together,
repeat the secret and sacred chanting to anyone, because that causes
there is a distinction between religious and medicinal treatment. In an
instant loss of magical power. Only in old age, when his powers start
atmosphere of suspicion, most healers feel insecure and become
failing naturally, should he identify a successor, or wait for a prospective
secretive; this in turn accounts for the death of knowledge and wisdom.
successor to approach him, and then, should pass on his chanting (and
Of the various healing processes documented, we are herewith
presenting four representative case-studies.
power) to the new initiates. After this transfer, he should content himself
by living as a guru of his new initiates, rather than as a healer.
An ageing healer gets distinct signals when his power starts
Treatment of Scorpion Bites
0)
receding. One old man treated a patient with a scorpion bite and sent
him home. The patient and his relatives, however, returned in an hour,
We could identify twelve persons in the 30,000 population (eighteen
saying that the pain had resurfaced. The old man at once understood
villages) who were publicly acclaimed as being able to treat scorpion
that someone else was challenging his powers and that he was
bites. Very possibly, there are many more such persons. The twelve
incapable of retaliating. He sent the patient back, with apologies, and
individuals were interviewed in detail about their socio-economic
sat down quietly for a long while. Then, all of a sudden, he asked his
background, their skills and mode of treatment. The healers come from
all castes, with none of them educated above matriculation. Except one,
twenty-five year old son, if he wanted to inherit his magical powers. The
all are above forty years of age. All healers are males.
Seven of the practitioners are 'specialists' in the sense that they
treat only scorpion bites. However, one reportedly is a bone setter and
treats guinea-worm infestations, too. Another gives medicines for
headache. Two persons also treat pneumonia in children. One treats
jaundice.
All except one (the only Muslim practitioner being the exception),
reported very similar methods of being inducted as a healer. In some
cases, an older healer 'chose' them: “You only have to look at somebody
once, to know that he is your successor”. In other cases, the present
son was only too happy, and so, he became the successor on the
subsequent eclipse night. The son has now been practising this skill for
the past twenty years and is confident of carrying the art for many, more
years.
The mode of treatment of scorpion bites by most healers is quite
similar. Some ashes (and sometimes a little kerosene) are applied to
the site of bite; and the healer keeps on mentally uttering the mantra,
whilst slowly and repeatedly moving his hand from the point of bite to
the extremeties; thus directing the ill effect out of the body. One healer
gathers herbs and roots (he won't tell their names) and asks the patients
to bite on them while he utters the secret chant.
healer approached a senior and requested him to pass on the ‘mantrd
(chanting) to him. In all such cases, the seniors approached were either
family elders (father, uncle) or close family friends. The senior, who was
now the ‘gurd asked the novice to wait until the night of the forthcoming
Healers are not supposed to ask for any material benefits from their
clients. This is necessary if one wants to preserve the magical power.
However, people do give some money or a coconut or grains on their
own, sometimes.
The authors are reseachers at FRCH who were living at
Malshiras while coordinating the Health Education Project.
5
The exception to this general story, as mentioned earlier, is the
forty-three year old Muslim practitioner, who along with balutedari owns
FRCH NEWSLETTER, VOL VII, NO. 5 , SEPT. - OCT. 93
a small mutton shop. “There are no spirits in Islam", he says. He learnt
dislocation of joints, the healer massages the area slowly, engages the
this art of treating scorpion bites from his mother, when he was twenty-
patient in conversation and when the patient relaxes, a sudden jerk is
five years old. His mother had started to lose her touch because of old
given, to set the bone in its place. “When the limb is pulled, the sheer
age and she taught the son how to make a betel-leaf ‘paari with herbal
(nerve?) that has climbed over another, gets back to its original
medicine.
position,also".
When a patient arrives, this healer makes some tea for him, and
The healer recognises a fracture by the accompanying depression
then he prepares the paan with lime, betel-nut, catechu, leaves of the
in the flesh, studies the direction of the jutting bone and massages the
‘shef tree, and one more herbal ingredient, the identity of which he
bone into its own position.
cannot reveal. He said that he had accepted his mother as his guru. He
Four bone setters said that they did not charge anything for their
does have a secret chant, but the real remedy is the medicinal paan. As
services; though occasionally they may recommend that the patient'
the paan dissolves in the saliva, the palliative effect starts taking place.
break a coconut for some God. One healer, who is a sixty-three year old
Most healers treat between 5-10 patients each, per month, the
poor labourer, said that he charges Rs. 20/- plus travel expenditure,
figures rising to 25 or 30 in the summer months. They derive immense
because he has to compensate for the loss of his daily wages. On an
satisfaction from the fact that they are being useful to the community. “A
average, a bone setter treats 5-7 patients (human and animals) every
particular God has given me the third eye which I use carefully in the
month.
benefit of all people", said one healer. The response from their families
All the healers pride themselves about being useful to the village
is positive, they say, in spite of the fact that patients arrive even at night;
through their diligence and hard-earned skills. Their esteem in the
and the community regards them with respect and affection. Most of the
community has increased over the years. Family members often prevail
healers are very religious. One of them is a sanyasi who has left his
upon the older bone setters to give up the practice. One forty-eight year
family and lives in Rajuri surviving on the flour that people give him
old farmer (whole family has high social status in spite of being
every day.
unprivileged balutedars) said that his family and friends pressurise him
to abandon bone setting because “it is below one’s status". The family
The Bone Setters (Human and Veterinary)
want him to pay more attention to farming.
Five bone setters, all male, were identified, one each from
Most of the existing bone setters are very old (four out of five are
Malshiras, Vanpuri, Pondhe, Rajuri and Guroli villages. The socio
above sixty of age, two being over eighty) and there are not enough
economic details of the five practitioners revealed that all healers were
successors. “Nobody wants to learn this art anymore. Years of
above forty years of age, none had attended school beyond the fourth
observation and practice are required to achieve this skill. Who wants to
grade and that most of them had some close contact with animals and
waste their time?" says one sixty year old bone setter. The others echo
cattle.
his concern. “If nobody wants to learn, we won’t teach them”, is what
Bone-setting and treatment of sprains is a secular art, learnt with
perseverance and keen observation. Except one healer, none use any
chants or mantras while they treat their patients. One healer amongst
them however said, “If you believe in God, the cure is faster”.
All the five bone setters learnt this art by observing, and originally
treating animals. Of the five, two were famous for their goat /
shepherding skills, and the third was very attached to his own cattle.
Eventually, these healers start attending to humans; yet they are still
one says. The oldest bone setter in the area (reputed to be over a
hundred years of age!), who started his career as a medicine seller (oils
from the Dhakal plant for massages on sprains), has taught his second
son some of his skills and hopes that the son will want to learn more.
The other old healer, eighty-one years of age, says that he started
treating animals and humans when no one else was doing this work.
Now the villagers say, “When you are dead and gone, this skill will be
lost to all of us".
called upon to treat cattle, sheep and goats, especially when the animals
are in obstructed labour.
Treatment of Jaundice
To ease a cow or buffalo in delivery, a healer gives an internal
Four male persons, one each from Pargaon, Rajuri, Pimpri and
examination to ascertain the position of the calf. If the presentation is
Naigaon were interviewed for their skills regarding treatment of jaundice.
breech, the cow is made to lie on her back, legs up, with region of the
Three healers were between fifty to fifty-five years of age and have
head being lower than the rest of the body. This helps the calf to turn
been practising this art for more than twenty years. The fourth healer, a
around. Then the cow is again made to stand erect. The calf then slips
young Muslim aged twenty-two years learnt the art eight years ago.
out of the birth canal, easily.
If a bullock loses a shoe and there is an infection at that spot, a
mixture of molasses and the Korphad plant is cooked and the warm
Some socio-economic details of the healers (treating jaundice) are
presented here:
A. Caste:_______________________ 2__________________
slurry is poured on the animal's feet. The adhesive quality of this mixture
I.Maratha
2
seals the shoe to the foot pads and the ‘poisonous’ qualities of Korphad
2. Unprivileged balutedars & Scheduled Tribes
1
kill the invading germs and maggots. This action is not accompanied by
3. Muslim
1
any magical chants.
Fractures of limbs in the cattle are treated by immobilisation of that
limb. A young bamboo is tied tightly around the leg and left there for
some days, until the animal is able to walk on its own, without limping.
B. Education:---------- —-----------------------------------------------I.Nil
2
2. Upto 4th std.
2
C. Occupation:__ _ _________________________________
Sprains, whether in humans or in animals, are treated alike. If the
1. Farming
1
sprain is muscular, the area is massaged with warm groundnut oil.
2. Labourer
1
Some healers use their feet or a rolling pin if the back muscles are
3. Masonry
1
sprained. If there is a swelling because of fracture, a hot mixture of
transformer oil and castor oil is dabbed on the area. In case of
FRCH NEWSLETTER, VOL VII, NO. 5 , SEPT. - OCT. 93
4. Bharadi/Gondhali
(religious folk performers)
1
6
Only one out of the four uses a mantra to cure jaundice. Twenty
Removing Foreign Particles from the Eyes
years ago, this healer met a maharaj who was travelling through his
village. The maharaj told him about his religious abode where they
performed yagnas and horns. During this occasion, various mantras
were passed on to new-comers. When our healer went there, the
maharaj wrote down the chant and whispered the same in the former’s
ears five times. Ever since then, he is able to cure jaundice.
Whenever a patient comes to him, the healer asks him to come
back on a Saturday morning, as soon as the patient wakes up, without
Two male healers, one a Kumbhar (potter) aged sixty years from
Malshiras and a Ramoshi Naik (a scheduled tribe) aged sixty-five from
Rajuri, were interviewed about their skill in removing foreign particles
from the external eye. Neither of them used any ritual or chants, and
had learnt the skill around twenty years from the same elderly
practitioner in Rajuri village. Both were eager to demonstrate their skill
and were very willing to teach anyone who was interested. Neither had
any formal education.
touching any water. He then sprinkles ash on the patient five times,
each time repeating the mantra. Then the patient has to offer a coconut
in a nearby temple. He gets 3-4 patients per month. His son, who is a
Whenever a patient arrives with a foreign body in the eye, the
healer takes a bit of clean cotton, makes a very fine and thin curtain of
this soft cotton, places it on the iris of the patient while holding on to one
school teacher advises him to give up the practice. “I know you can cure
end of the cotton piece. He then asks the patient to close his eyes and
patients, but if ever someone gets worse, they will blame you", he says.
then gently moves the cotton film all around. Occasionally, he removes
No fees are charged, for fear of losing the magical power.
it from the patient's eye and checks it for the irritant particle. When the
The other three healers did not use any mantra. Two of the three
patient feels relieved, the operation is complete. Each month, a healer
persons tied a string of roots around the patient’s neck, and one gave a
gets between 10-30 patients, whereas in summer (when the strong
betel leaf with a herbal ingredient. Interestingly, treatment is always
breeze blows dust all around) and during pre-monsoon periods, the
given on Saturdays by all four healers; and a coconut offering, to some
figure rises to 50 persons each month. No fees are charged for the
God, is a regular feature in all their healings.
service rendered.
Two healers learnt the art from family members (father and elder
The esteem of the healers in the community is positive and family
brother, respectively). The third healer had an interesting tale to narrate,
members do not object to them continuing with the practice. One healer,
as to how he learnt the skill. “In 1972, during the drought, I was thirty-
mentioned somewhat skeptically, “Sometimes, if the cotton film gets
five years old and we had gone to the outskirts of Pune city for our
caught in the eye, people get upset and angry. The entire procedure is
survival. There, I suffered from jaundice. It was taken to a healer, who
very delicate and requires patience on the healer’s part and cooperation
put a string of some roots around my neck. When he wasn’t looking, I
on the patients’ part. These days no one wants to learn this skill and
picked up a small twig of that plant and preserved it, very carefully. I
many call it a fraud”.
would carry it on my person, each time I went into the woods. One day,
I found the plant that I was searching for. Later on, our neighbour
suffered from jaundice and I tied the string around his neck. He was
cured, and that's how I became a healer, myself. Asked, if he would
Conclusions
1.
The more perseverance the acquisition and practice of a skill
teach someone else the skill he had acquired so ingeniously, he
involves, the more secular is the skill. Conversely, those skills
vehemently refused.
which involve religious chanting, do not involve rigorous pursuits
like observation, reiteration and improvement.
The healer who gives the betel-leaf (paan) with the herbal
ingredient, also refused to divulge the identity of the plant. He calls a
2.
patient on a Saturday, asks him or her to chew the special paan and if
Skills involving ritual depend on taboos (most being a guard against
being defiled or polluted) for the preservation of the skill. Many of
there is no effect he repeats the same treatment on the forthcoming
these taboos are directed against women, especially during the
Saturday. He gets around 2 patients each month.
menstrual and post partum period.
The fourth healer, a fifty-five year old person, whose livelihood is
balutedari and religious folk performances, was very candid. He learnt
3.
as compared to those who have learnt through hard work.
about the herbal string from his father ten years ago. But he had not
practised the art on anyone until four years ago, when a family member
Those who use tantras or rituals are more reluctant to teach others
4.
was ill with jaundice. When he successfully treated the patient, more
Taboos about purity exist only among those who treat scorpion
bites.
and more people started coming to him. He now gets 8-10 patients each
month.
5.
The others (secular skills) say that they have learnt the skill
Whenever anyone with ‘yellowed eyes’ is brought to him, he asks
themselves through hard work.
for some string and makes a sort of necklace with the roots of the
“Pandhara Vasai’ plant. This string is tied around the patient’s neck
When healers use ritual, they see their predecessor as a “gunT.
6.
All bone setters originally started as veterinary healers.
7.
‘Saturday’ features as the day of choice for treatmerit of jaundice.
8.
The Muslim healers are less inclined to practise ritual than their
tightly. Over the next one week, the string starts growing. By the time
the string reaches the abdomen of the patient, he or she is fully cured.
Then a coconut has to be offered to Siddheshwar. His family members
are very cooperative and his esteem in the village has enhanced since
Hindu, Scheduled Caste or Scheduled tribe counterparts.
he started this practice. He is ready to tell anybody the identity of the
herb (Pandhara Vasai) if they ask him.
9.
Women healers are absent (except the one case in which a mother,
a Muslim, taught her young son, the art of administering a medicinal
All the other three healers were very indifferent to the community’s
response to their skill. None of them felt that their status had improved
because of this special skill. As mentioned earlier, all the three healers
(like most other healers) were reluctant to pass on their knowledge to
anyone else.
7
“paarf to treat scorpion bites), or they have been missed (this is
rather unlikely) through this survey. In the next round, and when we
cover gynaecological healers and abortionists, women healers
should, in all probability, feature prominently.
contd. on pg. 12
FRCH NEWSLETTER, VOL VII, NO. 5 , SEPT. - OCT. 93
THE REALITY OF AYURVEDA MEDICAL PRACTICE
With Some Observations Jrom the Field
Manjiri Sule and Shirish Kavadi
The VIII th Five Year Plan in its strategy for promotion of the Indian
Systems of Medicine and Homeopathy (ISM & H) emphasizes —
1.
2.
But findings from some other studies contradict these popular
notions about the utilization of traditional medicine. A study by Dr.
The provision of adequate facilities for graduate and post-graduate
Banerji on the health behaviour of rural population in India, and that by
education and research in these systems.
T.N. Madan on the utilization of modem medicine, reveal that the use of
Integration of the practitioners of these systems in the mainstream
health care delivery system.
Indian Systems is second to that of modem medicine. According to
Banerji the Indian Systems are used either side by side with allopathic
medicine, or after allopathic medicine fails to give benefit, or when
Encouragement of research and standardization of indigenous
allopathic services are not available or accessible due to various
drugs and their production.
reasons, or most frequently when the illness is of a minor nature. T.N.
The utilization, conservation and regeneration of medicinal
Madan points out, that for the majority, the first preference is allopathy
plants.
The VIII th Plan reiterates the policy regarding the Indian Systems
(Gupta G.R. 1981). According to a recent report, the bed occupancy
rate in the Patiala Ayurvedic Hospital declined from 100 percent in 1978
of Medicine that has evolved from the recommendations of various
to 32 percent in 1991-92. From 1967 to 1991-92, the daily outpatient
committees appointed right from 1920. At that time, the Indian National
number declined from 200 to 60 (Hindustan Times, 10-6-93).
3.
4.
Congress, leading the nationalist movement, had resolved to regenerate
The NCAER studies covering all parts of India show that there are
Indian Systems of Medicine, (this excludes homeopathy) the role and
no regional variations in the utilization pattern. Eighty percent of the
status of which had declined under'colonial rule. But attempts at
illness episodes in the urban areas and 75% cases in the rural areas
promoting ISM have never been wholehearted. Though the ‘populist*
were said to be treated by allopathy. Only 8% of cases were treated by
model with its emphasis on the development of indigenous system
ayurveda in rural areas. In case of 60% cases treated by allopathy, the
gained government’s increasing acceptance during late 1960s and
perception was that the allopathic treatment was fully effective.
early 1970s, the ‘professional* model representing the interests of the
According to the KSSP study in rural Kerala the utilization of allopathy is
allopathic system dominated the policy of health personnel
72% compared to only 10% of ayurveda. Our own observations during
development. (Rushikesh M. Maru, 1985). In spite of the rhetoric of
our field study in Ahmednagar district appear to corroborate some of
developing Indian Systems, financial support in terms of the percentage
these findings.
6)
share of ISM in total health outlay decreased substantially from 4.34%
in the IVth Five Year Plan to 1.12% in the VIII th Five Year Plan.
Against this background of attempts at regenerating interest in ISM
this article looks at the ground reality and the role of ISM (shastrid or
institutional and not ‘folk*) as an alternate form of healing in health care
delivery; The reality suggests a downward trend in the role of ISM in
health care delivery as reflected in the declining utilization of these
systems in rural areas, precisely where policy makers seek to extend
and justfy its promotion. An inter-related factor contributing to this trend
is cross-practice on a large scale by traditional practitioners.
Ahmednagar District: field experience
Impressions gathered during a study on ‘Health Investment and
Expenditure in a District*, being conducted by FRCH in the Ahmednagar
district, demythify the widely held notions about the use and popularity
of traditional medicine. The census of health resources conducted in the
district, a series of workshops on health economics involving urban and
rural practitioners of all systems, two rounds of postal surveys, and the
actual investment and expenditure study—all combined, threw light on
issues concerning education and research facilities for traditional
Utilization of ISM
It is claimed that traditional medical practitioners are the “basic
providers of health care, to 80% to 90% of rural population, in countries
in South Asia and Africa” (Philips D., 1990). For instance, 80% of
population in Tamil Nadu is said to be covered by traditional / indigenous
practitioners (Ramesh and Hyma,1981, as referred by Philips). This
wide use of indigenous medicine is attributed to factors like
inaccessibility to modem medicine, the cultural acceptability based on
the indigenous notions of body, physiology, diet and aetiology of
diseases.
medicine, its utilisation, the problem of integration of ayurveda
practitioners in the primary health care delivery system, and the practice
of ayurveda medicine.
Our observations relate specifically to the low utilization of Indian
Systems, the high proportion of cross-practicing among ayurveda
practitioners and the preference for setting up practice in urban or rural
areas. The impressions gathered from tile field experience are that
economic factors determine the practice of ayurveda medicine and the
geographical location of ayurvedic practitioners. Economic and popular
demands lead to cross-practice among ayurveda practitioners. The
rural location of a majority of ayurveda practitioners is also the result of
the open and tough competition from allopaths in a market economy.
The authors are researchers at FRCH, presently working on
the project, ‘Health Investment and Expenditure in a District*.
FRCH NEWSLETTER, VOL VII, NO. 5, SEPT. - OCT. 93
Ahmednagar district has an ayurveda college established seventy
six years ago. Yet we faced great difficulty in selecting samples of
8
0))
‘ayurveda practitioners' to study their pattern of investment and
production resulting in high costs of drugs. On the other hand, because
expenditure in the provision of medical care. During our visits to the
of a large scale production and even the circulation of sub-standard
district and taluka places, we found that medical shop owners, officials
drugs, allopathic medicine is relatively cheap, hence economical and
in government health services and even medical practitioners could not
therefore preferred by the practitioners. It also gives a quick relief to the
provide reliable information about the qualifications of doctors practicing
patients especially in rural areas, who cannot afford to lose their working
in their locality. Why was this so? One of the reasons appeared to be the
days because of illness. Because of this demand for allopathic treatment
rampant cross-practicing by ayurveda trained practitioners.
from the patients, the non-allopathic doctors lack the opportunity to
prove the efficacy of their particular system of medicine. Economic
pressures and market competition force non-allopathic practitioners to
Cross - practice
submit to cross-practice. This was the general reason given by the
Several ayurveda graduates were stated to possess allopathic
qualification. The confusion arose from doctors practicing allopathy
instead of the system of medicine they were formally trained in. During
the sample check to verify our census list not a single doctor practicing
Indian Medicine could be found. None of the eight BAMS doctors
interviewed practiced ayurveda.
participants in the workshop for cross-practice by traditional doctors.
It was also observed that some medical qualification was primarily
sought to gain legitimacy. Any valid or even suspect and doubtful
degree, would do to start medical practice. In the majority of cases this
practice was of allopathy. This explains the spurt in non-allopathic
medical colleges in the district over the last few years. To set up a non-
Out of the thirty-one ayurveda graduates contacted for the
investment study, only five claimed that a certain proportion of their
practice was of ayurveda. Only two of them were found to be advocates
of pure ayurveda pracatice. One ran an ayurveda hospital while the
other owned and operated a manufacturing unit of ayurveda drugs.
Both had plans to establish bigger institutions and plantation schemes
for ayurveda drugs. Noticeably all the pure practitioners were situated in
the two towns of Ahmednagar and Kopargaon. This suggests that the
increasing trend from metropolitan and larger cities, of seeking alternate
systems of treatment, has reached smaller urban areas. A few of the
practitioners from our overall sample told us that they used ayurveda to
treat certain chronic illnesses but resorted to allopathy for the survival
and continuation of their practice.
The response to the questionnaires mailed to 3000 and odd doctors
listed with us was seventeen percent. From amongst these respondents,
a total of 221 had degrees in ayurveda, of which 147 were graduates in
pure ayurveda and 74 had degrees in integrated medicine. Of the total,
only twenty-two percent claimed to practice ayurveda alone. The
remaining practiced only allopathy or allopathy in combination with
other systems (Table I). We had no means of verifying the claims of all
those who said they practiced ayurveda alone. From amongst those
practicing a combination of systems, the proportion of ayurveda practice
allopathic medical college is much cheaper and easier than setting-up
an allopathic medical college. The non-allopathic medical education is
in demand because it is cheaper than allopathic medical education but
in no way a hindrance to allopathic practice and money-making. This is
a serious menace to the future development of ayurveda as an alternate
system of medicine, with a status of its own.
The threat to traditional practice is aggravated when attempts are
made to legitimize cross-practice. In spite of the Supreme Court's
recent decision, overruling the verdict of Kerala high court allowing
allopathic practice by non-allopath practitioners, the Maharashtra
Government issued an order on 25th November 1992, allowing
ayurveda graduates to practice allopathy. No arguments can be put
forth in favour of the Maharashtra Government’s decision which is
detrimental to the survival and cause of Indian Systems of Medicine as
an alternate form of treatment.
As if to further lower the status and esteem of ayurveda the Health
Secretary of Maharashtra, Mr. K.S. Sidhu, is reported to have said that
the government is ‘compelled’ to appoint the 'non-allopathic' qualified
personnel to fill up the posts of class II medical officers in the state
(Saka/, 13.8.93). This is an account of the reluctance on the part
allopathic graduates to join government health services. The specifics of
how integration of the systems can take place in the health service,
to that of allopathy was not known.
One of the reasons cited for decline of ayurveda was that the
system appeared stagnant and was perceived as being not based on
modern scientific principles. But there was also the problem of limited
facilities and opportunity for research in the system. Dr. Arun Shitre, an
ayurveda academician from the district lamented that the research
being done in ayurveda was quite limited in spite of great potential. One
of its practical reflections was the relatively small scale of drug
while still retaining the autonomy of ISM have never been outlined by
the advocates of integration. There appears to be some confusion about
the concept of integration. The emphasis is on co-opting the traditional
practitioners into the health services without any clear understanding of
how traditional medicine would meet the demands of basic health care.
The VIII th Plan for instance says that one way to overcome the
backlog of Sub-Centres, PHCs and CHCs is, “Re-organisation of the
Indian Systems of Medicine and Homeopathy (ISM & H) dispensaries /
hospitals in rural areas to create ISM & H health centres ..." and that
TABLE 1
SYSTEM OF PRACTICE
“the training of doctors of ISM & H will also be reviewed and reoriented
to make it congruent with the needs of national health programmes and
Degrees
System of Practice
Nos.
primary health care." It is difficult to fathom how this approach is likely to
Combination
Ayurveda
regenerate interests in indigenous medical science and redeem its
ALLOPATHY
ALLOPATHY
AYURVEDA
& AYURVEDA
&AYURVEDA
& HOMEOPATHY
& HOMEOPATHY
Ayurveda
Integrated
Medicine
147
45
99
2
declining status. The oft-repeated argument which finds place in the
Plan that, “These practitioners are close to the community not only in
geographical proximity but also in terms of cultural and social ethos and
1
as such they can play significant role in primary health care delivery”,
shows an astounding lack of understanding of the actual conditions.
74
3
71
1
•
A recent report says that an experiment is underway to integrate the
three main systems of medicine in health care delivery without affecting
Total
221
48(22%)
170(77%)
2
Note: This information relates to the ayurveda respondents to mailed questionnaires
9
1
adversely the autonomous status of any of the systems. This experiment
is being tried out in some hospitals in Kerala. The hospitals are
FRCH NEWSLETTER, VOL. VII, NO. 5, SEPT. - OCT. 93
attempting to integrate the different systems in the provision of medical
TABLE 2
GEOGRAPHICAL DISTRIBUTION
care through joint panels. These panels of doctors from different
systems examine the patient thoroughly and later provide the most
Place of Practice
PRACTITIONERS
appropriate treatment from the relevant system (.Times of India, July
1993).
Native
Overall
Nos.
Degree
U
R
U
After Migration
R
R
U
%
%
%
Geographical Distribution
We observed that socio-economic factors lead ayurveda graduates
Allopathy
132
60
40
28
19
32
21
Ayurveda
221
37.5
62.5
23.5
34.5
14
28
to set up practice in rural areas. According to our census, 52% of a total
of 1275 Indian Systems practitioners in the district are located in the
rural areas as against 37% of 959 allopathic practitioners. This shows
Note: This information relates only to the respondents of our mailed questionnaires.
the clear preference among allopathic graduates to be located in urban
areas and a higher tendency among ayurveda graduates to practice in
rural areas.
A point of clarification for the data in Table II is required. Migration to
urban areas has taken place mainly from rural areas, although a few
second preference. Thus the medical education system itself has given
may have moved from one town or city to another. The migration of
a secondary position to the non-allopathic system.
allopathic practitioners to rural areas can be explained as of doctors
who are employed in rural government health services, health units run
Conclusions
by missions or trusts or in some cases where those who were earlier
Much more, than a mere reiteration of the same old policy over the
employed by these agencies later retired or resigned to set a practice in
years, needs to be done to save ISM from degenerating into a 'dead
rural areas where they were posted. A few amongst these had a rural
science' or mere quackery. Perhaps it can be done in terms of providing
background. In the case of ayurvedic practitioners who migrated from
substantial material support, or perhaps in terms of a more honest
their native places to set a practice in rural areas, most had a rural
implementation of the policy. For too long, has the government taken for
background. Only a few were earlier residents of urban areas.
Participants in the workshops discussed the reluctance of allopathic
granted, the natural cultural affinity of the people for ISM, ignoring that
the traditional medicine is holistic and organically linked to social and
graduates to setting - up practice in rural areas as against compulsions
economic conditions of a different kind and time. Planners and policy
amongst the graduates of non-allopathic systems, to be based in rural
makers have turned a blind eye to the socio-economic and political
places. The participants with allopathic degrees from rural and semi-
factors which have no less significance for the development of ISM.
urban areas cited various reasons for their preference for urban areas,
The Indian government, under the dictates of the World Bank and
namely, the rise in their material expectations corresponding with those
the IMF, has undertaken a structural adjustment programme to liberalise
of their urban colleagues; knowledge of their market potentials in the
the economy. Austerity measures have included a substantial curbing of
urban areas and that a high standard of living, unavailable to them in the
rural areas, is within their reach. Non-allopathic practitioners complained
government expenditure in the social sector while the VIII th Plan clearly
states, "In accordance with the new policy of the government to encourage
about the poor standards of educational facilities, available to them as
private initiatives, private hospitals / clinics will be supported...”. It is too well-
as compared to those available in the allopathic colleges. The
known that any private initiative in the face of cut-throat competition in
accommodation, mess and teaching facilities, they said, are so poor that
an open market will resort to survival tactics, compromising principles.
as soon as a student gets his degree he prefers to go back home, even
The opening economy, which will further commodify health, is hardly
if it is in the rural area.
conducive to the practice of traditional medicine, indeed to its very
The more practical and economic reasons for this tendency were
survival. This is so, considering that its utilisation is declining, and that
also mentioned. In the towns, with the availability of allopathic
the practitioners themselves have a weak commitment to their own
practitioners, the demand for non-allopathic graduates practicing
medical science. They also appear to suffer from a low esteem
allopathy was relatively low. In the urban areas their status would
regarding their own status in the health care delivery system and the
always remain second to that of allopathic graduates. Ayurvedic
wider society itself. Obviously there is a gap between rhetoric, popular
graduates choose to work in urban hospitals for a short duration, to gain
beliefs and ground reality.
experience in allopathic treatment. On the basis of this experience
gained, they return to their rural homes to practice allopathy and to earn
References:
fulfledged status and prestige of a 'doctor*. They also have the
advantage of family contacts to carve out their clientele. They have the
1.
Baneiji D., Historical and Socio-cultural Foundations of Health Services System, Main
2.
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3.
Kannan K.P. el al, Health and Development in Rural Kerala: a study of the linkages
4.
Madan T.N., Who Uses Modem Medicine and Why; Main Currents in Iridian Sociology,
Currents in Indian Sociology, Vol. IV., Vikas Publishing House, Sahibabad, 1981.
additional advantage of supporting their income through agriculture or
inherited business. Besides, clientele is assured to them as the people
in rural areas, as mentioned earlier, prefer allopathy for quick results.
Considerations such as ancestral or agricultural property do not appear
between socio-economic status and health status, KSSP, 1991.
to compel allopathic graduates to return to their rural homes and set up
practice. But the general observation was that a very few allopathic
Vol. IV., Vikas Publishing House, Sahibabad, 1981.
5.
Mani R.M., Policy Formulation as Political Process: a case study of health manpower,
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1949-75, Public Policy and Policy Analysis in India, Sage Publishers, New Delhi, 1985.
practitioners came from an agricultural family or a rural background. In
the case of ayurveda graduates the general finding was that the majority
had a rural background. This suggests that people who have no access
to allopathic education, take up non-allopathic education, and only as a
FRCH NEWSLETTER, VOL VII, NO. 5 , SEPT. • OCT. 93
Policies Making Ayurveda Extinct, Hindustan Times,10.6.93.
7.
Sakai, 13.8.1993, Pune.
8.
Selected Chapters From the 8th five Year Plan Document of the Govt Of India,
VHAI, New Delhi, 1993.
•
10
YOGA AND HOLISTIC HEALTH
ShashankOak
A new approach has become popular among cancer patients and
therapists in the United States in the past ten years or so. This 'new*
approach is the result of the path-breaking study made by Dr. Carl
Simonton with Dr. Stephanie Simonton and the publication of their
book, ‘Getting Well Again’, in 1978. Cancer patients saw a ray of hope
in Simontons’ work and thronged their workshops in large numbers.
The work done by voluntary support groups like ECaP ('Exceptional
Cancer Patients' is a voluntary self-help group formed by cancer
patients in the U.S. under the guidance of Dr. Bernie Siegel) and the
best-selling books written by Dr. Bernie Siegel (Love, Medicine and
everyone of us participates in his health or illness at all times. A person
does not become ill because of some accident or because he is unlucky.
A disease does not catch people — they catch it by becoming
susceptible to it. This idea is not new. Hippocrates had once remarked
that he would rather know what sort of a person has a disease than
what sort of a disease a person has. Louis Pasteur and Claude Bernard
argued throughout their lives as to whether the most important factor in
disease was the ‘soil’ — the human body—or the germ. On his death
bed, Pasteur admitted that Bernard had been right, declaring, ‘It is the
soil’.
Miracles, 1986; Peace, Love and Healing, 1990) and by Dr. Deepak
It is recognised nowadays that an illness is not purely a physical
Chopra (Quantum Healing, 1989) further highlighted this approach and
problem, but rather a problem of the person as a whole. It affects not
made it even more popular among people. As a result of this, it has
only a specific organ or a system, but the entire body and mind.
become quite common to see cancer (and now AIDS) patients
Emotional and mental states play a significant role in making a person
meditating seriously; special programmes being shown on closed -
susceptible to disease and in his recovery from it. A disease, thus, is
circuit TVs in hospitals teaching patients the art of relaxation and
only an outward manifestation of some deeper problem in a patient’s
visualisation; patients carrying audio-tapes in operation theaters to be
life. These problems result in an emotional state which triggers a set of
played during the operation giving positive, healing messages to the
physiological responses which suppress the body’s natural defenses
anaesthesised patient; etc. In other words, it became a fad with the
and make it susceptible to illness. This change takes place through the
Americans and has made a number of doctors and writers extremely
central nervous system, the endocrine system and the immune system.
Now, if the state of the mind changes the state of the body, then it
rich.
can be a double-edged sword. If it cuts one way, it can be made to cut
Conceptual Basis of the ‘New’ Approach
Any serious student of yoga will notice a number of things
immediately, if he examines this approach. First of all, this so called
the other way. In other words, if a patient participates in the process of
getting well, then he will certainly improve his chances of getting well. If
the mind gets involved in the healing process, a miraculous healing can
take place. This can be achieved through simple visualisation exercises.
'new* approach is not new at all. The principles which these people
have ‘discovered’ have been known to us for a considerable period of
time. (In fact, the American doctors and scientists came to think about it
Yoga Techniques and Visualisation Exercises
after witnessing the miracles performed by some Indian yogis. They
The patient is first taught simple relaxation exercises and
developed the new technique of bio-feedback after interviewing these
meditation. This prepares him to be able to relate to and communicate
yogis). It will also be obvious to a serious student of yoga that the
with his body effectively. Then he is taught to visualise his disease in
visualisation exercises designed by these Americans are extremely
some form. For example, he forms a mental picture of his malignant
complicated and difficult for the patient to practice. We, the Indians,
tumour as a black mass of weak and disorganised abnormal cells. At
with our knowledge and understanding of yoga, will be able to design
the same time he is asked to visualise his therapy in a positive way. If he
exercises which are much more simple and effective (as I have done
is undergoing radiation therapy, then tig process is seen as millions of
over a number of years). Unfortunately, all this is being given serious
tiny, silver, bullets of energy which would hit all the cells in his malignant
thought in the United States and is being ignored or ridiculed in our own
tumour, destroying them. Then the patient is taught to form a mental
country. But this cannot be helped. We can only hope that as problems
picture of the most important process — his own white cells coming in,
become more severe and as the effectiveness of this approach gets
demonstrated, people will be forced to open their eyes to these age-old
swarming over the cancer cells; picking up and carrying off these dead
cells, and flushing them out of his body through his liver and kidneys.
techniques and utilise them fortheir physical, mental and spiritual well
Then he is supposed to ‘see’ his tumour decreasing in size and his
being. The idea behind this approach is very simple to understand,
health returning to normal.
though it may be a little difficult to practice. The basic idea is that
All this sounds very, very simplistic; but the results are so fantastic
that one cannot ignore it. This has opened totally new possibilities for
the treatment of, not only cancer but any disease. Once the basic idea is
The author is a lecturer and has written a book on industrial
Democracy’ and a novel in Marathi. He is a keen student of
yoga and a yoga therapist - presently concentrating on treating
the cancer patients.
11
understood, similar visualisation exercises can be designed for any
other disease and it can be used with a considerable degree of success.
contd on pg.12
FRCH NEWSLETTER, VOL VII, NO. 5 , SEPT. - OCT. 93
LIBRARY NEWS
Books
1.
Bhatia J.C., Dynamics of Contraceptive Use: a study in Karnataka
State, India, IIM, Bangalore, 1991, pgs.44.
2.
Chakravarty S.,'Selected Economic Writings, OUP, New Delhi,
3.
1993, pgs. 580.
DabreoD.A., Ideology and Process of Participatory Evaluation, ISI,
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Ramachandran L, Handbook of Management for Primary Health
Centre Personnel, Vikas Publishing House Pvt. Ltd., New Delhi, 1993,
12.
pgs. 108.
Ramchandran L and Dharmalingam, T., Health Education: a new
4.
New Delhi, 1993, pgs.121.
Dreze J. and Sen A., Hunger and Public Action, OUP, Delhi, 1993,
13.
278.
Rohde J., Chatterjee M. and Morley D., Reaching Health for All, OUP,
5.
pgs.373.
Jolly D. and Gerbaud I., The Hospital of Tomorrow, WHO, Geneva,
14.
Delhi, 1993, pgs. 524.
Saxena E.D., Child Abuse: a growing concern, VHAI, New Delhi,
6.
pgs.55.
Kananaikil J., Scheduled Caste Converts in Search of Justice, Part
15.
1993, pgs. 36.
Sehgal P.N. and Singh V., HIV and AIDS: what everybody should
7.
3,I.S.I, New Delhi, 1993, pgs.80.
Nayak R., Boal B.M. and Soreng N., The Juangs: a handbook for
16.
know, VHAI, New Delhi, 1993, pgs. 24.
SenguptaS., Proceedings of the National Seminar on Sustainable
8.
development,I.S.I., New Delhi, 1993, pgs. 226.
Padmanabhan A., Mandal Commission Judgement and the
17.
Agricultural Development, VHAI, New Delhi, pgs. 146.
Singh K., Intellectual Property Rights on Biotechnology: a status
18.
report, Biotech Consortium India Ltd., New Delhi, 1993, pgs. 130.
Training needs Assessment of Indian Systems of Medicine and
approach, Vikas Publishing House Pvt. Ltd., New Delhi, 1993, pgs.
Scheduled Castes and Scheduled Tribes, ISI, New Delhi, 1993,
pgs.45.
Prabhu K.S. and Chatterjee S., Social Sector Expenditures and
9.
Homoeopathy Practitioners for Delivery of Health and FW Services
1992, pgs.73.
Puri R.K., Sethi G.R., and Ramji S., Early Childhood Mortality and
19.
in Bihar, ORG, Baroda, 1992, pgs.59.
WHO, Health Research Methodology: a guide for training in
Perinatal Period Management in Urban Poor, MAMC, New Delhi,
20.
research methods, OUP, Delhi, 1993, pgs. 252.
Wishwakarma R.K., Health Status of the Under-previleged, Reliance
Human Development: a study of Indian states, R.B.I., Bombay,
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Publishing House, New Delhi, 1993, pgs. 283.
1991.
contd from pg. 11
contd from pg. 7
The reason why this approach becomes so effective is very simple to
10. Most healers are getting old and there is not an adequate
replacement by younger persons. The formal education level of
understand—it helps the patient to tap the infinite healing energy at his
disposal that lies dormant in his unconscious mind. Modern medicine
places such a great emphasis on technology that the inherent healing
powers a patient has; often go unnoticed. Of course, this does not mean
most healers is very low..
11. It is universally felt that magical powers are instantly lost if one
actively seeks for material gain through this service; Powers are
that we should dismiss the advances medical science has made. It must
be remembered that the conventional methods and these so called
‘alternative* techniques are not mutually exclusive. These ‘alternative*
techniques are not to be used at the expense of or to the exclusion of
lost, if one prematurely teaches anyone else, the art.
12. Most healers say that their esteem in people’s eyes is positive
because of this service that they render to the community; the
the conventional methods. They should, however, complement them
reaction of their family members is also usually positive. Family
members seem to be more in awe of those skills which involve
and enhance their efficacy. This is to be done by teaching the patient not
to receive the treatment being given passively, but to become active in
rituals. When hard work requiring long hours, or menial work like
the process of getting well and to assume the responsibility to cure
attending to animals is involved, they are sometimes resentful.
himself. He is to be encouraged to mobilise his internal resources, so
that true healing can occur.
I came across Dr. Simonton’s Work due to my interest in yoga
Acknowledgments
1.
The Indian Council of Medical Research (ICMR) forgiving the opportunity to stay in Malshiras
2.
for five years.
Bhanudas Jadhav; our colleague on the project, for helping with data collection.
therapy. Thereafter I have developed a number of exercises and have
helped a number of cancer patients with considerable success.
However this Work was done on a personal level, arid it Will require the
foundation of methodical research on a bigger scale to arrive at definite
conclusions. A lot of research is being done in the West and the results
are available. The results are mostly positive. But nobody has
undertaken a Similar study in our country. If research in this area is done
in our country, there is a possibility that the results will be better than
those in the West. This is because, we have more effective and
penetrating techniques at our disposal—due to our knowledge of yoga.
It is time that somebody takes the initiative to base these techniques on
a scientific foundation.
IS
FREE ABSTRACTING
The contents of this newsletter may be
abstracted without prior permission. However,
we would welcome acknowledgement of the
source and copies of any abstractions.
Edited by Rohini Lele, with secretarial assistance from Anita Nair and Sushama Joshi. □ Produced by the Foundation for Research in Community Health,
84-A, R.G. Thadani Marg, Worli, Bombay 18. (Registered under the Bombay Public Trusts Act.) □ Printed at Printext Offset, Pune 30.
O]
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