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I—v I—
Vol. X No.'2^^—
MD (UM Io) CM® y'
/a Bimonthly of the Voluntary Health Association of India
APRIL 1984
At the time of the
crusades, Godefory de Bouillon,
Duke of Lorraine, had placed the
Double Red Cross on his stan-
HEALTH FOR THE MILLIONS
Vol X
No. 2
April 1984
Pg. ■No.
-O-~
In this issue:
i
Mira Shiva
TB—How much do you know?
This issue of HfM was
put together and
^6
Mona Daswani
■
produced by
Augustine Veliath (Editor),
Aspi B. Mistry, Mira Shiva,
Chandra Kannapiran, Gloria David,
Padam Khanna, P.T. Thomas,
A Profile of Tuberculosis
•
•
10 *
Mira Sadgopal
Health "Care" vs The Struggle for Life
16
Indira Kotval
A Tuberculosis Control Programme
26
J.S Majumdar
Producution of Anti-TB Drugs
31
Annie George
Better Care in TB
36
VHAI Information Service—
Facts on File
46
L.K. Murthy and P. George.
Owned and published by the
Voluntary Health Association.
of India, C-14 Community Centre,
S.D.A. New Delhi 110 016 and
printed at J.K. Offset Printers,
Jama Masjid, New Delhi.
(Continued from Cover)
dard when he took possession of Jerusalem in 1099, and, after his return to France
it became the emblem of the House of Lorraine.
The Double Red Cross was considered singularly appropriate as the rallying sign
for the crusade against the most deadly scourge-Tuberculosis-which afflicts man
kind. Proposal for its adoption as the International Emblem of the campaign against
tuberculosis was moved by Dr. Sersiron, on October 23, 1902, at the International
Tuberculosis Conference in Berlin. The proposition was adopted unanimously.
The Council of the International Union Against Tuberculosis, Paris, in September
1928, decided that National Associations which are members of the Union should
adopt this emblem with a recommendation to the effect that it be legally registered in
order to prevent its use for commercial purposes.
In 1957, the Tuberculosis Association of India requested the Ministry of Commerce
and Industry, Government of India, to patent the Doub.e-Barred Cross in favour
this
Association and against fraudulent use of this emblem by others The Central r
ment by their Notification No. 4 (3J-TMP/57 dated 13th h i
iaro entral Govemsectionof the Emblems and Names the IDouble BarrenPr
‘ ,nC,uded
the
-Tuberculosis Association of India.
Double-Barred Cross as the emblem of the
The TB Situation in India
"1/ the eignificance of a disease is
measured by the number of victims
it
claims,
then all other diseases ... must
rank far behind tuberculosis. Statistics
shorn
that half of mankind dies
from
tuberculosis
and that, when only
the
middle, productive aye groups are consid
ered, it carries off one-third and more.
The public health services thus have reason
enough to devote their attention to so
deadly a disease .,. It therefore seemed a
pressing duty, above all else, to institute
detailed investigations into tuberculosis"
(Koch, 1882)
Mona Daswani, "A Profile of Tuberculosis,
Page 10)
are to form the basis of the
strategy against tuberculosis, much more
commitment is required in terms of re
sources, both material and human. While
the Sixth Plan outlay, for the National
Tuberculosis Programme is Rs. 7 crores, it
has been estimated that nearly Rs. 55
crores is actually needed if the programme
is to be really effective.
Notwithstanding the fact that TB control
is now part of the 20-point Programme,
"every time demands for increased funds are
made, the government trots out its old
When Robert Koch was writing these words excuse that finances are hard to come by".
more than a 100 years ago, tuberculosis had Writing in the Sunday Observer (11-17 March
already started declining in western coun 1984) Nikhil Lakshman reports further that
tries as a result of the improvement in the this is" a defense deflatea by the esti
standard of living. Yet very recently the mates committee’s findings that, except for
World Health Organisation was moved to 1977-’78, the actual amount spent on health
declare that "the world is experiencing an has always been half the proposed outlay.
epidemic of tuberculosis.
It is the most In 1981-’82,
for instance, the sum sanc
important specific communicable disease in tioned was Rs. 216.79 crores, while the
the world as a whole..... " It becomes
actual amount spent was only Rs.
100.85
abundantly clear that the burden of this crores. ’ Surely a part could go to fight TB
, epidemic is being borne most by the Third .... Surprisingly, in contrast,
the Bombay
Worldz where there has been no comparable Municipal Corporation (BMC) has undertaken
improvement in the standard of living and its TB programme on a war-footing. The
where the number of TB cases is increasing first organization in India to introduce
yearly.
In India it has the status of short term chemotherapy in its campaign,
killer number one,
in the hierarchy of the BMC has set aside Rs. one crore for
deadly diseases, "the Captain of all these these drugs, organised 90 diagnostic cum
Men of Death".
treatment centres and also started making
rifampicin for the city's TB patients".
In this country,
the
situation is
particularly acute.
It has been reported
We have a first hand account of one
that almost 12 million people suffer from aspect of this programme from Indira Kotval
TB, of whom nearly 6 lakhs die annually.
in Bombay ("A Tuberculosis Control Prog
By the time you have finished reading this ramme" Page 26 ) in which she describes
editorial, somewhere in India,
2 more her experience in a voluntary organisation
persons would have died of TB,
In the time working with the BMC.
it takes to read this special issue on TB,
nearly 100 persons would have died of the
In sharp contrast, in "Health 'Care
*
vs
disease. Yet only ten of chese deaths The Struggle for Life"
(Page
16 ), Mira
would have been identified as being caused Sadgopal from Kishore Bharati, in Hoshangaby tuberculosis.
bad, describes vividly, the problems in the
field,
in the rural areas,
where the
The Government's own estimate is that 10 patient is literally at the mercy of the
million are suffering from this disease, medical establishment. J.S. Majumdar (Pro
duction of Anti-TB Drugs, Page 31
)
has
but barely 10 lakhs have been identified.
dealt with the dynamics and politics of
If case'-finding and chemotherapy
(See anti-TB drug production and the role of the
HEALTH FOR THE MILLIONS
APRIL
1984
’
1
multinational^companies .
While this is planned to be a special
issue on Tuberculosis, we do not in any way
see it as the final word on the subject.
In this first part we have . laid more
■emphasis on problems in the field and
concrete experiences of individuals and
groups rather than on the medical aspects
of TB.
If the socio-economic and political
aspects seem.underlined,
this is a cons
cious effort to make this issue into a
’’curtain-raiser" for a more extensive and
in-depth debate, that we hope to follow up
in subsequent issues with the co-operation
and enthusiasm of our readers. The res
ponse to the diarrhoea issue has emboldened
us to introduce a "Readers Forum" and we
hope
that
this will be a continuing
feature. We invite not only feedback on
this issue and specifically on the script
for "Better Care in T.B."
(See Page 36 )
but also other'articles and news items both
on TB as well as on other health issues.
-Editors.
Readers’ Forum
Dear Averthanus, Mira and Augustine,
oral rehydration I believe that you
should mention the use of a naso
gastric tube before recommending the
need for intravenous fluids.
Health for the Millions, Volume 9, Nos.
5-6. DiarrhoeaJL Disease
Congratulations on a tremendous piece of
work. You have really searched the lite
rature for practical and relevant aspects
of how to manage and control this problem.
If I can make any criticism, it is perhaps
that you have tried to include too much in
one issue so that some people may be a
little daunted about where to begin. As an
old friend of VHAI, and of each of you
individually-’, I hope that you will permit
me to make a few comments about some of the
articles.
1.
2.
2
On page 3 you start with a definition
of diarrhoea which is very numerical.
The normal stool pattern has such a
wide range of variation that I always
think a practical definition is that
diarrhoea is a change from the normal
pattern, to stools which are
more
liquid, or different in consistency and
appearance etc.
to give the mother
concern.
For epidemiological studies
you may have to adopt a particular
number as a cut off point in defining
diarrhoea.
On page 17 when discussing the problem
of vomiting during administration of
3.
On pages 20 and 21 under the heading
antimicrobial agents I felt that the
lowest three asteriks do not ..seem. to
follow logically from what you have
said above and could cause confusion.
At the very bottom of the page you end
with a sentence ’’Below we give some df
the commonly misused antibiotics" and
there then follows immediately a table
of the only antibiotics recommended by
WHO! What you might have mentioned in
the section on antibiotic prescribing
is the danger of resistant organisms
from R factors and problems -arising
from inadequate dosage.
While on the subject of antidiarrhoeal
agents, it might have been useful to
give the references of two trials which '
showed that kaolin was quite ineffec
tive. I will give these below.
Recently I had reason to look through
the
literature on the antimotility
drugs including the opium, analogues
Diphenoxylate and Loperamide. They have
both
been
shown to be remarkably
effective in rats, but all the clinical
studies so far are disappointing. More
HEALTH FOR THE MILLIONS
APRIL
1984
an appropriate amount of
excellent for rehydration.
over, they are potentially dangerous in
children because of their central seda
tive effects.
7.
On pages 28 and 29 I was very interest
ed .to see the relative costs and the
large number of oral rehydration pac
kets on the market. At first I was
confused by the statement that a packet
of Electral cost 7 NP!
On page 38 you describe alternative
medicines for diarrhoea.
I have no
doubt
that some of these may
be
valuable, but perhaps it should be
pointed out that they.should also be 8.
subjected to clinical trials as applied
to kaolin and Diphenoxylate. The symp
tom pictures overlap confusingly.
In
some thirst and sweating, indicating
dehydration are not followed by any
recommendation
about
giving
extra
fluids, which we would consider impor- 9.
tant whatever medicine is being admini
stered. Symptom group G appeals to be
steatorhoea and H dysentry or possibly
giardia infection.
On page 42 you describe traditional
remedies including simple fluids. It is
now •_ known that rice congee mixed with
'Courtesy :
HEALTH FOR .THE MILLIONS
APRIL 1984
salt
is
On page 50 you deal with
certain
controversies. There are
of course
philosophical differences between
a
home and pharmacy made fluid. However,
the most important point is that for
each degree of severity there may be an
appropriate treatment. In extreme cases
intravenous fluid with precise replace
ment of lost salts and pH correction is
essential, while in the mildest cases
drinks of water can be useful.
At the bottom of page 52 you state
"two-thirds of all illnesses in India
are related to water-borne disease". I
do not believe this is true in view of
the numbers of respiratory infections
and cases of malaria.
I was happy to see on pages 60 and 61
the broad responsibilities which VHAI
feels it has in diarrhoea care. It may
be necessary to focus on a few of these
initially. In recent months I have been
particularly aware of the problem of
conflicting messages about the right
way to prepare oral rehydration fluids
and the consequent confusion in 'both
IOCU Action Pack.
3
health workers and the lay public.
I
believe there is a real need to find
what is the most appropriate message on
a
national or regional basis
and
campaign for that message. Otherwise
many different methods of mixing salt
and sugar, may result in wrong formu
lation of fluids which may be ineffec
tive or harmful. This can seriously
damage and undermine what is potentialy
a valuable and life-saving treatment.
To identify and propagate the most
appropriate method
is an
important
challenge.
With greetings and best wishes.
Yours sincerely,
William A.M. Cutting
Senior Lecturer in Child Health,
Dept, of Child Life and Health
University of Edinburgh
References:
Watkinson, M. (1982) A lack of therapeutic
response
to kaolin in acute childhood
diarrhoea treated with glucose electrolyte
solution. J. Tropical Paediatrics, 28. 306307.
Alestig, K., Trollfors, B. And Stenqvist,
K.
(1979) Acute non-specific diarrhoea.
Studies on the use of charcoal, kaolinpectin and diphenoxylate. The Practitioner
222. 859-862.
We are very grateful to Dr. Cutting for
Jiis insight and comments. As there has been
a tremendous demand for the Diarrhoea Issue
of HFM,
we are reprinting this issue in
booklet form. Needless to say,
almost all
the suggestions and corrections mentioned
above hape been included
- Editors.
Dear Sir c
The entire concept of ORT has been to reach
health care into the hands of the people,
especially the deprived sections of so
ciety. The etiology of diarrhoea and its
association with contaminated waters and
thus with poverty has been established
without doubt.
In this section, we assume that the people
who we are taking the message of ORT to aro
poor enough not to possess a measuring
spoon. And m the same breath,
in the
Indian context, that too, we expect them to
have a tin, a pair of scissors, a pencil, a
bottle cap, a glass, wood, a drilling
machine and bolts and moreover the techn
ology to measure in centimetres and to be
able to drill into wood. Not to mention
the fuel required to burn pieces of wood. A
simple question could be asked - would it
not be more economical just to possess a
simple measuring spoon rather than all
these exotic items and gadgets mentioned
above? If the poor man had enough fuel to
make a measuring spoon, his children would
have had a much lesser chance of contrac
ting diarrhoea and therefore needing ORT.
If the aim of propagating the ORT is to
make people independent then it is nec
essary to be vigilant so that no further
dependence is created on either the medical
system or on any industrialist due to the
prescription of a complicated and even
unnecessary methodology. It would be much
simpler to tell the woman to give her
dehydrated child her down to earth "nimbu
pani" and I can bet she will add just the
right pinch of salt and the proper handful
of sugar.
Sincerely,
Ms. Manisha Gup'te Awasthi
Research Officer.
The 'Foundation For Research
Health .
in
Community
This letter is with reference to your
October-December 1983
special issue on Dear Manisha,.'
diarrhoea and in particular to the section
on making measuring spoons for preparing a
Thank you for your letter.
I truly
"special drink'
.
*
I hope that section has appreciate 'the points raised by you.
been printed just as a joke,
becuase
otherwise in the Indian context it is
I must make a few clarifications first.
certainly appalling -to realise that in the HFM is geared to' 1 Health Personnel1 in the
process of demystifying medicine, what has field.
actually been achieved is only further
mystification.
I agree witn you that most poor people i
4
HEALTH FOR THE MILLIONS
APRIL
1984
do not have spoons and therefore, it is alt aspect was not dealt with here.
the more imperative that those involved in
training health workers can help the health
,
For those of us involved in health work
workers, produce for themselves standar- >in the field
*
it is painful,y clear that
dized the measures. A health worker should most of the health prob terns have their
be familiar with the differences of volumes roots in poverty. Neither ORT nor health
of salt and sugar with pinches and scoops tcare is the answer to that.
of . different individuals.
The
need to '
standardize the measures to a safe limit is
ORT alone can never be an answer to
not 'mystifying ORT. Being involved
in even diarrhoea care
*
but ensuring some
training of different levels of health change in diarrhoea management
*
in
even
personnel in the field
*
I realize the 50% health institutions
*
is definitely not
confusion and chaos that exists regarding adding to mystification.
measurements related to simple ORT.
The creation of unnecessary dependence
If rehydration is started early enough
*
by well intentioned medical technologies is
simple solution
*
weak tea
*
rice kanjee
*
any a very genuine fear Manisha
*
which I share
fluid will do. There is absolutely no need with you.
for measurements. Measurements are relevant
only for moderate and severe dehydration
I thank you very sincerely for your
and if health workers can share this in honest feed back.
turn with mothers as they are 'doing in
numerous community health programmes all With regards
*
over
*
India
I really, don't see
any
mystification.
I Yours sincerely
*
The central page that you were so Dr. Mira Shiva
critical about is from David
Werner's
'Helping Health Workers
Learn' .•
These Dear Sir,
methods have been used in Latin America
*
and I really see no reason why a little bit Recently for the first time I came across
bimonthly
publication
of creativity and excitement cannot be your
(vol. IX: No. 5added in the training programmes. Preparing 'Health for. the Millions'
these gadgets is a team building exercise 6) .
in itself
*
for the trainers and the health
It
workers. It is not at all necessary to do Let me tell you it is simply excellent.
:has made the matter of Paediatric diarrhoea
*
it
if it doesn't make sense.
management simple for me and I have also
If you read the chapter on Traditional prepared some charts out of the issue to'
*
ORS
where the rationale of rice kanjee educate my patients.
*
etc
is given
*
you will realize that the
purpose of this diarrhoea issue is not to I would request you to send me "Health for
mystify. Talking about 'nimbu pani'* nirnbu the Millions" regularly at my residential
is not very easy to buy in
all the address.
'villages
*
it costs anywhere up to 30 to 50
Dr^ Jayesn N. Jain, M.B.B.S.
paise even where available.
Our objective is to get the hospitals
who
are
VHAI members to accept
the
rationale of ORT and incorporate it even in
the Hospital situation. There is enough
material for training of VHW's and lay
people.
There is very little for doctors
and middle level workers in the field. This
issue is to fulfill that need..
Please send your feedback to:
Editorial Team
Health For The Millions
Voluntary Health Association
of India,
C-14 Cocnmunity Centre
A.
*
S.D
New Delhi no 016
Another issue of Hf/M had dealt with
water
and sanitation
*
*
therefore
that
HEALTH FOR THE MILLIONS
APRIL 1984
5
MIRA SHIVA
TB: How much Do you Know?
(For the correct answers :See page25)
8.
1.
How- many diagnosed TB
in India ?.
cases are there
4 Million
6
"
8
10
2.
How, many of
open cases?
9.
Sputum positive cases only
Suspect cases contacts
10.
11.
Incidence of TB
more common in
12.
5.
What is the percentage of
cases in the rural areas ?
The incidence of TB is
Increasing
Decreasing
Same
7.
s'
The dose of INH recommedned is
100 mg - 3 times a day
300 mg as one dose daily
TB
13; Which is the best
Tuberculosis?
diagnostic test for
E S R
Sputum for AFB
Sputum culture
X-Ray
20 %
40 %
60 %
80 %
6.
total
Short term anti-TB treatment is for
6 months
9 months
12 months
per 1000 population is
Rural areas
Urban areas
Equal in Rural and Urban areas
Treatment recommended is for
12 months
18
20
24
In India hotf many die of TB per year ?.
'10 lakhs
15
30’
50
4.
Under the National TB Control Programme
treatment is offered to
infective, i.e.
1
Million
1.5
"
• .
2.5
3.5
3.
Free
On payment
•
them are
Under the National TB Control Programe
diagnostic facilities and treatment are
supposed to be offered
•14. Is Mantoux ( P P D testing) recommended
as part of the National TB Programme ?
Yes
No
The number of TB cases is
15. Is B C G recommended ?
w
Increasing
Decreasing
Yes
No
HEALTH FOR THE MILLIONS
APRIL 1984
1'6. The incidence of TB started falling in
UK in early 20th century because of
20.
Improved socio, economic status
Anti TB drugs
Vaccination
What kind of a problem is TB ?
PhysicalPsychological
Economical
Social
AH
‘
17.
The highest incidence' of TB in the
world is in India and highest in the 21. In a district of 5 lakhs population how
community of
many cases of TB can be expected to be
found ?
Tribals
Tibetans
100
250 ’
Katkaris
500
18. How many people does' an infective TB
case ( not on treatment)
infect in one 22. The health budget as a percentage of
year on an average ?
the total budget in the First Five Year
Plan (1951-56) was
2
4
2.6 %
3.0 %
3.3 %
8
10
19.
One out of how many cases
cough is a case of TB ?
20
25
30
35
of chronic 23.
The health budget in the 6th Five Year
Plan (1980-85) is .
1.2 %
1.9 %
2.0 %
24.
The percentage of population
below the poverty line is
being 30.
10 %
40 %
50 %
80 %
25.
27.
have
MOST •
Sita with marasmus
Gita (3 years) with a rising weight
curve
In a child; where would you most often
expect to see lymph nodes enlarged by
TB ?
Munni with kwashiokor
Buntu Who
recovering
31.
Which of these is true ?
is underweight
from measles
and
is
An adult with infectious TB is usually
Completely well
All patients with TB are infectious
so ill that he has to stay in bed
Patients are only infectious if
live TB bacilli are leaving their
bodies .
32.
Well enough to work
A primary TB infection USUALLY causes
Severe symptoms
No symptoms
Mild symptoms
28.
children
Poonam who is newborn
In a child's neck
In the axilla
In the groin
Under the jaw
26.
Which of these
immunity To TB
Which of these diseases is LEAST likely
to cause difficulty when you are trying
to diagnose TB ?
Malnutrition
Cerebral malaria
Which of these children is most likely
to have TB ? The child who
Chronic pyogenic lower respiratory —
infection following measles
has had mild fever and a cough
a week -
for
Chronic urinary infection
swellings in
his
Chronic pyogenic lower respiratory
infection following whooping cough
has had tender
neck for 3 days
33.
does
not recover several
after whooping cough
weeks
Will not become1 ill with TB
Is legs'likely to become
TB . than a child who has
given BCG
has otitis media
has a chronic
infection
upper
A child who has been given BCG
respiratory
34.
ill
not
with
been
used
for!
APRIL
1984
BCG contains
TB presents as the child who
is not well and has had mild
and loss of weight
Toxoids
Living organism
Dead organism
Antibiotics
fever
has chronic abdominal swelling
35.
has had a high fever for 4 days
passes blood in his stools.
Which of these is not
preventing or treating TB ?
Thiacetazone
HEALTH FOR THE MILLIONS
BCG
Penicillin
Isoniazid
PAS
36.
Which of these is true ?
TB in"children seldom presents as a
cough with blood stained sputum
A different kind
infects children
TB is a
children
of
TB
been well for 4 weeks and who has
lost two kilos in weight.
38. Harsha ( 3 years ) had pneumonia four
months ago. He was treated with peni
cillin and he recovered a little but he
still had a cough and fever and was
losing weight. He was given INH for 3
months and is now much better. Should
he
organism
more chronic disease
Stop his INH
Go on with it for a year.
in
39.
Children get TB
often than adults
meningitis
less
Which- of these diseases
slowest ?
Cerebral malaria
Tuberculosis
Tetanus
Septicaemia
Diarrhoea with dehydration
Children infect one another whereas
adults do not
37.
Which of these
to have TB ?
children is most likely
40.
Prabha
(6 months) who has had a
cough for 3 days with respirations
of 80 per minutes
kills children
Tara is 3 years old. His elder brother
(21 years)
is sputum positive. Tara
himself has no symptoms. He should be given BCG and
care register
Usha (5 years) with chronic abdomi
nal ‘ pain who has gained a kilo in
the last six months
put on the special
told that, there is no need to worry
and sent home
Asha
(18 months) who is always
coughing and wheezing and who has
gained 3 Kg during the last nine
months
given PAS (aminosalicylate) only
Vidhya (2 years, 38.2 C)who has not
given streptomycin only
given
streptomycin,
and isoniazid
thiacetazone
LIFE SKETCH
ROBERT KOCH was bom on 11 December 1843/ in Clausthal villa^ in
the state of Hanover in Germany
*
He qualified as a Doctor from
Gottingen University in 1866. He set up a primitive laboratory in
his own backyard from where he launched a memorable hunt for mic
*
robes
He succeeded in isolating and demonstrating the microbe and
proved it to be the cause of TB ih just one year. He called it the
"Tubercle Bacillus11 *
Koch is known to have visited J.J. Hospital in Bombay and the Ins
titute of Veterinary Research in Mukteswar (U.P.). In 1905 he was
awarded the Nobel Prize in Medicine for his work on Tuberculosis
*
Koch died of a sudden death caused by cardiac arrest on 27 May 1910
*
(From Swasth Hind, June 1982)
HEALTH FOR THE MILLIONS
APRIL
1984
MONA DASWAN1
A Profile of Tuberculosis
Tuberculosis has been known to man from
ancient times; the earliest medical name
was,
"phthisis", derived from the Greek
word literally meaning to waste away. In
1882> Robert Koch identified the cause of
the disease to be the tubercle bacillus.
Today we have all the weapons required for
control of the disease:
the BCG vaccination
tive measure
as
a preven
X-rays and laboratory analysis to
facilitate detection
effective
llus.
drugs
against the baci
However, TB continues to be a major health
hazard in the developing world.
In India
alone there are an estimated 12-15 million
people who suffer from TB, resulting in
half a million deaths per years (2) '.
I
X-ray of the chest which will show
a shadow, known as infiltration
presence of bacteria in the sputum
(distinguish between
saliva and
sputum, which is coughed up spont
aneously from the lung in
the
morning)
tuberculin or Mantoux test; if a
person has a natural resistance
they will show a positive reaction.
From the point of view of disease
control at a national level, there are two
fundamental issues to be considered
:
whether to choose-a preventive measure such
as mass immunisation; or detection of all
infectious cases and treatment of these by
chemotherapy. The pros and cons must be
carefully analysed in the context of each
particular disease.
Disease Control
The main source of the infection is a
person who has already contracted
the
The BCG vaccine against TB has been in
disease.
IT is transmitted when droplets use since 1921. However, the effectiveness
containing the bacilli coughed into the air is still a matter of countroversy. A recent
are inhaled by a healthy person(3). These study was conducted by the Indian- Council
droplets pass into the lung where- the
bacilli are able to multiply. Although the
most commonly affected organ is the lung,
the
infection may also occur in
the
kidneys, bones, meninges or even be dis
seminated throughout the body.
It
is
estimated that an individual who is a
moderately infectious case is capable of
infecting 10-12 other individuals within a
period of one year (4).
If such a case is
not treated, the person will survive for
about two years: during this time 20-25
healthy individuals face the
risk
of
infection.
The leading clinical
symptom is a
persistent cough. This may be accompanied
by fever, fatigue and loss of appetite. A
complete clinical diagnosis of TB is done
by:
10
HEALTH FOR THE MILLIONS
APRIL
1984
of Medical Research in Chingleput District,
Tamil Nadu(5).
Between 1968-71,
2 l^kh
persons above the age of one month were
vaccinated. In the same area -80,000 people
comprised the control non-vaccinated group.
For the next 7 1/2 years there was a
continuous monitoring of tne incidence of
.TB in the area base on tuberculin tests and
sputum analysis. When the data was decoded,
it was found that the number of TB cases
was slightly higher in the adults who had
been vaccinated. Therefore the vaccine was
not effective as a preventive measure.
However this evidence was not extrapolated
to infants, and the vaccine is still usea.
Since the discovery of streptomycin
there are a whole range of drugs effective
against TB. The major draw-back of chemo
therapy is the long duration of treatment
for 18-24 months.
It is difficult
to
motivate the patients to take the drugs
regularly. When treatment is not continuous
there
is
the danger of the bacteria
developing resistance to the drugs, causing
additional problems. However today there
are short-course drug regimens
of 6-9
months that are highly effective, of low
toxicity and well-tolerated(6).
Since the efficacy of the vaccine is
questionable and the primary source is the
infected population, it is now felt that
chemotherapy is more effective than vacci
nation as a control measure(7); A study
group set up jointly by the World Health
Organisation and the International Union
Against Tuberculosis in 1982 states that
the most powerful weapon is a combination
of case-finding and chemotherapy(8). The
case-finding will locate the source and
chemotherapy eliminate the overall risk of
infection in the community.
Althogh the causative
agent
is a
bacillus,
it is now accepted
that
a
combination of socio-economic factors serve
to aggravate the problem. Undernutrition,
poor hygiene, lack of water and persistent
(infections such as diarrrhoea decrease the
level of natural resistance in an indivi
dual (9). The inadequate housing results in
{overcrowding
and a greater degree
of
jcntact••Vfith infected persons increases the
risk faced by healthy individuals(10).
suffer from ailments of the lung as a
result of overexposure to dust and other
particles face a special risk.
Infact, an
evaluation of the control programmes in the
country observed that TB is becoming a
disease of the elderly males(12). This is
interesting in that it serves to subs
tantiate the evidence that the most vulner
able groups are those working in quarries,
mines,' textiles and other industries where
the
nature
of
the
work has health
hazards (.'.3) .
Occupational Hazards
In a small town in Madhya Pradeshi
called Burhanpur, the incidence of TB is
*'
150/1000, which is the highest in the
country(14). This a premier handloom and
*
TUBERCULOSIS IS CURABLE
The Story of Wise Vithoba
A flash Card Series
by
VHAI
and
FRCH
...pg 13
It is also recognised that certain
groups of people are more susceptible to
the disease(11)• Among these those who
HEALTH FQR THE MILLIONS
APRIL 1984
11
Tuberculosis in Ancient Times
From the various skulls and other
bones which have been recovered from
different parts of the world,
tuber
culosis was found to be evident in
Neolithic man. The Egyptians of ant
iquity made statuettes,
engravings
and paintings on stone and recorded
some descriptions of consumptives.
Their mummified bodies have revealed
definite evidence of tuberculosis of
bones and joints.
Tuberculosis as
was
evident in mummies indicated
that, as early as 5000 B.C., man
suffered from it.
Hippocrates (460-377 B.C.) also
devoted part of his attention to
tuberculosis. He opined that attenttion to the tuberculosis patients was
a waste of time and that they were a
burden to the state.
In the famous
library of Leipzig, there is a folio
which contains information that Jesus
suffered from this condition.
During the dark ages,
all know
ledge of disease was lost.
Touching
the king's feet for the cure of
King's Evil (as tuberculosis diseases
were then known) wds prevalent during
the
11th
and 12th centuries in
England and elsewhere.
In Britain,
Edward the Confessor (AD 1004 - 1066)
exercised the right of touching the
tuberculosis patients for the relief
of the King's evil. Queen Anne was
the last English ruler who practised
quack medicine for the treatment of
King's evil.
Madhya Pradesh showed that among 8,822
colliery workers, 10 % had pneumoconeosis
and 118 of them had both pneumoconeosis and
TB(15).
Another deathly
respiratory disease
caused by exposure to high levels of silica
dust
is silicosis or the black
lung
disease(16). Silica exists in three forms :
quartz, tridymite and cirstolabite.
Of
these quartz is ubiquitous on the surface
of the earth and is used in abrasives,
refractories, ceramics, paints, fertilisers
and many manufacturing processes. Silicosis
tends to increase the individual's suscept
ibility to TB and also makes the symptoms
of TB more severe(17). The combination of
the two which is Silico-TB is fatal and
leads co death.
A study conducted on the plight ' of
agate workers near Surat showed the popu
lation to be highly prone to
various
categories of lung diseases(18). During the
processing of the stone, there
is
a
particular grinding procedure which produ
ces a lot of silica dust resulting in a
high incidence of silicosis
among the
workers. There are other industries where
the working conditions are . filled with
occupational health hazards(19). A worker
in the engineering unit of a plant manufac
turing
motors found he was constantly
spitting lumps of black particles. He was
diagnosed as a TB case and the lumps found
to be small particles of iron to which he
had been over-exposed. Even in a tailoring
establishment where workers stitch heavily
tStarched clothes all day the risks of TB
are unusually .high.
Government Programmes
. From the Textbook of Tubercu
losis, the Tuberculosis Asso
ciation of India.
The Indian Council of Medical Research
conducted a sample survey in 1955-58 to
provide a base for anti-TB work in the
country. The National Tuberculosis Progr
amme was. finally launched in ,1962 with an
emphasis on (20) :
bidi centre. There are powerlooms installed
in most houses where the workers are const
antly inhaling fibre and dust. Coupled with
early detection and treatment
poverty, squalor and congestion, the people
vaccination
rapidly develop a respiratory ailment call
training centres in each state
ed pneumoconeosis, which eventually pro
Rehabilitation
gresses to tuberculosis. Pneumoconeosis is
.research
also caused by prolonged exposure to coal
dust. A survey conducted in the richest However this control programme has failed
coal mining area in the country,
the to have an impact and the total, number of;
Jharia-Raniganj coal belt in Bihar and TB cases are actually on the rise. An
12
HEALTH FOR THE MILLIONS
APRIL
1984
.expert committee set up by the ICMR found If the patient does return to the clinic
•that the national TB programme was ineffe his case may be accurately diagnosed, often
ctive as the'case finding was poor, there after several months. The lack of co
was incomplete registration of cases, 60- ordination between the place of diagnosis
70% of the patients were not completing and place of treatment leads to frustration
treatment and BCG coverage of children was and the compliance of the patient drops.
poor (21) ., Recently the government has in
cluded TB control in the Nation’s revised The Community Approach
20-pdint Programme and the ICMR has identi
fied priority areas in TB Control and
A group from a Community Centre working
evolved
programmes to facilitate
it's with women from a slum community in that
control(22).
area found that the best way to tackle the
problem was to involve the people in their
’ Let us take a representative area in own health care(24). The knowledge about TB
Bombay which is endemic for TB and examine being a health hazard was wide-spread,
how the government facilities operate(23). however the people did not know how to
There is a recognised TB clinic in the tackle it. The community centre got itself
vicinity, and when a person develops a recognised as a drug dispensary. They used
persistent cough, he may visit the clinic. the clinic as a referral service, however
Here an X-ray is taken, the sputum analysed
and if both are positive a tuberculin test
done. There are 10 different drug regimens
which have been worked out and based on the
results of the tests an appropriate course
of treatment is prescribed. The patient is
told to get his medicines from a drug
,dispensary close to his home or work-piece,.
whichever is more convenient. As a follow
up measure there are health workers who
visit the patient at home after a couple of
weeks.
It seems like a fool-proof system on
paper, however what actually occurs, is
confusion. A patient on going from the
clinic to the drug dispensary often finds
that his casepapers have not yet been
transferred, hence the dispensary does not
know what drugs to give him. He is forced
to make repeated visits to the dispensary,
which he can ill afford. If by some lucky
chance, however, he does manage to procure
the
drugs, *
he
is not told that • the
treatment will be for a couple of months at
least. Hence he takes his medicine, the
cough gets better, which to him is an
indication to stop treatment. However he
finds in a' few days the cough returns.
Therefore another trip to the dispensary to
get another':injection or more drugs. The
danger of stopping and starting treatment
in this fashion is that the bacteria may'
develop resistance to the drugs and the
patient will not show a positive response.
Since the dispensary only hands out drugs,
they do not pick up the incidence of drug
resistant cases. Thus when the patient
returns for further treatment they give him
the same regimen which may now be useless.
HEALTH FOR THE MILLIONS
APRIL 1984
1. This is Vithoba and his wife
Rukhmani. They share the joys
and sorrows of bringing up their
family. they have two children,
Krishna and Shoba. They have
been
living happily together
but.....
...pg
17
13
Koch’s Discovery
The real turning point in the history of tuberculosis occurred on March 24,.
1882, when Robert Koch, a former country doctor from East Prussia, announced to
the Physiological Society of Berlin that he had identified and cultured the
tuberclebacillus.
Though the infectious nature of tuberculosis was first established by Jean • Antoine Villemin, he was not able to isolate the agent responsible for the
• disease, and his report received a very hostile reception especially from the
then prevalent notions of the scientific world, dominated and propagated by no
less a person than Rudolf Ludwig Karl Virchow, the creator of modern pathology,
who had caused a revolution in medical thinking. Virchow then was the Director
of the Pathological Institute (Berlin) which had been specially built for him.
The Pooh Bah of Pathology that he was, Virchow scoffed at Villemin1 s imperfect
proof and inability to isolate the causative agent.
Koch was well aware of the mistakes of Villemin and the reception Villemin's
paper had from Virchow and his cohorts. The lion of pathology
(Virchow)
dignified the meeting of the pathological society on that day (March 24, 1882)
with his presence. We can well imagine the shock he received when he sat
patiently listening to Koch's accounts of his experimental proof, executed
without a flaw and complete to the last essential detail. Virchow sat silent.
.witnessing the demolition of his dualism theory, the dogma he perpetuated for
the past 30 years, by a comparatively unknown Prussian doctor. Koch's address
over, the Chairman called for discussion, but there was no discussion. The
audience was spell-bound. According to the version given by Ehrlich who was
present at the meeting,
all eyes turned to Virchow as though demanding an
explanation. For once the Pooh Bah of pathology had nothing to say evei. though
the fortress of dualism propagated by him had come tumbling down and lay ruined
for ever. At the end Koch said, "I have performed my investigations in the
interest of public health, to which I hope they will bring greater benefit."
- adapted from "Pulmonary Tuberculosis"
by M.P.S Menon
they ensured that the papers were trans-’ perfectly capable of doing the disease as
ferred on time. The people were informed \ well
as
collecting
the
sputum
for
about the duration of treatment and each analysis(25) . However basic pathological
case carefully monitored. They were fore- facilities and an X-ray Unit are absolute;
warned about problems of drug resistance requirements for accurate diagnosis in the>
and pressure from the community was exer- case of tuberculosis. Thei important message
cised for difficult patients.
The problem is that these are to be used as referral'
was tackled at a community level using the facilities.
Increasing the
number
of,,
family as a unit, rather than singling out clinics alone will not reduce the incidence1'
an individual.
* of the disease. In fact the World Health
Organisation has recommended that tuber
culosis programmes be integrated into the
primary health care. For developing countThere is hope that with awareness and ries
this will translate itself
into. health education it is possible for people reality only when the majority of the
to cater to their own health needs. Even in People gain access to a meaningful form of
the rural areas village health workers are health care.
14
HEALTH FOR THE MILLIONS
APRIL
1984
This article was written in September 1983
and we are grateful to Mona Daswani,
The
Foundation
for
Research
in Community
Health, Bombay, and Centre for Science and
Environment, New Delhi for permission to
reproduce it in HfM:-Editors
10. Stott, H.,How treatment has evolved/
World Health, p.24-28, January 1982.
,11. WHO Expert Committee on Tuberculosis,
Technical Report Series No.552, World
Health Organisation, Geneva,1974.
12. Chakraborty, A.K.,Communicable Disease
Control, All Indian Institute of Hygi
ene and Public Health,/Calcutta, 1980.
13. VHAI'S
role in TB Care, Voluntary’
Health Association of India, New Delhi,
March 1983.
.14. Divedi, U., Indian Express,
1980.
REFERENCES:
'15. Miners in
1983.
Death,
Daily,
30th March
13th
16.
Dogra, B., Silicosis : A Slow Death,
Economic Scene/ 1st June 1983.
17.
Rele, S.J., Silicosis : Man’s
Curse, Daily, 11th May 1983.
18.
Clerk, S.H. Rastogi, S.K., Chandra,
H., The Plight of Agate Workers in
Gujarat,
Science
Today,.
p.45-47,
December 1982.
19.
Dogra, B.,
The Hazards of Working,
Indian Express, 17th October 1982.
20.
Park, J.E., Text Book of Preventive andSocal
Medicine, Banarsidas
Bhanot,
M.P., p.385, 1974.
1.
Tuberculosis in Profile,p.6-9, January 1982.
2.
10,000 TB Deaths in City Every Year,
Free Press Journal, 3rd June 1983.
3.
What everybody should know about Tuber
culosis, World Health, p.14, January
1982.
4.
Styblo, K.t TB cases over the last 30
years, Economic Times, 22nd May 1983.
5.
Tuberculosis Prevention Trial, Trial of
BCG vaccines in South India for Tuber
culosis Prevention, Indian Journal of
Medical Researth, 70, p.349-363, 1979.
Fox, W., Whither Short-course chemothe
rapy, Bulletin of the International
Union Against Tuberculosis, .56,p.3-4,
1981.
,21. Eswaran, L., TB Cases Up in
Economic Times, 22nd May 1983.
6.
7.
8.
9
World Health,
Sutherland,
I., The epidemiology of
Tuberculosis- Is prevention better than
cure, Bulletin of the International
Union Against .Tuberculosis,
56,p.3-4,
. 1981.
Tuberculosis Control, Report of a joint
WHO/IUAT Study Group, Technical Report
Series No.671, World Health Organisa
tion, Geneva, 1982.
Mahlet, H.,Defeat TB Now and Forever,
World Health, p.3, January 1982.
(HEALTH FOR THE MILLIONS
APRIL 1984
April,
Oldest
India,
22., Biomedical Research and the new
point Programme: Tuberculosis,
Bulletin, July 1983.
20-ICMR
23.
Forest Road TB Clinic, Byculla, Bombay,
Personal Communication.
24.
Kotval, I.,
Medical
Social
Nagpada Neighbourhood House,
personal communication.
25.
The Foundation for Research
nity Health. Mandwa Project.
in
Worker,
Bombay,
Commu
15
MIRA SADGOPAL
Health “Care” Vs The Struggle for Life
India’s people,
and the world's people,
are faced with a gigantic health "care"
establishment. It is far from being a vaccum, a situation of "neglect" as most poli
ticians and planners would have us believe,
or sometime themselves believe. Like a huge
and ungainly bureaucracy,
it is both orga
nised and unorganised. Its various parts
are linked with each other in both gross
and subtle ways; equally,
the parts func
tion in contradiction with each other.-Some
of the parts of the establishment succeed
in holding sway in certain spheres by
virtue of historical advantage and the
forces that back them at the moment. Any
group claiming to explore "alternatives"
must understand human health,
and likewise
any other sphere of human welfare
(like
education, economic development, legal jus
tice, etc.) in this perspective. The indi
vidual man, woman or child is powerless and
thus always prone to being sucked, duped or
dragged into the establishment system.
India provides a magnificent panorama of
such a health care establishment. Most
obviously, we have in'this country a giant
multi-tiered
Government-operated'
publ-ic
health infrastructure, the bottom levels of
which are organised into something called
the "primary health care" system.
It is
topped by a spread of state hospitals and
national medical institutes as well as.
various large central public health agenci
es. Ultimately, this government system is
empowered through finance by international
organisations and agencies like the WHO,
UNICEF, DANIDA, etc.
Second in consequence is the vast body
Of "qualified" Private Practitioners which,
although it. is less organised and partially
thrives on its own disorganisation, also
exhibits a hierarchy of influence and power
largely corresponding to the proximity of
its parts to the cities and the drug
industries. It includes graduates of "allo
pathic" medicine as well as graduates of
the ayurvedic colleges although most of the
16
latter depend on the use of modern allopa
thic medicines. The minimum requirement for
organisation to promote and protect and
protect the interests of their members as a
class is fulfilled by the Indian Medical
Association.
Taking third place in visibility, al
though it exerts the most pervasive and
devastating influence, is the huge drug
industry complex. There is a polarisation
within this group between competing indige
nous and multinational companies wl.ich is
unequal, so that indigenous industry either
succumbs or adopts policies in tune with
the multinationals. The multinational' drug
industry profoundly . controls polidy and
practice within the Government health sys
tem as well as the behaviour of Private
Practitioners by plying central Governmnent
committees and deploying a large army of'
medical representatives.
■ Fourth is a large group on the fringe of
the health establishment power structure,’
loudly
named "Quacks" by the
Private
Practioners. It is a very interesting group
without any real political power or legal
sanction which thrives on the- contradic
tions of the establishment, the extreme
powerlessness of the masses and the total
culture of mystification which maintains
this. This ’ -group finds its niche in the
rural areas and the lacunae of the towns.'
A fifth group exists in the twilight
beyond the fringe, often indistinguishable
from the masses but merging
into the
category known as "quacks". They cannot
really be called part of the establishment,
but they are quite often the first, last,
and sometimes the only resource of the
poor. These are the village dais,’ the
bonesetters, the guinas, ojhas and bhagats
(faith healers and magicians). ' They are
traditional, indivisable from the belief
system of the masses. The larger health
care establishment has an ambivalent atti
tude towards this section - it is largely
HEALTH FOR THE MILLIONS
APRIL
1984
ignored or riduculed. Recognising their
hold over the people, some members, such as
the dais, are sought to be co-opted by
Government training into the primary health
system.
Also according to establishment values
organised health services are operated to a
greater or lesser extent by large public
and private industries and by the central
Government for its employees. These are
also subject to the same pressures of the
health care culture which bear on society
in general and are only partially modified
by local or specific political conditions.
For practical purposes, we may add to this
category the attempts of
a number of
voluntary agencies to provide proper and
uniform health services in project areas.
Seeing the larger interconnecting struc
ture of the health establishment in this
way gives us an intellectual idea of its
magnitude, but what does it mean for the
common man and woman .in India?
For a start, we can listen to the
stories of hundreds upon thousands of men
and women suffering from tuberculosis in
our cities, towns and villages. Over and
over again we can see a plot thus exposed
in stark nakedness as each tells of the
struggle to be treated and cured by any
possible means.
For instance, a villager who gins cot.ton
may notice a gradual loss of -weight and
energy and may be - a cough for several
months. But so many of the
poor are
already exhausted and emaciated by life they find the line between relative health
and disease is imperceptively crossed - and
they think it is only "weakness". When work
becomes impossible they seek quick help
from private practitioners, knowing it will
cost, but anxious to get well and back to
work. They hope to get by with a strength
giving injection, a few pills may be, and a
bottle of life-giving tonic
which the
doctor will prescribe. So a couple of
chickens and some grain is sold to raise
money.
■ The doctor well recognises the story and
the appearance. He suspects it is tubercu
losis. He knows the capacity of the poorthey will pay for the belief that they will
get well, and as long as that belief can be
sustained, they will keep on paying the
HEALTH FOR THE MILLIONS
APRIL
1984
same doctor. He also knows that • this
disease, if properly managed, has a good
chance of continuing without
cure for
several years before the patient dies.
Furthermore,
the widespread attitude that
TB is incurable, supported by the vast
majority of cases which eventually end in
death, and the doctor's own observation
that patients cannot sustain regular treat
ment does not lead him -to nurture any
professional interest in obtaining a cure.
Therefore, neither is he interested in
proving the diagonsis. A private practi
tioner will avoid telling that
he is
treating a man for TB as long as possible.
Otherwise he is sure to lose his patient to
another doctor. Likewise, sending him for
sputum test or X-ray, which may be availa
ble through the nearest government hospi-
tai, would be giving him away, or privately
done, would use up available funds. He is
not interested in prognosis either - it
will be sufficient to see that the man gets
temporary relief and is kept fluctuating
within a safe margin between cure and
death, with an occasional .dramatic rescue
form death
s
*
clutches,
for as long as
possible.
What does the doctor’s treatment consist
of, aside from its psychological content?
First on the list is Streptomycin injec
tions, one daily if possible, which is more.
likely impossible if the patient lives far
away. (He may be given tablets of Isoniazid
in various proprietary preparations
in
place of streptomycin, in which case he is
certain to be sent off with a couple of
impressive on-the-spot injections, such as
liver extract and red-coloured vitamin B12)
Next, he will be prescribed ethambutol
tablets
(under one of the marketed brand
names), a second line drug for TB which is
comparatively expensive but which is being
promoted by multinational companies through
their medical representatives as a firstline drug. Third, a corticosteroid hormone
like betamethazone (again, under, numerous
brand names) will’ be routinely given or
prescribed by most private practitioners at
the start of anti-TB treatment, as it is
expected to bring about rapid relief from
symptoms and a specific false sense of
physical well-being which may be the major
factor in hooking the patient. Fourth will
be a large bottle of mineral and vitamin
tonic which also ironically contains some
thing to stimulate the appetite of the
person who is basically dying of hunger
anyway. Fifth, a syrup will be added to
suppress the cough.
The expense of the first week .of such—
treatment works out as follows
(approximately):
1. Inj.SM @ Rs.3.00/day X 7
21.00
r
2. Tab. Ethambutol I twice/day
@ Rs.2.50/day x 7
17.50
3. Tab.Betamethazone 1 thrice/
day x 7 = 21 tablets
8.00
• •
4. Vita-mineral tonic - single
large bottle
20.00
5. Cough syrup - single bottle
8.00
74.50
The doctor's initial fee will vary, but
he will also take a daily fee for injecting
.streptomycin.
If he is a good dramatist
and psychologist, and the family is obvi
ously prepared to pay, he may set up an
intravenous drip and charge heavily.
Quite often, the person does not have
enough cash to
buy
*
some of the medicines.
Typically, the tonics and non-TB medicines
will be bought and the anti-TB medicines ,
will be partially or totally dropped from
the list. (A survey done by Veena Shatrughna has shown that many1 doctors write the
tonics and less necessary medicines first,
perhaps to oblige the drug companies, and
the specific curative medicine last.).
with apologies to R.K. Laxman
18
How long is this to go on? We have found
that a doctor tells the patient initially
that his treatment may take a varying
period between two weeks to three months.
He may decide to further prepare a mental
frame by stating that the man is lucky that
.the doctor has caught the ‘'disease
'
*
at this
HEALTH FOR THE MILLIONS
APRIL
1984
stage because, although he doesn’t have TB
yet, ’’There is a chance of it turning into
TB! ”
Even if a man has collected enough funds
for the initial treatment, he may not be
able to follow up. After a varying number
of visits to the doctor, and. especially
after a marked improvement, he stops goinghe may go back to work. He also meanwhile
consult a gunia of his community about
warding of th? risks of getting TB, and
after certain divination the gunia advises
him to carry out certain rituals
and
sacrifice, which are usually done.
After some time, he again loses weight
and his cough worsens. He thinks about
returning to the doctor. The Doctor's men
tion of TB has scared him, and he is
ambivalent. He may do one of three things:
he may go to another private doctor or a
quack, he may go to the Government doctor,
or he may return to the same doctor after
all. If he goes to another doctor, he goes
with a blank slate- he doesn’t mention that
he has seen another doctor, or flatly
denies previous treatment. Hence, a second
version of the first experience is likely
to unfold.
new cases of TB are clear and rationally
the full treatment of eighteen months is
provided under the National Tuberculosis
Control Programme.
After three months of treatment, sputum
examination is to be repeated
(if the
patient is still coughing up sputum). There
should be no more tuberculosis bacilli
if not
detectable in the sputum. Then,
before an X-ray screening is called for if
feasible"from the nearest TB X-ray facility. The reduction in the extent of lung damage is thus monitored every six months
until six months have passed since disappearance from the X-ray of the signs of
-damage, when treatment may be officially
discontinued.
If progress is
satisfactory
Streptomy-
3
■ I-
j ;
A .streak of realism may hit him. He may
realise that the choice he has TB is high
now, and decides to see the government
. doctor. At least he may get a clear answer
even if he doesn't have faith in the
government treatment.
The government doctor is a strange kind
of super human. He is invested with the
power to treat when he pleases at the
Government's expense. (He also carries out
a respectable private practice in/his homeat the Government's expense). A patient
approaches him in fear and ’ trembling.
Diagnosis for purposes of initiating Gove
rnment treatment is obtained through sputum
exam or X-ray whichever is feasible. Anti
TB treatment is started on the doctor's
orders. He tells the patient he has TB, or
he says,
"There is chance of it turning
into TB" depending on the role he wishes to
.play
in
the drama with the Patient1 Government Doctor or Private Practitioner.
Sometimes he adopts a dual role,
issuing
(Government drugs from the Primary Health
Centre for seeing privately at home, too.
Government rules
for
HEALTH FOR THE MILLIONS
the
3. As days pass, Vithoba gets
thinner. His cough gets worse.
He coughs up thick sputum every
morning.
His coughing
keeps
Rukhmani awake at night. Vithoba
feels very tired. One day he
agrees to go to the doctor at
the Health Centre.
• • -pg
21
treatment of
APRIL 1984
\
19
cin injections are to be replaced after
three months by another drug,
usually
Thiacetazone (THZ) but it might be ParaAmino
Salicylic
Acid
(PAS). The PHCs
dispense Isoniazid and Thiacetazone
in
combined INH/THZ tablets to be consumed
daily for the total remaining period of
treatment. To ensure that a patient keeps
up regular treatment, he is supposed to be
called every month on a particular date
three days before the drugs with him are
due to finish. In case he does not turn up
within a few days, a printed postcard
reminder is to be sent to him.
(If he does
not respond to three such reminders and he
has not died) , he is known as a ’’defaul
ter".
d) doctor’s impatience
e) mystification of doctor's role
f) poor relations/faulty * communication
* between PHC staff *
3.
Problems
Issue:
of
Drug
supply
and Regular
genuine short supply to PHC from
District HQ
b) siphoning off of TB drugs into the
market
c) siphoning off of TB drugs into pri
vate practice
d).incomplete issue of drugs
e) doctor's failure to indent (malad
ministration)
a)
4.
Problems of Medicine Cost from the
Market when unavailable through govern.ment supply
high/rising prices of
essential
first-line drugs, especially Strep
tomycin injections
b) shortage of all first-line drugs in
the
market due to gross under
production.
c) increase in market supply of expen
sive second-line anti-TB drugs like
ethambutol, rifampicin
a)
5.
But what really happens to the ordinary
patient, or to our villager friend who gins
cotton? •
brainwashing of doctors by medical
representatives
b) overproduction beyond licenced cap
acity, of tonics, etc., by large and
multinational drug companies
c) mystification among the masses abo
ut tonics and the desperation for
quick life-giving cures
a)
There are innumerable obstacles in the
way that ensure failure or treatment or
"default". We can list these, as follows:
1.
Problems of Diagnosis
sputum exam:
technician not availa
ble, or refuses
b) x-ray/screening facility distant,
expensive, out of order, x-ray pla
tes not available.
a)
2.
Failure of Communication
Doctor:
a)
20
6.
Problems
of
Local
Inject Streptomycin
Arrangement
to
unavailability of doctor/health wo
rker to inject
b) fee for injection daily
c) PHC may refuse to issue injections ,
to patient to take home
a)
to Patient by
intention, or lack of intention of
doctor to inform
b) patient’s fear
c) contradictions in the belief system
in society about•disease
Unnecessary Medicine Cost on Vitamin
and Mineral Injections dnd Tonics and
costly Cough Mixtures
7.
•
Problems of Transport
a) distance
b) cost in time,energy,fare
c) irregular public transport services
HEALTH FOR THE MILLIONS
APRIL
1984
8.
The Social Milieu at Home
poverty - poor shelter, starvation
demoralisation
sex-rbias in case of women, especia
lly when childless or without living
male offspring
d) belief in magic and lack of scien
tific .concept of disease
a)
b)
c)
9.
Conditions of workplace and Occupation
a) economic'exploitation
b) noxious physical conditions, like
inhalation of cotton fibre and poor
ventilation, etc.
c) lack of safety standards
d) lack of alternatives-
10.
Specific Malpractices
Doctor
ort has arisen from a couple of workshops
on issues related to rational drug therapy.
organized in 1982 in joint collaboration
with the Medico Friend Circle. During the
workshop held in Jaipur in August, evidence
from within the pharmaceutical industry was
presented by spokesmen of the Federation of
Medical Representatives
Association
of
India (affiliated to the All India Chemical
and Pharmaceutical Employees- Federation, a
non-party trade union organisation) to show
that the large multinational drug companies
are manipulating the supply of anti-TB
drugs by producing essential first-line
drugs far below their licenced capacities
and promoting the newer second-line drugs
which are at present imported from abroad.
A number of field groups, including members
of the Medico Friend Circle, members of the
by PHC Staff and
a). Private' practice.
b) misrinformation
or non-information
of patient
c) failure to . record (incomplete) iss
ue of drugs
d) neglect of monitoring schedule
e) failure^ to maintain treatment card
f) failure to contact defaulters by
postcard.
.
.^bJow-r—irt is sufficient to • say that the
average poor man. of India who gets TB today
is likely to face every single one of these
obstacles, except' B(c) as he is not a
woman. Inevitably,, he becomes a defaulter,
or he dies, or more likely both. Are there
really any alternatives?
Numerous groups and individuals are mak
ing attempts to . join with others,
to
challenge . the
*
might of the establishment.
The outlook of all at this point is at
best, partial. Again, the
problems of
tuberculosis can serve as a useful referen
ce point for illustration.
Action
is
occuring at national, regional and local
levels. We will mention a few of these
efforts known to us which we consider
significant.
The Voluntary
Health Association of
India
(VHAI) is at present carrying out a
countrywide investigation, with the help of
a number of local and regional groups, of
the widely reported shortage of first-line
anti-TB drugs in the market and in the
Government TB treatment centres. This eff
HEALTH FOR THE MILLIONS
APRIL
1984
4. At the health centre, the
doctor examines Vithoba’s chest.
He asks "Vithoba, how long have
you been having sputum?"
Vithoba : "For about one
doctor."
month,
Doctor : "I will give you some
cough medicine for your cough.
But if the cough is still bad
after five days, I would like
you to come back again. Before
you come please spit Some'sputum
into a clay pot and bring it
with you next time. We will test
- the sputum next time."
...pg
23
vital information about the TB drug situa
tion has already been mentioned. Some of
its regional units are particularly active.
State Voluntary Health Associations, and
local units of the Federation of Medical
Representatives are collecting
data, to
assess the magnitude of the problem and
whether, as many suspect, the incidence of
TB among the people is on the increase.
The first weapon against the establish
ment is information. A second can be formed
from a "network of socially
conscious
health workers" (quoting form VHAI<s appeal
for cooperation in collecting field data^on
TB drugs and incidence).
The ultimate
weapon is a conscious^movement _within the
masses.
~
As in many parts of the world, we see in
India today, various attempts being made in
the
direction of building a conscious
people’s movement. Only thus will it be
possible to really challenge the establish
ment on issues of health care and more
important, to gather the necessary power
and democratic perspective for evolving a
real scientific alternative which rests on
social justice. At present these initia
tives are small and fragmented, particular
ly in the sphere of health action. There
fore _ they are weak in comparison to the
total strength of the establishment.
How
ever, the experience steadily being built
up and the link with other democratic
developments is significant.
On the regional and national
*
level is
the surprising example of the Federation of
Medical Representatives’ Associations in
India,
a
healthy, growing
non-partyaffiliated trade union organisation with a
vision of society which is somehow startlngly free from the blindfold of' narrow
conomism. This group’s-role in collecting
22
Another regional example is that of two
other non-party organizations in the seven
districts of the Chhatisgarh region of
eastern Madhya Pradesh - the Chhatisgarh
Mine workers Union (CMU) and the Chhattis
garh Mukti Morcha
(CMM). The
CMM, an
organisation drawing strength from agricul
tural labour is constructing a peoples’
hospital and both organisations launched a
joint movement in 1981 which they call
"Struggle for Health". At present, under
standing of health issues is crude:primari
ly a realisation of what is grossly wrong
and a struggle against blatant injustice.
Slowly and painfully these two organisa
tions are struggling to overcome their own
inadequacies, faulty habits and traditional
beliefs to build up a viable and just
health care alternative.
At the local level in areas where there
is. no established mass organization, small
activities and micro-ini.tiatives are being
carried out which begin to challenge parts
of the health establishment. This has been
the case in our own group's work. In the
form of a series of three block-level
"Youth Leadership. Training Camps" (Govern
ment of~Ihdia)~"6f nOShangabad; we organized
groups of literate youth to study ... the
social aspects of the problem of tuberculo
sis by moving among the people and listen^__
ing to men and women with the disease’tell
their stories. The campers compared the
people’s experience with the provisions of
the National TB Control Programme
and
analysed
reason for the discrepancies.
They organized a diagnosis camp, poster
exhibition and cultural programme and a
public question-and-answer meeting in the
presence of the Government doctor and the
district TB Control authorities. Many con
tradictions arose which could
not
be
resolved.
At the village level, we initiated an
interesting experiment with the women of
the labouring class. The male villagers of
one large village had formed a labourers
union ’about eight months previously. One
day, knowing that I am a doctor, a woman
named Bhagwati suffering from untreated
advanced TB dragged her emaciated frame to
my door. She related a story of neglect and
desperation. Her husband was an inactive
HEALTH FOR THE- MILLIONS
APRIL
1984
member of the union, although she was not
even aware of the existence of the union.
Her husband Kaliram had failed to take her
to the government hospital for diagnosis
and she insisted that the elders in her
family wanted her to die. We brought up the
case in the union meeting, but were shocked
to find total apathy towards her plight.
The only concern was that, her husband, who
failed to attend meetings, was 4 scoundrel
and coward and not worth any attention at
all. It appeared as if his wife was only an
appendage of him. Up until that time, no
women had been involved in the
union
meetings. We decided to see how the women
would react to 'this woman’s problem.
Approached individually and’ in small
groups the women’s response on hearing that
TB is curable and the treatment provided
for through the Government PHC was sponta
neous. They decided to hold a meeting of
their, own to build up pressure for her
treatment. This they did in the meeting. I
agreed to act in a supervisory capacity to
see that the treatment given through the
PHC was started. At the time I was working
there voluntarily on a once-a-week basis,
so I was able to intervene.to some extent.
We trained a . local person
to
inject
Streptomycin and, on my responsibility, a
month's supply was issued from the PHC.
The initial phase
of treatment was
stormy. Bhagwati had high fever and severe
lung damage. We held an emergency meeting
one night to help the family, now alarmed,
to decide whether to take her to the
Government TB Hospital at Chhindwara. Four
women related stories of their relatives
who had gone to the TB Hospital. In three
cases, the victims, had died anyway. The
fourth person, alive and well, had gone
there twenty years before when the hospital
was- run by a mission. Nowadays the hospital
\s ridden with corruption at all levels and
over-crowded so that the expense is great.
It was pointed out that the modern treat-.
ment would be no different from that she
was getting at home from the PHC. So it was
decided that the wisest course was to
continue to take care of her at home..
In the first ten days, one or two yomen
began to visit her daily along with me,
turn by.turn. This was a hurdle for them,
as Bhagwati is a Harijan and, although all
the women were poor, they were nearly all
non-Harijans tribals. Muslims and low-caste
HEALTH vFOR THE MILLIONS
APRIL
1984
Hindus who were used to strictly abiding by
the code of untouchability when relating to
Harijans. They had never set food on the
aangan of Bhagwati's hut and they had not
seen her about the village for several
months. It was an unforgettable sight when
one woman, seeing her shrunken form on the
cot, irresistably lifted aside her veil,
with which she had covered her face in
shame, and exclaimed, "Oh, my sister, what
has happened.to you!"
The women were so ' excited at the first
two meetings that they decided to meet
frequently. At their next meeting the women
who had already visited the house described
Bhagwati's condition and observed
that
there were obstacles to her treatment at
home. Her mother-in-law was being nasty and
‘5. After another 2 to 3 days
Vithoba did not feel any better.
So Vithoba decided to see the
doctor again and get the medi
cine
changed. This time the
doctor said that Vithoba was
very sick, but that he would get
better
with
treatment. . The
doctor
said
that there was
tuberculosis in Vithoba’s chest
and teaset in the sputum. Vithobahad feared that he had TB for
some time. Rukhmani
believed
that this was their fate, and
started crying. But the doctor
explained that tuberculosis was
not a matter of fate but is a
- disease. This disease the doctor
said, is caused by germs in the
?sputum.
•
•...pg. 25
23
uncooperative,
refusing to give her food
and continuously commenting that she would
be better dead. The rest of the family was
demoralised and the house was messy. I told
them that it was a problem for me as a
doctor to keep on giving necessary advice
to improve diet and hygiene which had gone
unheeded for a week.
They decided
to
control the mother-in-law and had a lively
discussion about a proper diet for a TB
patient and about fixing up Bhagwati's
surroundings to make the place liveable and
hygienic. The next -day one woman tackled
the feisty old mother-in-law and convinced
her to draw a truce in the battle with her
daughter-in-law until Bhagwati would be fit
to fight back again. Another woman sat on
the edge of the cot explaining to- her
husband and eldest daughter what, she could
be fed, how to arrange that part of the
hut, and how to dispose of infected sputum.
The heat was sweltering. The next day we
were surprised to find that Kaliram, a
bamboo worker’, had woven a large overhead
fan and attached a long grass rope to it.
The small children were kept at a safe
distance pulling the rope to and fro in
turns, singing songs to the rhythm of the
fan. The house was tidy and clean. The sick
woman’s fever was much less. She
was
smiling. Her mother-in-law was grumbling,
but about other things, and in masked good
humour. The family had got . the taste of
self-respect through social concern.
Recovery was steady
for
some time
thereafter. At the end of one
month,
Bhagwati was anxious to get her sputum re
examined because she wanted to be able to
hold her four-year-old son on her lap, and
she wanted to sit-in at the women's weekly
meeting. She had lost her one-year-old
daughter a year previously, probably bec
ause of having infected her with TB. To
collect her sputum, she scrubbed a Strepto
mycin vial thrice with soap and boiled it
in water (so as not to kill any bacilli!)
and waited for the bus on the road from
MX DOCTOR WfU. TELL
You -WT ir YOU ARE TENSE
OR O^rKAUMF 1WEKE IS
OWE SUKE UMT TV PEEL
----- -------------------- sjSETTEK^
eight in the morning. The eight o’clock bus
did not come. At 11.15 she began walking in
the scortching sun barefoot. -The PHC was
seven kms. away, and she was afraid it
would close, so she nearly ran the whole
distance. One hour later; .she reached the
PHC to find that it had closed at 12
o’clock. She waited until it reopened at
4.30 p.m. and proudly offered the vial of
sputum to the compounder-technician.
He
grabbed the vial and threw it on the ground
shouting,
”We won’t do your sputum test
seventeen times; Bring it after
three
months”. Then she asked for her month's
supply of drugs, only to be told that the
doctor had gone and she would have to come
.the next morning.
Bhagwati returned home exhausted,- down
cast, but amazed at herself that she had
been able to make the journey. Next’ day,
she had fever, but she was determined to go
back to get her medicines. Kaliram accom
panied her. He decided in addition, to take
her to the next town and get her first Xray done and the sputum test repeated
privately. When they faced the PHC doctor,
they had to tolerate his sarcastic comment
that they had "become big people now". All
the drugs were given, but no amount was
recorded on the card. In the next town,
they paid Rs. 5/- for the sputum exam and
Rs.
24/- for an X-ray. The Sputum test was
negative. The X-ray showed cavitation, but
signs of active healing.
Probably because of the heavy exertion,
Bhagwati was not well for about two weeks,
but again began to pick up." The following
month she went to a wedding and took her
vials of Streptomycin and pills along with
her, getting them injected by an available
doctor. In the fourth month she started
work again. She is a traditional dai as are
all the women of her caste. An orphan, she
had started her midwifery career at the age
of seven, as she described to me later. In
the
same
month, some other villagers
SIMfLf UE VUlTW YOUC
This is hushed ur, of
IT U)0UO>
HERO iM YOUr WflTEKDiSH! COJfcSt
CCHraTEQ’RUlrt ME
-C^-JP^PROOr 6cnf>IAJIE>.
HEALTH FOR THE MILLIONS
APRIL 1984
Answers to T.B. Quiz
(1) 10 Million (2) 2.5 Million (3)
50 lakhs (4) Equal (5) 80%
(6) Increasing
(7)
Increasing (8)
Free
(9) Sputum positive cases only (10)
18 months
(11)
6 months
(12)
300 mg as one dose daily
(13)
Sputum for AFB (14) No
(15) Yes
(16) Improved socio-economic status
(17) Tibetans
(18) 4
(19) 20
(20) All (21)
250
(22)
3.3%
(23) ’ 1.9%
(24)
50%
(25)
In a child’s neck
(26) If live TB bacilli are leaving their bodies
(27) No symptoms
(28) does
not recover several weeks after whooping cough
(29) is not well and has had
mild fever and loss of weight for several weeks
(30) Gita
(31) well enough to
work
(32) Cerebral
malaria
(33)
less
likely
(34)
living
organisms
(35) Penicillin (36) TB is a more chronic disease in children (37) Vidhya
(38) go on for a year (39) TB (40) given BCG and put on the special care
register.
(Some of the questions and answers are based on "Primary Child Care"
by King and King)
reported to me that she was catching
in the river with her nephew.
fish
In' the fifth month, Kaliram discovered
that Bhagwati had brought back only white
tablets from the PHC. Streptomycin had been
discontinued, but he knew that anti-TB
drugs were necessary, and she had been
receiving both Isoniazid (white-colouredl
and Thiacetazone (yellow-coloured)
in the
form of combined .light-yellow
coloured
tablets. He took the pills back to the
doctor the next day complaining squarely
that she had been given "only one" anti-TB
drug by mistake. He didn’t flinch when the
doctor's cold gaze hit him, and after a
moments's hesitation; the compounder was
called and told to exchange the white
tablets for the familiar light-yellow ones.
And so her treatment will go on, may be
without serious lapse until she is totally
cured. Kaliram now attends union meetings
when he can manage it. Bhagwati attends the
women's meetings. He farms his small piece
of land, and plays music at weddings. They
make bamboo baskets. She delivers babies.
They are people of courage,
like the
others. In . the meetings they don't talk
about TB, but of the struggle to survive
and thrive against the forces
of the
establishment.
This article by Mira Sadgopal of Kishore
Bharatiy Hoshangabad was first published in
two parts in the September 1983 and October
1983 issues of the Medico Friend Circle
Bulletin.
We are grateful to them for the
opportunity of reproducing it here.
HEALTH FOR THE MILLIONS
APRIL 1984
6. In order to convince them
about these germs the doctor let
them look through the microscope
and see the germs that cause
tuberculosis. These germs were
found in Vithoba's sputum. The
doctor said the germs spread
from one sick person to others
when they cough, spit or.sneeze.
But Vithoba and Rukhmani did not
remember much of what the doctor
said. They were too upset.
. .--pg
27
------ ----- --------- ——-----25
INDIRA KOTVAL
A Tuberculosis Control Programme
The Nagpada Neighbourhood House is based in
Byculla,
one of Bombay's most densely
populated areas.
It covers Ward D and E of
the Municipality (Population 4,44,666 and
4,54,490 respectively) and tuberculosis is
endemic in the area. Our concern is the
many unidentified cases who are suffering
from the disease but are not being treated
either because they are unaware, or because
fear and ignorance keep them away.
Objectives
One of our aims is to help the community
make better use of existing health faci
lities and not to duplicate
services.
Therefore when a patient came to us with
the symptoms of the disease we would refer
him to the nearest Municipal clinic where
investigations and drugs are given free.
Months later the same patient would cpme to
us for some other illness and we would
notice he was no b’etter. Invariably, on
questioning we would find either he had not
completed the tuberculosis investigations
or for one reason and another he found that
continuing with the treatment
was too
difficult. We therefore resolved to start
a programme in cooperation with the Bombay
Municipal Corporation.whereby they would do
the investigations and supply drugs when
they found a positive case of tuberculosis
and we would be responsible for dispen
sation of drugs,
additional nutritional
supplements, follow up and continuation of
treatment until the patient was cured of
the disease. The strength of a voluntary
organisation lies in staff motivation and
the personalised service it can offer. We
thought that if we could couple
this
advantage with the facilities provided by
the government we might be able to run a
more effective programme.
Strategy
Accordingly we approached the Municipality
who were most cooperative and agreed to do
investigations and prescribe
the
drug
regimen. Once they had issued the patient
26
with their cards
(in the name of our
clinic) they would issue the drugs to me
and I had to and account for them. It was
our duty to ensure drug compliance, bring
the patient for checks and any
other
necessary referrals.
We started with the idea of building up to
cover 100 patients and their families. We
intended to focus on the family as the unit
and to give nutritional inputs to all of
them; build up health awareness and equip
them all with an understanding of the
disease, its spread and its consequences.
We believe this is the only realistic
approach if the patient is expected to
complete treatment with the help of his
family. Starting with screening all con
tacts we built up the programme slowly and
presently have 88 patients under our care,
many of whom are siblings and relations.
Environmental conditions cannot always be
changed but much can be done to help the
patient understand the nature
of
the
illness, the reasons for regular medicine,
the meaning of drug immunity and
the
futility of interrupted medication. Once
the person undertands the reasons he is
more likely to participate in his own cure
and then the battle is won.
To bring this message home needs time and
concern for the client. With
a large
impersonal
clinic and several
hundred
patients this is not possible. Our strategy
emphasises individual counselling and in
formal health education as an integral part
of the programme.
Problems and how we overcame them
The Municipality supplied us with a month's
supply of drugs for each patient and at
first we issued them accordingly. However,
we soon realised that in the initial stages
very careful monitoring of the drug taking
had to be done to ensure the medication was
being taken correctly. When on a multi-drug
regimen,
patients who were unlettered,
HEALTH FOR THE MILLIONS
APRIL
1984
would find it very confusing to remember
the dosage for each, inspite of • the fact
that we gave them separate bottles and
coloured stickers on each to indicate the
dosage. Certain drugs, particularly Rifam
picin, has unpleasant side effects, and
patients would either omit or limit the
amount of this medicine as they wanted. It
was only when they returned with
the
bottles that we would realise this, and'a
month would already have gone
by. We
therfore decided to issue drugs on a once a
week .basis, and found that it took approxi
mately three weeks to sort out all indivi
dual problems concerning the drugs.
The other advantage of this weekly issue is
that we use the day as a meeting and
discussion day. Sometimes we show audio
visuals, at other times cooking demonstra
tions of soya bean meal or ragee
(which we
supply as nutritional supplements), are
carried out. Women are encouraged to show
how they cook green and iron rich veget
ables and group discussions on various
issues related to the disease are held. It
is at these meetings that many of the
unvoiced problems are brought
up. The
stigma attached to tuberculosis,
fear that
a young daughter may not marry and even
fear of loss of sexual potency are distussed over a period of time. There was
even an instance when a mother who was
irregular with her child's treatment was so
pressurised by the group that she had to
make a choice as to whether to move from
the spot she occupied on the pavement or
comply with the treatment.
Non Compliance
Inspite of efforts there are always a few
defaulters and this is a problem we have
not been able to overcome. Because of the
belief that injections are all powerful, it
has been noticed that often a patient will
come
regularly until the
streptomycin
course of thirty or sixty injections is
over.
After that drug taking
becomes
irregular. By this time the symptoms of the
illness are already disappearing and it is
difficult to believe one is still ill and
must continue with pills for another six
months. Oral drugs are considered second
class and the motivation to continue is
weak.
whose roots remain in the villages. During
marriages, deaths and harvest time the
family will disappear for a month or two
without prior notice and of course drop out
of treatment. Over several group meetings
we have been able to explain that for such
contingencies medicine will be provided for
a longer period, but often decisions to
leave are made on the spot and informing
the medical clinic has very ‘low priority.
Dependancy
When trust and belief is built round people
rather than the treatment,
it
becomes
difficult to duplicate a system or call a
halt to the dependency. We had decided that
once we started to reach our target of 100
patients and 'their families,
we would
7. But Vithoba remembered then
that his brother who stayed with
them a year ago, used to cough
up a lot of sputum. His brother
had since died. If perhaps his
brother also had tuberculosis
then this was how Vithoba had
caught the disease. The doctor
said again that Vithoba would
get better if he took treatment
for 18 months. It would take 18
months for the medicine to kill
all the germs in his chest.
Vithoba heard what the doctor
said, but he was still thinking
about his brother. He was also
worrying how to pay for such a
long treatment.
--•pg 33
Many
of
our
patients
HEALTH FOR THE MILLIONS
are rural migrants
APRIL
1984
27
IL
Mantoux Test
The Mantoux Test is a tuberculin test to . find, out whether a person is
already infected or not. A tuberculin test does not give any idea as to whether
the individual is suffering from tuberculosis, since infection does not always
lead to disease.
In the standard Mantoux Test 0.1 c.c..of P.P.D. (Purified Protein Derivative
- the purified form of tuberculin from which the constituents of the medium in
which tubercle bacilli were made to grow have been removed)
is injected
intradermally on the front of the left forearm approximately midway between the
bend of the elbow and the wrist. This particular position is chosen so that
there should be uniformity in the test all over the world and if an illiterate
person has to be questioned as to whether the test has ever been done before or
not, one can ask whether an injection has been given in the left forearm.
The test is read after 72 hours. To read the test before 48 hours and after
96 hours'is not reliable. The transverse diameter of the swelling at the site
of the injection is measured. If the diameter of the swelling is 10 mm or more
the test is usually called positive meaning thereby that the person is already
infected with tubercle bacillius. However since the allergy takes about 6 weeks
to appear tuberculin test will be positive only 6 weeks after the infection. If
the test is carried out within 4 to 40 weeks (average 6 weeks) of the infection
the test may be negative but it does not mean that the person has not been
infected.
.
From the community point of view the tuberculin 'test gives some idea about the
amount of tuberculosis in a community. Since tubercle bacilli are excreted by
patient suffering from tuberculosis, the number of persons found infected by
tuberculin test will give an idea as whether there are many tuberculosis
patients in that community or few of them. For example, in India nearly 50% of
the children are infected (i.e. give a positive Mantoux test) by the time they
are 14 years old. In America, however, where the number of patients in the
community is very small, less than 3% of the children get infected by the age of
15 years. In our country, practically everybody gets infected by the age' of 25
years or so, at least in the cities.
transfer those patients who .were now taking
treatment regularly and for at least six
months, to the nearest municipal clinic.'
This way our personalised service would be
available to an increasing number of new
patients who require careful handling at
the
initial part of treatment.
Older
patients, once exposed to checks at munici
pal clinics would, we hoped,
lose their
fear of the authorities and
use • the
services of the municipality independently.
We met with extreme opposition both from
the
patients and the government.
The
patients were reluctant to transfer and the
municipality envisaged that the’paper work
28
involved was too cumbersome. They suggested
that we see all our patients treatment
through to completion and only add new
patients to our list when we were ready to
take more. At- this point we have not
decided how to deal with the problem.
Some Observations
There is far more tuberculosis in the city
of Bombay than we are currently aware of. A
random mantoux test conducted on our underfive population showed that out of 145
cases tested 39 were positive cases and a
further 28 cases investigated as contacts
were also positive. Early diagnosis and a 7
HEALTH FOR THE MILLIONS
APRIL 1984
month drug regimen based on Rifampicin can
control the disease. From a total of 348
cases investigated, 88 were found to be
positive. Since the government provides
free drugs and investigations,
it
is
possible to treat all patients provided a)
an awareness of the problem and the need
for cure is understood, and b) voluntary
agencies assist the government to implement
these programmes more efficiently.
unpleasant that the patient is
drop out of treatment.
forced
to
Environmental conditions, poor health and
undernutrition are the main causes
of
tuberculosis and unless the social and
economic conditions in our country improve
I am convinced the
disease cannot be
eradicated.
Patients drop out of
treatment mainly
because they do not understand the need to
take drugs regularly and because
they
cannot explain their problems adequately. A
personal service with individual attention
can help this a great deal.
POSTCRIPT: So far there has not been any
problem of drug shortages. But in March
1984 the BMC apparently fell short of funds
and they are now waiting for the new budget
to replenish the coffers. As a result there
has been no money to purchase drugs and
hence a drug shortage. Drugs are purchased
as follows:
It is important that tuberculosis patients
be given nutritional inputs in the form of
vitamins, irons and nourishing food because
the strong drugs taken with a meagre diet
cause severe side effects that can be so
Streptomycin/PAS/paracetazone from private
companies. Rifamycin/Isonex/Ethambutol/ are
produced by the government at Kasturba
Hospital, Bombay from 1984.
NEW REHABILITATION COURSE FOR THIRD WORLD ANNOUNCED
The Tropical Child—Health Unit of. the Institute of Child Health, London
University, is setting up a Diploma Course for Trainers and Supervisors of
Community Rehabilitation Workers in Developing Countries under the direction of
Professor David Morley. This Course will run for nine months (October/July) and
an initial Course is planned for October 1984.
The Institute of Child Health already runs a course leading to the degree of
Master of Science (University of London) in Mother and Child Health. It is hoped
that the new Diploma Course may eventually become a similar MSc Course in
Community Rehabilitation. For the time being a Diploma, recognized world wide,
will be awarded to successful students.
Dr. Pamela Zinkin, who will be in charge of developing the Course has
recently returned to the UK after spending five years as Professor of
Paediatrics, Maputo, Mozambique, said: It is important that Rehabilitation
should be more available to disabled children in remote rural and slum areas of
the Developing World. And it is important that this rehabilitation is tailored
to fit the circumstances and needs to these children. By training those who will
return to their countries to set up training courses and supervise Community
Rehabilitation Workers we plan to achieve a revolution in the management and
rehabilitation of disabled children in what have been up to now the forgotten
corners of the world.
For details write to :
HEALTH FOR THE MILLIONS
Institute of Child Health
(University of London)
Tropical Child Health Unit
30 Guilford street
London WC IN 1EH
APRIL 1984
I
Bombay Tuberculosis Statistics -1983
The Bombay Municipal Corporation has calculated that by the end of 1984 a
total of 1 million people (out of a population of 9 million) will be under their
tuberculosis treatment.
This excludes patients getting treatment from private
doctors. These figures are based on statistics gathered during the tuberculosis
campaign year 1983 when 88,000 people were under municipal treatment.
On a 7 month rifamycin and supportive drug therapy (known as second line
treatment and given when the first line treatment fails to give a response or
when a quick therapy is sought) within the campaign year, it was found that 25%
of the patients were completely cured of the disease. 38% are still under
treatment because of the severity of the disease. 30% came in the last quarter
of 1983 and they are expected to complete treatment in early 84.
7% dropped out
of treatment. An analysis done by the BMC as to the causes of drop out with a
percentage wise break up of the 7% is listed below.
PERCENTAGE
REASONS FOR DROP OUT
26%
Non residents of Bombay who came forward &
have now moved back to rural areas
10%
Investigations done at BMC clinics but chose
to be treated at private clinics
5%
Died of the disease
12%
Moved out of the municipal area where they
were being treated and health visitors are
unable to do adequate follow up.
26%
Refused to take treatment either because of
unpleasant effects of the drug or insuf
ficiently motivated.
13%
Wrong address given
attached to disease.
8%
Miscellaneous reasons.
for
fear
of
stigma
Incidence of tuberculosis in Bombay city is recorded by the BMC as follows.
37,000 cases treated by BMC
50,000 cases treated by BMC
65,000 cases treated by BMC
88,000 cases treated by BMC
There are two ways of interpreting this data. BMC argue that the rise in
figures show that more people are coming forward for treatment because of
effective propoganda. One could also state that TB is on the rise due to rural
migration to the city and because the infection is not being controlled.
1980
1981
1982
1983
COST OF TREATMENT FOR BMC:
-
30
FIRST LINE TREATMENT:
STREPTOMYCIN/ISONEX/PAS/THIACETAZONE
Rs. 135.00 p.m.
SECOND LINE;
RIFAMYCIN/ETHAMBUTOL/PZA/ISONEX.
Rs. 186.00 p.m.
RIFAMYCIN/ETHAMBUTOL/ISONEX/STREPTOMYCIN
Rs. 276.00 p.m.
,'EALTH FOR THE MILLIONS
APRIL
1984
J.S. MAJUMDAR
Production of Anti - TB Drugs
J.S Majumdar is the Secretary of the Federation of Medical
Representatives Association of India and an active member of the Drug
Action Network. The above article is extracted from "A Study on
Prevalent Diseases in India and Production of some Essential Drugs "
which was a paper presented by him in the Drug Workshop organised by
VHAI in August 1982. It is being reproduced here as a 'case study to
show some of the dynamics of drug-shortages in the case of life
saving and essential drugs.
On 20th April,
1982 Sri Dalbir Singh,
the
Minister
of State for Petroleum,
Chemicals and Fertilizers, made a statement
in the Lok Sabha that PAS and its salts,
and INH production were showing a declining
trend during April, 1981 to February, 1982.
He further stated, “the decline in produc
tion is due to (1) demand constraints or
shifts, (2) Industrial unrest,
(3) Availa
bility of cheaper imported drugs.”
From the available data and facts it will
be revealed that the Minister was either
wrongly
informed or was giving
wrong
information.
There are no demand constraints or shifts
as far as anti-TB drugs like INH and PAS
are concerned. It was earlier stated that
of an estimated 10 million patients__suffe
ring ’from active tuberculosis._of .lungsL.Qver
6 lakhs patients (except in a few States)
were reported under treatment. Vast number
of other patients have no access to modern
medicines. The talk of demand constraints
or shifts is only to hide this fact. The
projected requirements during the sixth
five year plan does not show that there is
a declining demand of INH & PAS as reported
by the Minister.
The compound- rate of growth, during
this period, of INH is 20%, PAS
and
Thiacetazone 15%, Ethambutol 22% and Rifam
picin 16%.
Source : Report of the ’’Working Group
on the Drugs and Pharmaceutical Indus
try for the plan period (1978-79 to
1983-B4)”, Government of India, Minis
try of Petroleum, Chemicals and Ferti
lizer
(Department of Chemicals
and
Fertilizers)
Streptomycin, INH, PAS and Thiacetazone
are well established anti-TB drugs. The
auto-toxicity of Streptomycin
has been
accepted as a hazard of the treatment and
Actual Production and Requirements of Anti-TB Drugs in Tonnes
Name of the
Product
I N H
PAS
Thiacetazone
Ethambutol
Rifampicin
Actual
Production
77-78
Requirements
78-79
82-83
Base year
Sixth plan
79
548
26
3
Nil
175
750
35
40
3
HEALTH FOR THE MILLIONS
APRIL
1984
—375—..
1300
60
90
6
.
Rolling plan
450
1500
70
110
7
31
sufficient care Ms being taken. Similarly,
Thiacetazone is also recommended with cau
tion. But, the fact remains that indigenous
technology is available for the production
of these drugs and the country can be fully
self reliant with proper planning. .Resis
tance to these drugs are rarely reported
when properly used in combinations. There
fore, there cannot be any demand const
raints for these reasons nor there are
demand shifts. It is well established now
that poverty, malnutrition and absence of
proper hygiene prepares the ground for
invasion of the tuberculosis. Most of the
T.B. patients cannot purchase medicines of
their own.
If any demand constraints are
there,
it is due to the price factor and
that too, not the total expenditure but the
daily expenses on drugs. Therefore,
there
cannot be shift in general towards Rifam
picin and Ethambutol.
Further, Rifampicin is not indigenously
produced. The drug is totally imported. The
imports of this drug were as follows:
80
1979-
1980-81
1981-82
5413.5 kg
8948.5 kg
15785.5 kg
Such a small quantity of imports can
hardly meet the actual needs of the T.B.
patients. In addition. Rifampicin is also
used for the treatment of Leprosy
in
combination with Dapsone.
The drug is
costly. The CIF cost per unit during 198182 was Rs. 4130/- per kg. The technology of
manufacturing of Rifampicin is only known
to two companies in the world - one is in
Italy^ the other is in Switzerland.. They
have the monopoly in the manufacture of
this drug. The donor for Rifampicin in
India is the Swedish International Develop
ment Agency (SIDA).
It will lie evident from these facts
that demand can hardly be shifted towards
Rifampicin, which is costly, wholely impor
ted and for which technological know-how is
not available in India.
As far as Ethambutol
is concerned, the
WAITING FOR THE "SPACE INVADERS"......
AND THE ENEMY WITHIN
In the year 1980 the world spent a million
dollars a minute on armaments.HEALTH FOR THE MILLIONS
APRIL
1984
take
various pleas including so-called
labour unrest. In reply to a question in
the Lok Sabha on 18th August, 1981, the
Minister of State for Petroleum, Chemicals
and Fertilizers, stated,
’’Periodical shor
tages of PAS _granul.es manufactured by M/s.
Pfizer Ltd. were reported from Delhi in the
recejit past. The matter was taken up with
the manufacturers who reported that as they
had closed down for. some time due to labour
unre5;t and later were affected by go slow,
their production and supplies of the above
formulation was affected."
DEATH WARRANT - MNC STYLE.
Whereas, the factory manager of M/s
Pfizer Ltd. issued a notice on 26th March,
1981 which reads:
'
TO EMPLOYEES OF PAS SECTION:
actual production in the
country from
imported intermediaries during 1979-80 was
23.53 tonnes.
In addition, 96.19 tonnes
were imported during this period.
From this, it will be evident that more
emphasis is given to be import of the drug
rather than the actual production.
On the one hand deliberate attempts are
made to create shortages of INH & PAS by
cutting down indigenous production, on the
other, import of costly drugs are encou
raged on the plea of demand shifts, instead
of a natural demand shift, attempts have
been made to deliberately create conditions
to make room for costly and_ importecfdrug's,
and tor this millions of poor T.B. patients
have to pay the price.
The production pattern of Pfizer Ltd.
is a classical example of under-production
of essential anti-T.B. . drugs and over
production of non-essential products.
Products
Licenced
capacity
Production
19.78
1979
(in Tonnes)
INH
PAS and
its salts
Protinex
80
110
45
90
52
94
110
269
290
(Source : From Company reports )
In their attempt to.
deliberately__ cut
production, .the industry and Government
HEALTH FOR THE MILLIONS
APRIL
1984
8. The doctor said that INH
tablets only cost about Rs.
3
per month and INH tablets for TB
were also free at the health
centre. So Vithoba started trea
tment. ' Sometimes there were no
free drugs and he had to buy the
medicine in the
bazar.
The
doctor explained that the strep
tomycin injection if needed cost
about Rs. 1 for each injection
for the first month, but that
the injections would be availa
ble free at the health centre.
...pg 35
In the Lok Sabha
UNSTARRED QUESTION NO. 1434
TO BE ANSWERED ON THE 6TH MARCH, 1984
Manufacture of anti-tuberculosis drug "Rifampicin"
1434.
(a)
SHRIMATI MADHURI SINGH:
will the Minister of CHEMICALS AND FERTILIZERS
be pleased to state:
the steps to be undertaken
drug "Rifampicin":
for the manufacture, of the anti-tuberculosis
(b)
whether it is a fact that the large-scale import at dump prices by multi
nationals has proved to be a disincentive for domestic, manufacturing ’ of
this vital drug which is equally effective for the treatment of leprosy;
and-
(c)
the quantity of
drug?
Rifampicin
being
imported and estimated demand for the
ANSWER
THE MINISTER OF CHEMICALS AND FERTILIZERS
(SHRI VASANT SATHE)
'
(a)
Government had issued 7 Industrial approvals for the manufacture of
Rifampicin.
Foreign Collaboration proposals were also approved wherever
they conformed to the parameters of Government policy.
(b)
No instance of dumping of Rifampicin has come to the notice of the
Government.
However, it is possible that the fall in CIF prices of
Rifampicin in 1982 and 1983 had an impact on the investment in the
indigenous manufacture of the drug.
(c)
The 6th Plan Working Group had estimated that in the year 1984-85 Annual
Demand of the drug would be 24 MT.
Imports for the last Three years had been as follows:-
YEAR
81
1980198182
83
1982-
IMPORTS (MT's)
8.95
16.07
36.90
HEALTH FOR THE MILLIONS
APRIL
1984
"It is hereby notified for the informa
tion of Employees of PAS section that due
to the sudden steep increase in the price
of MAP without a corresponding increase in
the price of the finished product
it has
become • un-economical to produce PAS~~ <and,
therefore,
it has become necessary • to
suspend operations in the PAS section of
chemical plant. We are making all efforts
to secure a price revision of the finished
product.
Employees of
PAS
section will be
temporarily transferred to other departto
ments with effect from April 6, 1981,
date from which PAS operations will be
suspended."
THANE. DATED MARCH 26, 1981
and Anti-TB .dosage forms will be very
uncertain". This conclusively proves that
there was no demand shift from INH and PAS
but an artificial shortage was created of
these drugs.
A survey in the market also revealed
that PAS of Pfizer and Biological Evans
were not available since early 1981
Similarly, Streptomycin from Pfizer and
Glaxo has not been available for many
years. INH is_.also in short supply periodi
cally.
'
The above facts will prove that there
was neither, a demand shift nor labour
unrest but a deliberately induced declining
trend in- production.
for Pfizer Limited
Sd/- B.B. Roy
Factory Manager
From the above statements it would be
evident that attempts were made by the
company to hide the fact that they stopped
production of PAS granules as theprofit
margin was less compared to products like
'"
*
Protein
Hydrolysates, Tetracyclines, vita
mins etc.
The Government did not care to investigate the facts and^simBly-^passed on the
false, information given by the company’.T*
In reply to another question in the Lok
,Sabha on 18th August, 1981, the Minister
informed the House that though Pfizer's PAS
granules were in short supply,an equivalent
brand of PAS granules (Biological Evans)
was available. A study in the
market
revealed that PAS granules of Biological
■Evans was not available since December,
1980. The company had stopped supplying PAS
granules from January, 1981. This is only
an example to show the manner in which the
Government machinery functions in finding
out the facts about the supply of essential
drugs.
By a confidential circular dated May
26,
1981, Pfizer Ltd.
informed
their
Regional Managers that they could quote a
special hospital price for their tetracyc
line and some other group of products in a
special rate less than the usual trade
price. But, the circular states, x "The
availability of narrow spectrum injectables
HEALTH FOR THE MILLIONS
APRIL 1984
9. Vithoba did
not want to
spread the disease to his child
ren. So whenever Vithoba coughed
and wanted to spit, he did not
spit on the ground where the
children played. Instead he spat
into an old clay pot and covered
his sputum with ash. Every night
Vithoba emptied the old pot •in
the fire for 10 minutes to kill
all the germs. Then he used the
.same pot for spitting into the
next morning.
P9 37
35
ANNIE GEORGE
Better Care in Tuberculosis
"Better Care in TB" is the draft version- of the latest booklet in the
"Better Care" series published by VHAI. Those of you who have seen
the earlier booklets like Better Care during Diarrhoea, Better Care
in VD,would know that each message or teaching point is accompanied
by an appropriate photograph or visual, with a new page for each
point. The idea is to get across the most crucial points of "Better
Care" in the simplest and most direct manner possible, so that it is
understood even by semi-literate persons. Of course, the booklets, are
translated in almost all the regional languages. We would be happy to
have your valuable feedback to enable us to modify the script given
below so that a correct and even better version of fBetter Care in
TB,f is produced.
Can T.B. be cured ?
1.
What causes T.B. ?
*
Yes, T.B. is completely curable.
*
Very small germs cause T.B.
*
It is never
treatment.
*
They are so small, they cannot be
seen with your eyes.
*
Early treatment can cure all types
of T.B. completely.
*
If you have any of the signs of
T.B.,-seek medical help immedia
tely.
too
late
to
take
These things do not cause T.B. :
*
Bad blood
*
curse of the gods
*
a bad horoscope
*
fate
*
evil spirits
*
wrong foods
*
worries and anxieties.
What kinds of people get T.B ?
2.
36
3.
*
Any body can get T.B.
*.
Rich people
get T.B.
and
poor
people can
can
*
Young children
T.B.
*
People in villages and people in
cities can get -T-.B. •
♦
Good and bad people can get T.B.
-*
Men, women
T.B.
and
and
old
.children
get
i.
T.B. can affect many parts of the
body but most people having T.B.
have T.B. of the lungs.
4.
Can T.B.
another ?
spread from
one
person
to
APRIL
1984
can get
Yes.
HEALTH FOR THE MILLIONS
body in the village who has T.B. A
person who takes treatment regu
larly does not spread T.B.
to
others.
How does T.B. spread ?
5.
*
T.B. germs are present in the
sputum, pus, urine, faeces of a
person having T.B.
*
When a healthy person comes in
contact with these ' germs, that
person may get T.B.
7.
*
*
*
6.
If a person having T.B. does not
cover his mouth when he coughs,
the healthy persons near him may
get T.B. germs in their body.
If a person
with
T.B. spits
anywhere like the road, market
place, or the court yard of his
house, the healthy people there
may get T.B. germs in their body.
What are the signs of T.B. in adults ?
*
Cough lasting for -more than 4
weeks,
especially - just
after
waking.
*
Chronic weight loss.
*
Mild fever,
evening.
*
There may be chest pain.
*
Blood may
sputum.
especially
be
present
in
the
in
the
Usually when T.B. germs get inside'
a healthy person’s body, the germs
die. But sometimes the T.B. germs
remain alive in some people and
can cause T.B.
How can we stop the spread of T.B. >
' We can stop the spread of T.B. by
observing, .the following:.
*
Person with T.B. must always cover
his mouth when he coughs.
*
Person with T.B. should never spit
on the floor or open place.
*
Person with T.B. must
covered container and
sputum every night.
spit in a
burn the
should have a
separately for
*
Person with. T.B.
plate and glass
him. ■
*
He should
glass.
*
No one else should use the plate
and glass of a person having T.B.
*
As long as the person with T.B.‘
has a cough, the person should
sleep separately
from his family.
•z
*
T.B.is very contagious. Know the
symptoms of T.B. and locate every-
use only that plate and
10. Vithoba did not'want his
children to catch tuberculosis.
So he slept on the verandah
until his cough and sputum went
away. Then the children did not
have to breathe the air when he
coughed.
After
taking
his
tablets every day for 8 weeks
his sputum disappeared and cough
was much less. But doctor said
that he must take treatment for
18 months or the disease would
come again, worse form. If this
happened, the doctor said that
it would be difficult to cure
him then.
...pg 39
HEALTH FOR THE MILLIONS
APRIL 1984 .
In advanced cases:
8.
*
The doctor will know if you really
have T.B.’ by asking about the
signs and symptoms.
*
Coughing up blood
*
pale, waxy skin
*
Examining you physically.
*
voice grows hoarse (very serious)
*
Asking you
done.
* .
Asking you to have an x-ray of the
chest done.
*
Finding out if anybody else in
your family, neighbourhood or work
place has T.B.
*
Asking you
you do.
*
Children with T.B.
cough or mild fever.
*
The most important sign in child
ren having T.B. is loss of weight,
even if the child is eating well.
may not have
If a child who eats well does not
gain weight for two successive
(one after the other)
months,
always suspect T.B.
12.
In a small child, T.B.
is very
dangerous and can kill the child.
T.B. is curable. If you have any
of the signs of T.B. seek medical
help.
Early
cure.
treatment ensures
T.B. is curable, yet millions die
from T.B. every year. If you know
the signs of T.B. and are on the
lookout for them you will be able
to take early treatment.
where can you get treatment for T.B ?
*
All primary Health Centres and sub
centres treat T.B. patients.
*
All municipal and public hospitals
treat T.B. patients.
*
Most voluntary health centres also
treat T.B. patients.
Your CHW will guide
nearest T.B. Clinic.
you
cure T.B.
/
It takes at least 12-18 months to
cure T.B. completely.
*
Your symptoms will disappear after
2-3 months of treatment. But, you
are not completely cured. The T.B.
germs are still inside your body.
The treatment has made the T.B.
germs weaker but has not killed
them completely.
*
To kill the T.B. germs completely,
you will have to take treatment
for 12-18 months.
*
If you take treatment regularly,
T.B. is completely curable.
What will happen if
taken regularly ?
is
not
i
to the
How will the doctor/nurse know that you
really have T.B ?
treatment
If you do not take complete and.
regular treatment, all the T.B.
germs in your body will not die.
So even if your symptoms
(ie
cough,
fever)
have disappeared,
you still have T.B.,
and the
symptoms may reappear.
*
*
★
to
complete
13.
10.
take
*
Why should you know the signs of T.B ?
__ ____
38
a sputum test
about the type of work
How long does it
completely ?
The CHW will advise you on what to
do.
11.
get
What are the signs of T.B in children?
*
9.
to
14.
'
If you stop treatment before you
complete the full course, you may
develop T.B. again.
If a person takes treatment sometime
and does not take treatment other times •
•HEALTH FOR THE MILLIONS
APRIL
1984
is it dangerous ?
*
*
Yes. If a person with T.B. takes
treatment sometimes and does not
take treatment other times, the
person can become very ill.
The T.B,. treatment is effective
only when the drugs are taken
continously. If the patient stops
and starts treatment the drugs can
sometimes loose their effect. This
is very serious, then^only very
costly drugs will be able to cure
T.B.
Always inform your doctor or CHW
before hand if you cannot collect
the drugs for the days you will be
unable to attend the T.B. clinic.
15.
Is it necessary for a' person
T.B. to stay in a hospital ?
*
he always
.coughing,
covers
his mouth while
*
he always
snezing,
covers
his
*
if he works in a dusty atmosphere
he should cover his mouth and
nose.
nose while
19. Does a T.B. patient need to take milk,
eggs, fish and meat ?
*
.These foods are not necessary for
a T.B. patient.
*
If he can afford it, he should eat
it.
*
If he cannot
affort it, he should
who has
No. A person who has T.B. can be
looked after at home.
16.
What care should the family members
take if one of them has T.B. ?
See question 6 above : How can we
• stop the spread of T.B. ?
Also :
17.
*
Keep the patient in a room where
, there is lots of sunlight and
fresh air.
*
All family members should take a
sputum test (or x-ray) to find out
if they have T.B.
How soon can a person
bak to work ?
who
has T.B. go
He can go back to work as soon as
his symptoms have disappeared and
a sputum test shows that there are
no T.B^ germs in his spit.
18.
Are there any precautions a T.B patient
should take while at work ?
1
He should•ensure that
*
he does not spit in a public, open
place,
HEALTH FOR THE MILLIONS
1
•V
APRIL 1984
The- doctor asked Rukhmani to
bring the children for checkup.
He found Krishna and Shoba both
healthy. To help protect them
I from tuberculosis he gave the
children BCG injections. These
injections
are given on the
shoulder and do not .cause fever.
Vithoba had been off work for
two months. They had very little
money left. Vithoba decided they
could not afford to have another
child;
They were happy with
their two healthy children. So
Vithoba
decided to ask
the
.‘doctor about family planning.
...pg
41
39
eat a lot
every day.
of the foods he
eats
If you get T.B. after you have
taken BCG, usually the TB will be
easier to cure. You must come
early and take treatment regu
larly.
20. Do people die of T.B ?
Yes, many people in our. country
die of T.B. every year. If they
come -for treatment early and take
treatment regularly, they will not
die but become cured.
23.
the
patient
The CHW should tell the
having T.B. that :
person
What should a CHW tell
about treatment ?
21. What can you do to avoid getting T.B ?
c
1
if the person starts treatment
right away, the person will be
cured,
*
after a few months of treatment.
the person’s symptoms will disap
pear and the person will feel
stronger. Don’t stop treatment at
that time.
BCG is available at all muncipal
and other public hospitals.
*
Treatment for T.B. takes a long
time, at least 12-18 months.
Your CHW will inform you where BCG
is available.
*
Treatment for
regularly .and
tion.
*
the person should continue to take
treatment till the doctor says to
stop.
A BCG vaccination will protect you
from T.B.
*
Anybody
tion.
*
The BCG immunisation are available
at all Primary Health Centres.
*
*
•
1
• *
*
can
take
a BCG vaccina-
J'
t1
£
■
22. Does BCG always protect you from T.B ?
•
*
No,
some people get T.B.
even
though they have taken BCG.
I.
•
.
.
T.B. must be taken
without interrup
—
B CG
r
1
B.C.G. stands for Bacillus Calmette Guerin. B C G is a living bacillus but
differs from the tubercle bacillus in its being harmless. In other words, the
tubercle -bacillus is so changed that in the form of BCG, it loses the power to
produce disease but retains the power to produce anti-bodies. Calmette and
Guerin were the two French scientists who achieved this by making the bovine
tubercle bacillus grow repeatedly on a special medium containing bile for 13
years, till it was unable to produce disease even in a guinea-pig.
.
In order to remove some of the difficulties of storage and transport, freeze
dried vaccine is being now used, and can be used within three months of
manufacture.
If BCG is given to an uninfected child, a small nodule appears in 7 to 10
days at the site of vaccination.
It grows bigger, a small pustule forms which
later on breaks and in about 3 to 4 weeks time there is a small ulcer which
heals in about 3 months’ time. This is the normal reaction which most children
get after vaccination.
If, however, an infected child is vaccinated, the nodule
and ulcer are formed very quickly (Koch's phenomenon).
i
j-’.
-
•
’
It has been found that if uninfected children are given BCG, the chance of
their developing the disease is reduced by about 80%. Millions of children all
over the world have been vaccinated and it has been proved beyond all doubt that
BCG is harmless and can be safely recommended even for new born babies.
'
I,
;
v
40
HEALTH FOR THE MILLIONS
APRIL
1984
News from the States
West Bengal
"Drugs Vs Peoples Health"
•
A one day seminar on "Drugs vs Peoples
Health" was organised-by the WB VHA on 16th
March- at • Max Muller Bhavan, Calcutta. The
seminar
was attended by Dr. Zafrullah
Chowdhury,
of • Gonosasthya
Kendra,
Bangladesh who was invited as the guest of
honour. Speaking on the occasion.
Dr.
Chowdhury said that India with its large
complement of . scientists
and qualified
people was in a better position to formulate its own drug policy. It was ironic
that the Hathi Committee report which had
inspired Bangladesh's drug policy had not
been implemented in India.
voluntary sector in the implementation of
the various programmes initiated by/ the
Government.
Mr. Singh welcomed the proposal of Mr.
D'Souza
to
form a joint consultative
committee. He said that it will be a
positive step towards formalising the coop
eration between the. voluntary health sector
Dr, Mira Shiva, Coordinator, Low Cost Drugs
and Rational• Therapeutics, VHAI,- stressed
the . need to safeguard health as a human
*
right and pointed out that essential drugs
based on the health needs of the majority
—were—not-be-ing_jgiv_en_priority in produc
tion, distribution or even prescribing^-----
Bihar
The 16th General Body meeting and one
day seminar on the National Health Policy
were the major events of February 1984. Mr. .
Averthanus
.D'Souza, Executive Director,
Voluntary Health Association of India, who
delivered the keynote address on the theme,
"National Health Policy and its implementa
tion", suggested1, in his talk that to ensure
better ’ participation of. the
voluntary
health
sector, ' a
joint
consultative
committee should be set up. This committee
would facilitate the planning of operatio
nal strategies and help to remove adminis
trative bottlenecks.
12.
After
a few months of
treatment Vithoba is back to
work, feeling much stronger. He
I is not so thin. He has gained
several -kilos weight. Rukhmani
makes sure that he takes his
tablets regularly. She does not
want this disease to come back
again. She wants Vithoba to take
the tablets for 18 months as the
doctor said.
...pg
45
Minister of
/Mr. Brij Kishore Singh
State for Health, in his inaugural address
pleaded for the active cooperation
of
HEALTH FOR THE MILLIONS
APRIL 1984
41
11
and the Government of Bihar. He promised to
examine this proposal favourably.
The National Health Policy was discu
ssed with special consideration being given
to reorientation of Health Education and
training,
low cost drugs and rational
therapeutics,
nutrition and mother
and
child health care.
There was a panel of 5 speakers. Dr.
Ramaiya from Kurji Holy Family Hospital,
Patna,
shared ,his views on the present
education
and
training
system.
Dr.
Sathyamala and Sr. Lorraine spoke about
Mother'and Child Health Care, Ms. Sibane
Chakraborthy from Calcutta presented her
research paper on Nutrition,
and
Mr..
Majumdar, General Secretary, Federation ofMedical Representative Association of India
highlighted the drug situation
in India.
Fr. Britto briefly shared his views on the
indigenous system of medicine.
■
I
I
I
.
•
Training Programmes:
The second programme in the series on
"Social Security Legislations" was held on
27th January at the Rajagiri College of
Social Sciences, Kalamasserry. Twenty dele
gates from Ernakulam and Alleppey Districts
attended the programme where the legisla
tions dealing with Provident Fund, Grat
uity, Minimum Wages and Maternity Benefit
were discussed. One more programme in the
same series will be arranged at Quilon for
the southern districts, in May 1984.
The KVHS Secretariat is busy organising
a one day panel programme on the entire
procedures related to import and customs
clearance of equipment and supplies. The
first course will be arranged at Ernakulam
and the faculty will consist of senior
officials from the customs department and
also from non-governmental agencies.
Andhra Pradesh
■
COCONUT WATER USED IN
DETECTION OF TUBERCULOSIS
Directory
‘f
Kerala
. . .
:
•
•
.
■
.
■
The AP VHA Directory is ready to be
released. This is an effort—tG—bring..- dll-~.
the___heaJrth—care—institutions and health
related organisations in the
voluntary
sector in Andhra Pradesh, into one compen
dium. It is felt that this directory will
have value for the voluntary organisations
themselves and also prove useful to the
state government.
Office centre :
AP VHA has managed to get a site for an
independent office at Secunderabad. It will
be adjacent to the new CHAI office and is
about 4 km from Secunderabad station. The
new centre would be ready by 1985.•
Coconut water which is usually
discarded has now been used in
the Philippines to develop CEM
or Coconut Water Egg Malchite
Green Medium, one of the prim
ary tools in mass detection of
tuberculosis. CEM was found as
efficient as the Lowenstein
Jensen medium which is normally
used in a TB bacteriology ser
vices < Using 1976 prices, a
laboratory using LowensteinJensen medium spent US$ 59
while only US$ 7.60 or 1/8 th
of the former is needed for
CEM.
Study
AP VHA is making a study of cultural
practices of mother and child care to
assist in planning appropriate health care
delivery systems in the rural areas.
- The Cocomunity Newsletter
Vol. II No. 12 June 1981.
HEALTH FOR THE MILLIONS
APRIL
1984
VHAI INFORMATION SERVICE
Further Reading on T.B..
*
(6)
BOOKS
(1)
.
Tuberculosis Case-finding & Chemo
therapy Questions and Answers
by Toman K
World Health Organization, Geneva,
Switzerland
1979 ; 239 pg ; Price Rs. 15.00
Diagnosis, Treatment and Prevention
of Pulmonary TB for General Practi
tioners
.Tuberculosis in Children
(7)
The Tuberculosis 1 Association of
India, 3 Red Cross Road, New Delhi
110001; 18 pg
Handbook of TB
(2)
(3)
by Miller, E J W
Churchill
Livingston,
London, UK
1982 ; 294 pg.
~
by S P Pamra,
Tuberculosis Associatibn of India,
3 Red Cross Road, New Delhi-110001; .
1980 ; 110 pg.
JOURNALS
Introduction to Tuberculin Testing
and BCG Vaccination
fl)
Indian Journal of Tuberculosis
Periodicity : Quarterly- '
Published by : TB Association of
India, Red Cross Road, New Delhi
Annual subscription : Rs. 50.00
by Shashidhara, A N
IBH Prakashan, Bangalore
1980 ; 119.pg
(4)
•
Pulmonary Tuberculosis
(2)
by Menon, MPS
National
Book Trust,
Park, New Delhi-110016.
pg; Price Rs. 23.25
•
(5)
<
A-5 Green
1983 : 254
X
by Rao K N & others (ed)
,2nd Revised .edition
Vikas Publishing House Pvt Ltd,
5 Ansari Road, New Delhi -110002
1980 ; 607 pg ; Price Rs. 30.00
APRIL
1984
s
*
American
Diseases
Review
of
Respiratory
Official journal of the American
Thoracic Society
Periodicity : Monthly
Published from : 1740 Broadway, New
York, N Y 10019
Textbook
of Tuberculosis - The
Tuberculosis Association of India
HEALTH FOR THE MILLIONS
Edinburgh,
(3)
Tubercle - 1919
Longman•Group Ltd, Journals Divi
sion, Fourth Avenue, Harlow, Essex,
England
43
A 4) Tuberculosis 1963-1977
(8)
Periodicity
Quarterly
Published toy!: International Union
Against Tuberculosis, 3 rue Georges
Ville, 375116 Paris France
ARTICLES AND RESEARCH REPORTS
Summaries
* Studies
Tuberculosis
book 1978
Control of TB
11 nos
English
Audio Visual Unit, CMC Hospital,
Vellore
632 004, Tamil Nadu
(2)
Tuberculosis
Madras
Prevention
Domiciliary
rapy
Trial,
FLIP CHARTS
10 nos
Hindi
TB Association of India,
3,
Cross Road, New Delhi 110001
(1)
Natural History of childhood tuber
culosis - the characteristics of
Childhood TB”'
(TbNH)
Rs 24/- (colour slides)
(2)
Pathology of Tuberculosis in Child
hood - Macroscopic and Microscopic
TB - A New Thrust (article)
(bp)
Rs 24/- (colour slides)
Principles of Internal Medicine
Tuberculosis * is
of 15 slides
George W & Thorn (edited)
1977 : 900 pg
(D-81)
Rs 15/- (Black and White)
(3)
44
Red
SLIDES
INDIA TODAY
November 30, 1982 : pg no 49
(7)
Tuberculosis Control
Problems of TB in Indian Children
by Gopal Sharan
Tropical Doctor, July 1979,
pg 104-5
(6)
(1)
Tuberculosis Chemothe
Indian Journal of Medical Research
(special issue)
Vol 73
(suppl)
April 1981
ICMR, New Delhi
. (5)
Tuberculosis is Curable
15 nos
English & Hindi
VHAI, C-14 Community Center, SDA,
New Delhi - 110016
OR Foundation 'for Research in Comm
unity Health, 84 A,
R G Thadani
Marg, Bombay 400018
Research Centre Hand
Indian Journal of Medical Research
(special issue)
Vol 72 (suppl) July 1980
ICMR, New Delhi •
(4)
Dia
FLASH CARDS
Indian Council of Medical Research
Spur Tank Road,
Chetput, Madras
600031
(3)
Genital
of National TB Institute
Volume One July 1976 and Volume One
July 1977 (Yearly abstracts)
Published by : National TB Insti
tute,
DGHS,
8
Bellary
Road
Bangalore 560003
(2)
Male
Journal of Indian Medical Associa
tion
'
January 1983
(1)
(1)
Tuberculosis,
gnosis
curable
HEALTH FOR THE MILLIONS
-
a set
APRI'L
1984
AGENDA FOR THE NATION - THE NEW 20 POINT PROGRAM
ITEM 14 - Control of TB, Leprosy and Blindness.
During the Sixth Plan period the scheme for establishment of TB
centers and TB beds has been included in the state sector.Under
the centrally sponsored sector/ material and equipment and anti
TB drugs are being supplied to the district TB centers
located
in states ona 50:50 sharing basis and to the TB centers located
in Union Territories as 100% sponsored. Anti-TB drugs run by vo
luntary bodies are being supplied as a 100% centrally sponsored
scheme.
Booklet./20 point Program
»
....
I
13.
18 months go by. Vithoba
visits the doctor for a final
checkup. The doctor is pleased
and-say s-tha t—Vi thoba_ .is comp la
tely cured. This doctor says is
because he has taken his tablets
every day. for 18 months. He has
no. cough or sputum. He has no
fever. His appetite is good. He
can work all day without getting
tired. Vithoba
knows
he is
cured.
HEALTH FOR ’THE MILLIONS
APRIL
1984
14. Vithoba is glad. The child
ren are not going to get TB.
He
is glad they did not have more
than two .children. '• Vithoba’s
doctor had-ftold him the truth.
Vithoba knew that he was alive
and well now because he had
taken his tablets daily for 18
months. The TB would not come
back. He was happy to be able to
work. The whole family is happy
and healthy again.
VHAI INFORMATION SERVICE
Facts on File
TABLE
I
\
TARGETS AND ACHIEVEMENTS
OF BCG VACCINATION•DONE DURING
(in Lakhs)
1982-83
Age-wise Performance (Years)
SI.
No.
State/UT
Target
Achieve
ment (%)
1
2
3
1.
Andhra Pradesh
2.
Below
year
1 -4
5+
Total
Round
4
5
6
7
8
13.0
130.6
Assam
3.50
86.9
3.
Bihar
5.00
142.9
4.
Gujarat
12.00
99.75
5.
Haryana
5.00
83.8
6.
Himachal Pradesl1 2.00
30.4
7.
Jammu & Kashmir
2.00
87.5
8.
Karnataka
10.00
31.4
9.
Kerala
6.00
96.7
10. Madhya Pradesh
9.00
34.6
11. Maharashtra
17.00
199.6
— 0.30
40.0
13. Meghalaya
0.20
114.8
14. Nagaland
0.10
280.0
15. Orissa
5.00
101.0
16. Punjab
*
6.00
73.1
17. Rajasthan
8.00
54.5
*
18. Sikkim
0.07'
169.3
2.84
(16.85)
0.24
(7.74)
0.64
(9.0)
7.32
(61.15)
1.18
(28.16)
0.28
(46.55)
0.50
(28.57)
1.21
(38.48)
1.74
(30.00)
0.74
(23.80)
15.20
(63.51)
0.02
(16.66)
0.04
(15.53)
0.05
(19.44)
0.33
(6.51)
1.73
(39.51)
0.68
(15.66)
0.01
(9.93)
12. Manipur
#
9.22
4.81
(54.63)
(28.52)
1.15
1.66
(37.80)
(54.56)
2.14
4.32
(30.17)
(60.83)
2.56
2.09
(21.39)
(17.46)
1.32
1.69
(31.50)
(40.34)
0.30
0.02
(49.67)
(3.78)
0.53
0.72
(30.29)
(41.14)
0.66
1.27
(21.04)
(40.48)
0.76
3.30
(13.10)
(56.90)
1.06
1.31
<34.03)
(42.17)
on
7.92 , — n . or.
(33.08)
(3.41)
0.05
0.05
(41.67)
(41.67)
0.12
0.08
(33.12)
(51.35)
0.08
0.14
(50.87)
(29.69)
1.48
3.24
(29.37)
(64.12)
0.68
1.95
(44.40)
(15.45)
1.30
2.37
(29.90)
(54.44)
0.02
0.04
(18.90)
(32.19)
16.88
3.04
7.10
11.97
4,19
0.61
1.75
3.14
5.80
3.12
23.93 '—
0.12
0.23
0.28
5.05
4.39
4.36
0.12
Age-wise Performance (Years)
SI.
No.
State/UT
Target
Achieve
ment (%)
1
2
3
19. Tamil Nadu
*
Below
year
1 -4
5+
Total
Round
4
5
6
7
8
13.00
92.35
0.30
66.6
21. Uttar Pradesh
18.00
131.1
22. West Bengal
12.00
34.0
23. A & N Islands
0.02
163.5
24. Arunachal Pradesh 0.05
131.6
25. Chandigarh
0.15
126.6
26. D & N Haveli
0.02
132.6
27. Delhi
1.8
138.3
28. Goa Daman & Diu
0.20
109.0
29. Lakshadweep
*
0.01
200.0
30. Mizoram
0.14
61.01
31. Pondicherry
0.14
116.1
2.61
(21.73)
0.05
(24.18)
3.33
(14.09)
0.92
(22.50)
0.01
(30.08)
0.03
(51.86)
0.03 •
(15.0)
0.02
(55.86)
0.33
(13.30)
0.04
(20.22)
0.003
(15.00)
0.04
(39.22)
0.04
(28.64)
6.44
(53.62)
0.13
’(65.50)
18.44
(78.. 14)
2.86
(69.80)
0.005
(15.53)
0.02
<32.72)
0.07
(38.23)
0.001
(5.92)
0.36
'(14.49)
0.01
(5.54)
0.007
(35.00)
0.03
(35.38)
0.01
(5.04)
12.10
20. Tripura
2.09
(17.39)
0.02
(10.32)
-1.83
(7.77)
0.31
(7.61)
.0.02
(54.39'
0.01
(15.42)
0.09
(46.77)
0.01
(38.22)
1.71
(68.66)
0.16
(74.14)
0.002
(10.00)
0.02
(25.-40)
0.11
(66.32)
Total : 1982-83
150.0
. 92.84
41.16
(29.58)
40.03
(28.76)
57.04 139.26
(41.66)
1981-82
150.00
90.49
29.35
(21.56)
31.86
(23.62)
74.27 135.74
(54.82)
1980-81
150.00
86.89
15.. 25
(11.70)
24.89
(19.10)
90.20 130.34
(69.20)
#
G.20
23.60
4.09
0.03
0.06
0.19
0.03
2.49
0.22
0.02
0.10
0.16
=
Data from 4/82 to 8/82 only.
=
Age wise break up not available for 2814 vaccination for Punjab 4618
for Sikkim, 862 34 for Tamil ' Nadu, 8836 for Delhi and 1174 for
Lakshadweep figures in bracket indicate
% population to total
population.
HEALTH FOR THE MILLIONS
APRIL
1984
I
TABLE
II
Statement showing State/UT - wise estimated number of
T.B patents,.
SI.
No.
1
2
1.
2.
3.
4.
5.
6.
7.
8.
9.
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Himachal Pradesh
Jammu & Kashmir
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Nagaland
Orissa
Punjab
Rajasthan
Sikkim
Tamil Nadu
Tripura
Uttar Pradesh
West Bengal
•
16.
y
Al.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
•
-j'j
Name of State/U.T.
Estimated
X-ray cases
(in lacs)
Estimated
Sputum cases
(in lacs)
4
3
8.05
3.0
10.50
5.10
1.95
0.60
0.90
5.55
3.80
7.80
9.45
0.25
0.25
0.15
4.00
2.55
5.10
0.10
7.25
0.30
16.65
8.20
■
2.00
0.75
2.60
1.25
0.50
0.15
0.25
1.40
0.95
1.95
2.35
0.05
0.05
0.05
1.00
0.65
1.25
0.05
1.80
0.10
4.15
2.05
•
UNION TERRITORIES
23.
24.
25.
26.
27.
28.
29.
30.
31.
j
I
1
—
A & N Islands
Arunachal Pradesh
Chandigarh
D & N Haveli
Delhi
Goa Daman & Diu
Lakshadweep
Mizoram
Pondicherry
0.03
0.09
0.08
0.02
0.90
0.15
0.01
0.08
0.08
0.01
0.02
0.02
0.005
0.22
0.04
0.005
0.02
0.02
Total
102.94
25.71
Source : Lok Sabha Question - Answer Dec 1, 1983 no 1442
'
48
health
FOR THE MILLIONS
APRIL
1984
TABLE
III
TREATMENT FACILITIES AVAILABLE FOR TREATMENT OF TB PATIENTS 1982
SI .
No .
Name of State
Union Territories
1
T.B Demonstration
Centres
2
1. Andhra Pradesh
2. Assam
3. Bihar
4. Gujarat
5.
Haryana
6. Himachal Pradesh
7. Jammu & Kashmir
8.
Karnataka
9.
Kerala
10. Madhya Pradesh
11. Maharashtra
12. Manipur
•______ i.
13. Meghalaya
—x
T-/!
na
1 a nH
*4 -•----- Wja
iNcxy
exxcxiin
15. Orissa
16. Punjab
. .
17. Rajasthan
18. Sikkim.'
19. Tamil Nadu
20.v Tripura
21. Uttar Pradesh
22. West Bengal •
..
Total No.
of other
TB Clinics
District
T.B
Centres
Number of
T.B. Beds
3
4
5
6
1 ’
1
2
1
—
1
1
1
1
1
27
8
. 18
6
6
10
5
5
12
2
2
6
2
4
41
20.
102
22
10
25.
■19
9
8
9
19
10
45
26
____ 2 2
1
13
10
26
1
15
2
56
16
2699
799.
1799
3388
275
643
705
3445
2199
1699
7149
iio
304
100
1
801
921
2018
90
3609
50
3437
5948
1
1
—
4
—
10
3
—
2
3.
1
1
—
1
1
—
1
1
17’
329
353
1
1
. 1
1
1
1
2
27
1
•’ /.
UNION TERRITORIES
23. Andaman & Nicobar
Islands .
24. Arunachal Pradesh
25. Chandigarh
26. Dadra &■Nagar Haveli
27. Delhi
28. Goa Daman & Diu
29. Lakshadweep
30. Mizoram
31. Pondicherry
—
1
—•
-
Total
Source : Health Statistics of India, CBHI, DGHS, 1983
hEALTH for the millions
APRIL
1984
67
.
182
10
—
1539
276
62
178
.44502
■I
TABLE
IV
Recommended dosages of Anti-Tuberculous Drugs (I.U.A.T 1982)
DOSE
Drug
i. I.N.H (H)
Action
Daily
Phase
Intermittent
Phase
Adverse
Reactions
12-15 mg/kg
maximum
700mg
Polyneuritis
Rarely hepatitis
and Psychosis
9-12 mg/kg
*
maximum
600mg
Same as
in daily
phase
Hepatitis
30 mg/kg
maximum
2 gm
50 mg/kg
maximum
3 gm
Arthralgia
20 mg/kg
maximum
1 gm
Same as in
daily phase
Giddiness/
deafness
Bactericidal 5-8 mg/kg
maximum
300mg
2_ Rdfamoicin(R)
—do—
f’Cv
, >
3. Pyrazinamide(Z) -do-
; ♦
4. Streptomycin(S) -do-
r"
’
—
< •
5. EthaIPj?utol (E) Bacterio.— ic
•
6. Thiacetazone(T)
-do-
25 mg/kg
40 mg/kg
for 6 weeks maximum
15 mg/kg
thereafter
2 gm
150 mg **
- •
—*«■ -- ___•
z
——- - -- Skin reaction
and hepatitis
Rarely, exfolia
tive Dermatitis
5 gm B.D
**
-
Anorexia
vomiting
Diarrhoea, etc.
8. Ethionamide/
-doProthionamide (N)
250 mg
**
-
Anorexia,
nausea,
vomiting.
Diarrhoea, etc.
9. Cycloserine (C)
250 mg BD **
7. PAS (P)
-do-
!
-do-
••
Epileptiform
convulsions.
Psychosis.
■
*
Usual daily use for adults is 450 mg if the patient’s weight is less than 50
kg, and. 600 rhg if the weight is 50 kg or above. Dose for children is adjusted
suitably. In intermittent phase, usual dose for adults is 600 mg.
★*
Maximum adult dose.
'
/
For
’
'
children
and
under-weight
adults,
reduce
dose
proportionately./
x-,
X.
50
Optic
neuropathy
\
HEALTH FOR THE MILLIONS
APRIL
1984 z
-
TABLE
V
Suitable Regimens for Treatment of Pulmonary Tuberculosis
(I.U.A.T 1982)
Conventional
SHT daily for 2 months plus
SHP
SHT
HT daily for
10 months
Total Duration
12 months
ii
ti
ii
II
II
HP daily for
10 months
Total Duration
12 months
ii
it
it
II
II
SH biweekly
10, months
Total Duration
12 months
''
Short -course
SHRZ for 2 months plus
:
■ -
RH daily for
4 months
Total Duration
6 months
it
it
II
it
RH biweekly for
4 months
Total Duration
6 months
EHRZ w
it
It
it
RH daily for
4 months,
Total Duration
6 months
EHRZ
II
it
II
ii
RH biweekly for
4 months
Total Duration
6 months
SHRZ
II
ii
II
it
SHZ daily for.
4 months
Total Duration
6 months
SHRZ
II
ii
II
it
HT daily for
6 months
Total Duration
8 months
RHZE
Thrice weekly
for 6 months
Total Duration
6 months•
RHZS
Thrice weekly
for 6 months
Total Duration
.6 months
SHRZ
N.B
Intermittent chemotherapy should
of every dose.
only
be given under full supervision
Source : Lectures on TB for General Practitioners - Tuberculosis
India.
HEALTH FOR THE MILLIONS
APRIL 1984|
- -■
Association of
TABLE
VI
drug' REGIMENS
Recommended in National Tuberculosis Programme
a) For sputum positive TB patients
Code
No.
Drugs and Dosage
Mode and Rhythm of
administration
Instructions
R
Isoniazid 300 mg +
Thioacetazone 150 mg
Both drugs in a
single dose ’or in
two divided doses
orally, daily
Self-administered
at home after meal.
Collected monthly
from DTC/PHI
Inj Streptomycin
0.75 g / 1 g.+
Intramuscularly
Isoniazid 600 to
700 mg (15 mg/kg
body weight) with
Pyridoxine 10 mg
Orally
Both drugs given in
the same time under
supervision at DTC/
PHI twice weekly at
intervals of 3 and
4 days.
Isoniazid^ 300 mg +
PAS 10 g.
In a single dose.
In two divide doses
Both drugs orally
daily
Self-administered at
home after meal.
Collected monthly
from DTC/PHI
Isoniazed 300 mg +
Ethambutol 20 mg/kg
body weight,i.e
800 mg for pts.
weighing
50 kg
and 1200 mg for
50 kg
Both drugs in a
single dose, daily,
orally
Self-administered at
home after meal.
Collected monthly
from DTC/PHI
1
BI WEEKLY REGIMEN
R
2
R
:
3
R
4
BIPHASIC REGIMEN
a. Intensive phase
Inj.
Streptomycin
0.75 g/ 1 g +
R
- Isoniazid 300 mg +
Thicacetazone 150. mg
5
or Ethambuto 20 mg
. per kg body weight
i.e.800 mg for pts. ,
weighing 50 kg and
1200 mg for those ,
50 kg or PAS 10 g.
b. Continuation phase
First two months
Intramuscularly.
daily
In a single dose
orally, daily.
(PAS and Thioaceta
zone may be given
in two divided
doses)
Injection given
under supervision
and the rest to be
self-administered at
home.
Remaining period
With Rl, R2, R3, or R4 As for each,regimen As for each regimen
Cont’d on next page
HEALTH FOR THE MILLIONS
APRIL 1984
b) For the sputum negative TB patients (Suspect cases)
TB patients in whose sputum AFB arc not seen, are proscribed Regimen R1 i.o.
Single done orally
daily for 1 to 1) years
Isoniazid 300 mgm *
Thioacetazone 150 mgm
Patients, allergic to Thioace tri zone can be treated with R4
Duration of Treatment
All patients should bo treated for a minimum of 1 year or optimum of 11 years
duration irrespective of their disease status. By duration of treatment for 1
year to 1} years is meant that intensive efforts should be made to keep the
patient on regular treatment for atloast one year. Even if patients at the
end of one year are regular, treatment should be continued upto 18 months in
order to prevent relapses.
Treatment can be continued upto 2 years after review at the end of 18 months
but continuation beyond two years has no added advantage.
From:
National TB Institute, BANGALORE-560 003
TABLE VII
COUNTRY'S REQUIREMENTS OF TB DRUGS (METRIC TONS )
Si.NO.
Name of the Drug
79-80
80-81
8.1-82
82-83
83-84
84-85
1.
STREPTOMYCIN
300
330 •
363
400
440
485
10
2.
RIFAMPICIN
5.4
7.3
9.8
13.3
18.0
24.0.
5
3.
I N H
200
240
290
300
415
500
20
4.
PAS
600
630
660
700
730
770
5
5.'
THIACETAZONE
40
42
44
46
48
50
5
6.
ETHAMBUTOL
60
78
101
132
170
225
30
7.
PYRAZINAMIDE
8
8.4
8.8
9.3
9.7
10.2
5
HEALTH FOR THE MILLIONS
APRIL
1984
Increase
TABLE VIII
PRICES OF IMPORTS
(Rs. in iakhs)
78-79
79-80
80-81
1.
Streptomycin
280.12
274.20
123.69
2.
INH
12.43
11.90
3.06
3.
Rifampicin
95.26
311.11
448.2
4.
Ethambutol
223.7
322.17
92.50
SOURCE
:
Mr.
B.R. Verma,
Senior Investigator, E & S Section (Drug
Sector) , Ministry of Chemicals and Fertilizer, Government of
India, New Delhi.
TABLE IX
PRODUCTION OF TB DRUGS
a.
b.
c.
Imports
(Metric Tons)
80-81
1. Streptomycin
76.12
72.82
44.01
2. INH
23.8
26.2
6.8
3. Rifampicin
1.7
5.4
8.9
4. Ethambutol
66.2
96.1
29.1
Local (Metric tons - larger companies like HAL, CADILLA)
1. Streptomycin
220.7
220.1
227.3
2. INH
81.72
112.53
129.20
3. Ethambutol
10.18
23.58
24.87
Small scale sector (see NOTE Below)
1. Streptomycin
not produced ....
...
2. INH
-
41.8
150.5
3. Ethambutol
-
0.7
10.1
SOURCE :
54
79-80
78-79
Mr. B.R. Verma,
Sector)
Ministry
India, New Delhi.
Senior Investigator, E & S Section (Drug
Government of
of Chemicals and Fertilizer,
, HEALTH FOR THE MILLIONS
APRIL
1984
LIST OF RESEARCH CENTRES
3.
Dr. H.P. Basu,
Honorary General Secretary,
Bengal TB Association (P.O. Entally)
24, Dr. Sundari Mohan Avenue,
CALCUTTA - 700014
4.
Dr. A.A. Mallick,
General Secretary,
Bihar TB Association,
Abedin Building, 1st Floor,
North Wing, Frazer Road,
PATNA - 800001
5.
Dr. M.M Singh,
Honorary General Secretary,
Delhi TB Association,
Rajan Babu TB Hospital,
Kingsway Camp,
DELHI - 110009
AND ASSOCIATIONS OF TUBERCULOSIS
1. Tuberculosis Research Centre
Spur Tank Road
Chetput
Madras - 600031
TAMIL NADU
Tel. 665425 (5 lines)
2. National Tuberculosis Institute
Director General of Health Services
No. 8, Bellary Road
Bangalore - 560003
KARNATAKA
—
3. Tuberculosis Association of India
No. 3, Red Cross Road
NEW DELHI - 110001
6.
Dr. Damodar Bhounsule,
Honorary Secretary,
Goa, Daman & Diu TB Association,
18th June Road,
PANAJI, (GOA)
7.
Dr. S.H. Patel,
Honorary Secretary,
Gujarat State TB Association,
F/6, Saraswati Apartments,
Opp. Gandhigram, Rly. Station,
Ellis Bridges,
AHMEDABAD - 380006
8.
Dr. O.P. Dehar,
Honorary Secretary,
TB Association of Haryana,
36, Madhya Marg, Sector 7-C,
CHANDIGARH - 160017
9.
Dr. D. Umapathy Rao,
Honorary General Secretary,
TB Association of Andhra Pradesh,
3-4-760, Barkatpura,
HYDERABAD - 500027 (A.P.)
Dr. Tahir Mirza,
Honorary Secretary,
TB Association of Jammu & Kashmir,
Opposite Chest Disease Hospital,
Dalgate,
SRINAGAR (KASHMIR)
10.
Honorary Secretary,
Himachal Pradesh TB Association,
Kennedy House,
SIMLA - 4. (H.P.)
Dr. L.N. Chintey,
Honorary Secretary,
TB Association of Meghalaya,
Police Bazar,
SHILLONG - 793001
(Meghalaya)
11. Dr. T. Manickam,
% Honorary Secretary,
Karnataka State TB Association,
No. 3, Union Street,
BANGALORE - 560001
4. Dr. S.P. Gupta
Assistant Director General
of Health Services (Tuberculosis)
Room No. 350, 'A' Wing
Nirman Bhavan
NEW DELHI - 110011
Tel. 385993
5. Dr. Aneja
New Delhi TB Centre
Jawahar Lal Nehru Marg
NEW DELHI - 110002
LIST OF STATE TUBERCULOSIS ASSOCIATIONS
1.
2.
HEALTH FOR the MILLIONS
APRIL
1984
*
*
•
i •
1
55
12.
Dr. N. Siyanandan Pillai,
Honorary Secretary,
TB Association of Kerala,
TH Centre,
Rod Crcww Road,
TRIVANDRUM - 1. (KERALA)
13.
Dr. D.P. Verma,
Honorary Secretary,
Madhya Pradesh Stntc TB Association,
TH Hospital,
Idqah Hi IIn,
BHOPAL (MADHY/i PRADESH)
Dr. K.C. Mohanty,
Honorary Secretary,
Maharashtra State Anti-TB Association,
O.H.T. Clinic,
Jarbai Wadia Road,
Scwrce,
BOMBAY - 400015
14.
15.
Prof. Harihar Das,
Honorary Secretary and Treasurer,
TB Association oi Orissa,
Health Directorate,
BHUBANESWAR - 751001
(ORISSA)
16.
Dr. V.K. Padmanabhan,
Honorary Secretary,
TB Association of Pondicherry,
TB Chest Clinic,
PONDICHERRY - 605001
17.
Dr. K.K. Gambhir,
Honorary Secretary,
TB Association of Punjab,
Red Cross Bhavan,
Sector 16-A,
CHANDIGARH - 160017
18.
Dr, T.N. Sharma,
Honorary Secretary,
Rajasthan State TB Association,
Hospital for Chest Diseases,
Bani Park,
JAIPUR - 302006
(RAJASTHAN)
19.
Dr. L. Venkata Vittal,
Honorary Secretary,
Anti TB Association of TAmil Nadu,
259-61, Anna Salai,
MADRAS - 600006
20.
Sh. B. Ganesan,
Organising Secretary,
Anti-TB Association of Tamil Nadu,
259-61, Anna Salai,
MADRAS - 600006
56V v
21,
Dr, N, Dob Barman,
Honorary Secretary,
TB Association of Tripura,
AGARTALA - 799001
22. Dr. M.M.S. Siddhu, M.P.,
Honorary Secretary,
Uttar Pmdesh TB Association,
1-A.P. Sen Road,
LUCKNOW (UTTAR PRADESH)
23.
Dr. J.N. Bhuyan,
Honorary Secretary,
TB Association of Assam,
L. G. B. Chest Hospi ta1,
GAUHATI
(ASSAM)
Shri R. Narayanan,
Development Commissioner, & Secretary,
Sikkim Anti-TB Association,
G.M.C, Building,
GANGTOK (SIKKIM)
25. Dr. M.S. Aqnihotri,
Hony. Jt. Secretary,
Uttar Pradesh TH Association,
1-A.P. Sen Road,
LUCKNOW (UTTAR PRADESH)
24.
26.
Shri S.S. Sangal,
Deputy Secretary,
Uttar Pradesh TB Association,
1-A.P. Sen Road,
LUCKNOW (UTTAR PRADESH)
TB SEAL ORGANISATIONS
1.
The Administrative Officer,
Andaman & Nicobar Administration,
Directorate of Medical & Health
Services,
PORT-BLAIR - 74-4104
(A & N ISLANDS)
2.
Dr. M.C. Murry,
Assistant Director of Health Services,
(BCG),
Government of Nagaland,
KOHIMA.
3.
Dr, N, Kala Singh,
Secretary,
Manipur TB Association,
Lamphelpat,
IMPHAL - 795004
(MANIPUR)
4,
Dr, D.D, Nimawat,
Organising Secretary,
Medical & Health Services,
JAIPUR (RAJASTHAN)
HEALTH FOR THE MILLIONS
APRIL
1984
Milestones in Tuberculosis
TB lesions found on 3000 year old Egyptian mummies
Hippocrates (460-370 B C) Father of Medicine First described TB
1865
Jean-Antoine Villemin, French Militry Vet.
by inoculation.
1882
German Physician Robert Koch discovered TB Bacilli on April 24.
Surgeon experimented transmission of TB to animals
1890
Robert Koch produced Tuberculin
1895
Roentgen—X-ray of chest
1905
Koch was awarded Nobel Prize
1910
Koch died
1921
French scientists A Calmette and C Guerin discovered BCG
1944
Selman A Waksman and colleagues (USA) discovered streptomycin; Waksman received Nobel
Prize in 1952
1945
PAS, INH, highly effective and cheap drugs appeared
1948
First mass vaccination campaign by Scandinavian Red Gross Society
1956
Domiciliary treatment of TB proved effective
1964
Twice weekly chemo-therapy treatment introduced
1966
Rifampicin proved excellent against TB
SOURCE: World Health, WHO, January 1982
Landmarks : National Tuberculosis Programme
1906
The first TB Hospital in India—in Tilaunia
(near Ajmer) Rajasthan, founded by a Christion Mission.
1951
Mass BCG Vaccination Campaign intro
duced in India.
1955
National Tuberculosis Sample Survey.
1917
First Tuberculosis Clinic in Madras by Dr
Chandrasekhara Aiyer.
1956
Establishment of
*
Tuberculosis
therapy Centre, Madras..
1928
First Intracutaneous BCG vaccination
India by Dr A. C. Ukil—West Bengal.
in
1959
Establishment of National Tuberculosis
Institute (NTI), Bangalore.
1929
King George Thanks-giving Anti-TB Fund
started.
1962
1939
Tuberculosis Association of India was esta
blished.
Establishment of New Delhi TB Centre (as
a Model TB Clinic)
Evolvement of District Tuberculosis Progra
mme at NTI and its acceptance on country
wide basis.
1975
Constitution of. Expert—Committee
evaluation of TB Programme.
1977
Involvement of Multi-purpose Health Work
ers-in case--finding, '"treatment /and BCG
vaccination activities.
1940
1948
Establishment of BCG Laboratory, Guindy,
Madras BCG vaccination introduced in
India.
SOURCE : Swasth
d, June 1982.
Chemo
for
i
In India
600, 000 people die annually of TB
4,000,000 people are infectious
12,000,000 people suffer from TB
Nearly 50% of the children are infected by the age of 14
Nearly 90% of the population is infected by the age of 24
Nearly 60% of all Indian TB patients drop out of treatment
An untreated case has an average survival time of 2 years:
During this time he/she infects 20-25 more individuals
The central government has allotted Rs. 2 crores to fight TB
The Sixth Plan outlay is Rs. 7 crores
Actually, Rs. 55 crores is needed for the National TB Programme
The number of TB cases is increasing.
For Private Circulation Only
«...
ft
-
CHRISTIAN FELLOWSHIP
COMMUNITY HEALTH CENTRE,
Santhipuram, Ambilikkai-624612
Dindigul Anna Dt. Tamilnadu.
Present Hospital frontage
- Christian Fellowship Community Health
Centre is run by a registered charitable society. It
was established quarter of a centuary ago by a
group of Indian Christian Youth at Ambilikkai, a
remote village in Dindigul District where there
was no medical or educational facility. It was an
adventuie in faith relying on God almighty to supply
the
needed resources. Objective is to serve
the rural poor and the sick irrespective of caste,
colour or creed in the sp rit of Jesus Christ and to
improve the quality and life style of
the
oppressed and suppressed people in the area by all
possible ways and hoping to achieve total develop
ment of the place so that poverty and ignorance will
be wiped out.
Hospital campus in the sixties
LOCATION
Ambilikkai is on the Oddanchatram-Dharapuram
Road 7 Kms from Oddanchatram. It is in the low
ranges of beautiful Kodai hills, about 35 km from the
famous temple town of Palani. Though Ambilikkai
is in the Dindigul Dt, it is surrounded by Madurai,
Coimbatore & Periyar Districts of Tamil Nadu.
The C.F.C.H. Centre campus with an area of 100
acres is called Santhipuram and the medical and
educational institutions are spread out on it. Most of
the Staff are also given quarters in the same campus.
ACTIVITIES
Medical & Health - Main activity is the
C.F.C.H. Centre Hospital with 300 beds with General
medical. Surgical,
Peadiatric, Obstetrics and
Gynaecology, Cancer, Tuberculosis, Leprosy and
Opthalmology units. 200 more beds are under
construction to accommodate surgical and medical
patients.
Coba It Tele Therapy Unit
Specialists are
available in the major
disciplines. Basic facilities like a 1st class Laboratory
Pharmacy, X-ray, diagnostic and therapy, U/S and
Scopies are available to patients.
ASSOCIATED EDUCATIONAL ACTIVITIES
Under the Dr. MGR. Medical.. University, the
Post Graduate diploma courses in Nutrition & Health
& Development.
Health and Development Institution
and School and College of Nursing
COLLEGE & SCHOOL OF NURSING
Library, Hostels, playground etc are available to
students. Many young people are trained for the
last 20 years in the Community Health field.
Mini Health' Centre
Community Health activities through the 24
mini Health centres spread over the Oddanchatram
Panchayat Union, area and around, t C. F. C. H. C
Hospital is the referal centre for these village
units. Rural development programmes are integrated
with the health activities. General Education " in
English medium is .imparted through the Christian
Matriculation Hr. Sec. School Oddanchatram.
Christian Matriculation Hr. Sec. School
The<e is a Tamil medium Shanthinikethan Hr See
School at Ambilikkai. Altogether about 2300children
are studying in these 2 schools. Balwadies tooare
run by the society in areas where no Government
feeding centres are available.
TECHNICAL EDUCATION is
given
through
the
Christian Institute of Technical Education (Poly
technic) and the I.T.I. More than 300 young.
people are getting job oriented training through
these institutions and there by better opportunity
for Employment is opend,
Santhinikethan Hr.Sac. School
SETTLEMENTS ARE ESTABLISHED for landless poor
ha<ijans at Bethelpuram, Siruvattukadu, C. Nagar
and Kari/ampatty. Foundation for the Home for the
aged and blind has been laid at Kallimandayam
by Bro. Dhinakaran.
WITH NATIONAL PROGRAMES.
The society co-operates with all the National
Health schemes like family welfare, Literacy Pro
gramme, Leprosy Eradication, Tuberculosis control
Programmes for both the Government of India,
and government of Tamilnadu.
VISION FOR THE FUTURE is mainly to consolidate
what is established' Super speciality like cardiothoracic surgery, urology. Nephrology, other units
are in the minds of the younger members of the
fellowship. Eradication of Tuberculosis, Leprosy and
unemployment in this area is in the heart of the
founders. 40 acres of land has been acquired for an
Arts and Science College at Oddanchatram under
the same society and it will soon be a reality.
STATISTICS
I.M.R.
Leprosy privilance rate
T. B. privilance rate
Birth rate
Death rate
Immunisation rate
Family planning acceptors
1960
160/1000
25/1000
35/1000
35/1000
18/1000
25%
10%
1992
50/1000
1.6/1000
2.3/1000
17/1000
7/1000
95%
70%
LITERACY RATE
Men
Women
1960
30
15
1992
49
35
MORAL, RELIGIOUS AND SOCIAL ACTIVITIES
Realising the fact that there is
no use
uplifting the community without infusing moral
and spiritual values, the society has appointed
a team of dedicated people to spread the good
news and to save people from moral degradation
drinking, smoking, dowry problems and neglect
of children.
IMPROVEMENT OF WATER
FECILITIES OF THIS AREA
AND
HOUSING
Nearly 40 check-dams and number of tube
wells were made in the project area. Nearly 1500
families were helped for house construction.
On the average
200 young men are helped
with jobs
after
technical and professional
trainings every year.
Our thanks to all the friends, Indian and foreign for
their support and above all to God the almighty
who gave the inspiration to come to this needy area
and who has upheld us in all our venture, inspite
of our failures. To Him be the glory for ever and ever.
BHARATH CHARITABLE HOSPITAL,SARGUR
(Sponsored by Lions Club of Sarg.ur& B.C.CH.(.Trust)
LAB REPORT
Date
Lab No:
Age:
Name
PID No
Stool and Urine Complete Analysis
STOOL
URINE
1 Colour
Colour
2 Consistency
Appearance
3 Reaction
Sp. Gravity
4 Mucos
Reaction
5 Blood
Albumin
6 Occult blood
Sugar
7 Reducing substance
' - -- -- ---- •
!
'"'Acetone
- Fr—....... ......... ....................
------------ .
Bile Salts
Bile pigments
Uro Bilinogen
MICROSCOPIC EXAMINATION
Pus cells
Pus cells
RBS
Epithelial cells
Ova
Bacteria
Cyst
j*
Crystals
Larva
Casts
Amoeba
Flagellates
Flagellates
Others
Bacteria
Pathologist - B.C.H.
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, • Why TB has remained an intractable problem despite a ' >“
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Read in reports based on in-depth, field based research studies conducted
> by an inter-disciplinary team of researchers for projects funded by the
;
World Health Organization (WIIO), Geneva and the
International Development Research Centre flDRC)? Canada
<
The foundation for Research in Community [Health
Tackling TB : The Search for Solutions
Mukund Uplekar, Sheela Rangan
This book is based on a research study carried out to understand why
tuberculosis continues to remain an intractable problem. The approach
is simple — identify all the actors and activities concerned with tuber
culosis control in an area and study them closely. And study not just what is being
done, how and by how many but also why! Interestingly, literature does not cite any,
such single study that comprehensively examines in the same setting and at the same'
time, every major aspect of tuberculosis control. And it is this approach which brings
out from the study, not only the overt weaknesses within the various programme func
tions and the functionaries, but also the covert reasons of why the weaknesses have
persisted throughout. The study begins with the people and ends with the people,
highlighting all the man-made advantages and obstacles that advance and impede
them from reaching the goal of living a life free of tuberculosis. The origins of these
obstacles, by themselves, prompt solutions — short term and long term, as well as
superficial and deep. Like most studies several more issues and areas for research also
emerge.
< Prt.ges.-200 < Price .-Rs 100
Tuberculosis Patients and Practitioners
in Private Clinics
Mukund Uplekar, SanjayJuvekar, Sudhakar Morankar
Eighty percent of the qualified medical personnel in the country are in
private sector and an estimated 60 percent of TB patients seek care at
private clinics. And yet the private sector is uninvolved in the National Tuberculosis
Programme. Also, virtually no pertinent information is available either on TB patients
in private clinics or the private medical practitioners who manage them. What Ls the
help seeking pattern of TB patients in private clinics? How are they diagnosed? What
treatment do they receive? Do they adhere to the treatment prescribed and to the doc
tors who prescribe it? And how do private doctors delect, treat and ensure adherence
of lung TB patients in their clinics? This report is based on a study undertaken to seek
answers to these questions hitherto unanswered.
• Pages : 30 ' • Price : Rs 15
<
Non Governmental Organisations in Tuberculosis
Control in Western India
Sheela Rangan, Aditi Iyer, Susbma Jhaueri
Though the efforts of voluntary organizations in health are known and
ackowledged, their role in tuberculosis control has not been well docu
mented. This study of non governmental organisations(NGO) working in health and
TB in Maharashtra and Gujarat gives an account of the extent and variety of anti-TB
services provided by NGOs. The study also provides an in-depth analysis on NGO
approaches to TB control and their effectiveness and discusses ways to strengthen
their contribution to the national TB control efforts.
• Pages : 125 • Price: Rs 75
Urban Tuberculosis Control : Problems and
Prospects
(Ecl)• AK Cbakraborly, Sbeela Rangan, Mukund Uplekar
Communicable disease control in cities poses a great challenge due to
various problems peculiar to urban settings like overcrowding, muIti■ plicity of health care providers, prominent for-profit private sector, and migrant popu
lations. All these, compounded by the recent emergence and rapid rise of HIV in cities,
complicate further the scenario of tuberculosis control in urban areas. This book, the
first compilation on the subject, puts together useful material of high practical rele
vance. Tuberculosis experts including programme planners and managers,
researchers, representatives of voluntary organizations and private medical practition
ers present their analyses of the situation based on ground realities, experiments and
actual experiences — past and present — in urban settings as diverse as Delhi,
Bombay, Bangalore and Hyderabad. Several pointers that emerge from the discussions
form the elements of a cohesive strategy for tuberculosis control in urban areas.
* Pages - 150 . • Price: Rs 75
Tuberculosis Management in Everyday Practice
This booklet presents in a simple and clear manner what every practic
ing doctor ought to follow in diagnosing, treating and curing patients of
tuberculosis. All aspects of pulmonary TB are touched upon including
emerging problems like multi-drug resistance and HIV-TB association,
as well as facilities available under the National Tuberculosis Programme, lists of NGOs
offering anti-TB services and periodicals and books for further reference. The informa
tion provided herein is a compilation of well-researched, nationally and internationally
recognized and recommended facts. For various reasons, many of these are either not
known to doctors or not put into practice.
• Pages : 75 • Price: Rs 50
About FRCH
The Foundation for Research in Community Health (FRCH) was
established in 1975. It is a non-profit, voluntary organization
which carries out research and conducts field studies to gain a
better understanding of the socio-economic and cultural factors
which affect health and health care services. FRCH’s larger aim is
to create a people’s health movement by demystifying medicine and
increasing public awareness. One of the areas of interest of the
Foundation has been tuberculosis. Using TB as a window, FRCH
has been trying to understand the social and operational problems
plaguing the health and health care services — public, private and
voluntary.
ALTHROCIN TABLETS
erythromycin estolate
250 mg & 500 mg tablets
The greatest artist was once a beginner.
AiemD,c
ALTHROCIN PAEDIATRICS
erythromycin estolate
chewable tab., kidfab., liquid & drops
L(jJ.k^2>x0^—
Pay attention to your enemies/for they are the first to
cjgcover your mistakes.
£iemt”c
HERMIN
INFUSION
essentia! amino acids
for parenteral nutrition
To know what Io do Is wisdom. To know how to do it is skill.
To do It as it should be done is service.
Aie>r»t’*c
*.
Phene
260-01553
Gteme :
HOSPITAL, AMBIL'KKAI.
—
CHRISTIAN FELLOWSHIP COMMUNITY HEALTH CENTRE,
(Registered Charitable Society S. No.
42, of 1979
OBC.
dated 17-10
78)
*
(I, T. 12-A. No.O of 21-4
79)
*
Santhipuram,
Ambilikkai-62461?,
Dr. Jaoote Gherian bsc; FRCs.(Ed)
MBBS., FRCS.(Gt)., F13S., FACS., FIGA.
Sireeter & Chief Surgeon.
Anna Dist.
Dr. Mrs. Mary Charian frcp (64)
MBBS.. DMCW., FRCP. (GI)., DCH.,(LON)
Asco. Director & uhief Physician
STATISTICS OF CHRISTIAN FELLOWSHIP COMMUNITY HEALTH CENTRE
TB
CONTROL AREA FOR LAST 10 YEARS
1985
1995
303
148.
87 %
93 %
Tb Prevalence
3.2
1.2
Tb Incidence
1.6
0.5
No. of Patients in our area
% of patients who
■ XV
STATISTICS OF CHRISTIAN FELLOWSHIP COMMUNITY HEALTH CENTRE
HOSPITAL FOR LAST 10 Yrs
Year
Out Patients
1985
1931
251 .
1986
2095
226
1987
2321
227
1988
3187
186
1989
3466
101
1990
2957
158
1991
2091
139
1992
2603
192
1993
1825
191
1994
2133
212 __
Inpatients
CHRISTIAN
FELLOWSHIP
SHANTHIPURAM,
AMB1LIKKAI-624612.
ANNUAL NEWS LETTER-1994
Dear Friends,
Christmas is again with us reminding us of God's
love for each one of us. Though we see bribery,
corruption, inflation, violence, degradation of moral and
ethical standards all around us, and sickness, sorrow and
death of loved ones and our experience, let us like the
Psalmist declare His loving kindness in the morning and
His faithfulness every night. Let us spend more time in
prayer and studying the Word of God in the New year so
that we gain strength to stand against the evils in this
world.
NEWS FROM THE
VARIOUS CORNERS OF OUR
INSTITUTION
The main hospital work is going on well as shown
by the hospital statistics for the year 1994.
GENERAL
TUBERCULOSIS
LEPROSY
CANCER
O.P 51,963
In-patients
4,103
2,133
2,246
3,946
212
575
977
Total: 56,066
2, 345
2, 821
4,923
The new Surgical block with 3 operation Theatres,
a Surgical
ICU
and a special
ward
was
inaugurated by the Hon'ble central Minister for social
Welfare Sri. K V. THANGABALU, The Vice Chancellor of
Dr. M.G.R. Medical University Dr. B.P, RAJAN, presided
over the function.
The Indian Medical Council has recognised our
Institution for Dip. N.B, in Family Medicine and for
General Surgery. You may be knowing that Dr. Jacob
Cherian has been doing Closed Mitral Valvotomy operation
rom1970 onwards. This year a new dimension was added
when our
visiting
Cardio - Thoracic
surgeon
did
V.S.D.
Corrections
Dr. Daniel Issac and his team
on 2 little children.
Major Surgeries done :
300
(Including 1. Closed
Mitral Valvotomy
& 2-V.S.Ds)
Minor Surgeries
: 610
r
o
.
Cataract ; 181
Eye Surgeries
,
a
Others :
36
Dr. Jacob Cherian our Director received the
National Award for "THE BEST EMPLOYER OF THE
HANDICAPPED" for this year from the Presitdent of
India on behalf of the Institution.
The O.P.D. also has been shifted to the beautiful &
spacious new block, thanks to the untiring efforts of our
dear "Mathaehen" and those who helped him. It was
dedicated by Rev. K.T. ALEXANDER at the time of the
Annual Society meeting in August.
The Society meetings were held in the Christian
Matriculation School this year and Dr. Prasad Cherian
and Mrs. Meema Cherian were inducted as Asso.
Memebers. Mr. V.T. Chandapilla and Bro. Varadharaj
attended as advi ors.
Our congratulations to the following staff for
getting admission in C.M.C. Vellore.
Dr. Oby Cherian. for M. Ch (Urology)
Dr. Thomas Joseph for D.M. (Nephrology)
Dr. Thomas Paul for M.D. (General medicine)
Miss. Bindu Abraham for M.Sc (Nursing)
We are glad to welcome Dr. Shantha Fredr.ick who
has joined as our Obstetrician and Gynaecologist and
Dr. Jeyanthi,
Dr. Cenita Sam,
Dr. Mathias Arthur
Dr. Prem Navaz, Dr.Sivamani & Dr. Robert Kennady who
joined as Junior Doctors in 1994. We say Good bye to
Dr. Sathyanarayanan who helped us for nearly 2 years.
We do need a good Christian Physician, Surgeon and
an Anaesthetist urgently.
RESEARCH ACTIVITIES
Dr. Rajkumar & his team have done a study on
Iodine deficiency Disorders in Dindigul Anna District
and discoverd an unexpected prevalance of about 30%
in certain pockets of our Project area
A Cancer Cervix screening
programme was
launched in our project area about 4 months back and
Dr. Rajkumar is doing
it
with the
help of
Dr. P. Krishnakumar our Radiotherapist and Dr. Shantha
Fredrick our Gynaecologist. About 652 Pap smears
have been taken so far from our area.
Many of
our
Doctors
attended
conferences and meetings during the year.
various
COMMMUNITY HEALTH WORK IN THE
MINI HEALTH CENTRES
Are going on with the encouragement and
supervision
of
Dr. Rajkumar,
Mr. Jayaraman,
Mr. Ponnusamy, & Mr. Sakthivel. The total No. of
patients who attended the 24 Mini Health centres this
year is 1, 74, 346.
An extensive Leprosy control programme is going
on in our project
area under the leadership of
Mr. Santhiago.
Dr.' Chandrashekaran professor of Community
Medicine, Sri. Sidhartha Medical College, Tumkur gave
guest lectures to our staff & Students in early December.
SOCIAL & DEVELOPMENT ACTIVITIES
This year 30 new houses were constructed and
about 61 houses were repaired for the poor villagers in
our area with the help of World Vision of India. The KNH.
World Vision and other hostels continrue to help rural
Children
as in the
previous
years,
thanks to the
dedicated service of the Wardens and Teachers.
The Leprosy Rehabilitation school and the Dairy
and Agricultures projects continue to do very good work
under the leadership of Mr. Abdul Abraham and
Mr. Alangaram respectively.
Our CORD Press is also doing excellent work
under the leadership of Dr. Selwyn Ebenezer and
Mr. Immanuel Panchacharam.
EDUCATIONAL ACTIVITIES
THE TRAINING INSTITUTE with the Community Health
Guide course and the University P.G. courses in Nutrition
of Dietetics & in Health & Development & Rural
deveolpment are running well
and
are enabling
many to get employment in India and abroad. Miss. Annie
Mathai has joined as lecturer in Nutrition and Dietetics.
THE SCHOOL & COLLEGE OF NURSING
Continues to impart excellent Nursing education
under the able Leadership of Ms. Salome Kandasamy. The
Number of seats have been increased to 50. Additional
rooms have been added to the hostel. The results in the
university examinations for the various semesters have
been very good.
CHRISTIAN MATRICULATION HIGHER SECONDARY
SCHOOL At Oddanchatram is at the threshold of its
Silver Jubilie year. This year also we had 100% success
in the Matriculation Examination and excellent results
among the 1300 students in various classes.
THE SHANTHINIKETHAN
HIGHER SECONDARY SCHOOL
Hosted the annual sports for the Palani Educational
District this year in a grand scale. The results in the 10th
and 12th standard examinations were very good this
year also (97% pass in 10th Std and 85% pass in +2).
SPIRITUAL ACTIVITIES
The year started with a retreat for all the staff at
'Uppar Dam' Every one from ward aids to Doctors
enjoyed Prof. Barnabas's exhortations.
A Pastor's conference sponsored by the All India
Prayer Fellowship was held in our campus in November
Dr. P.N. Kurien and 3 pastors from U. S. A. led the
sessions and about 150 Pastors
& Evangelists
participated.
The Musical team 'Navodhaya' of FMPB enriched
us with their spiritual songs, messages and skits in
early December. We are grateful to Bro. Zac Punnen,
Bro. C. V. Samuel, Dr. Thomas Gnanamuthu and many
others who spoke in our chapel during the year.
Rev. E. Richard, Miss. A. T. Achamma, Dr. John
Mr Abdul Abraham and Mr. Immanuel Panchatcharam
& others continue to lead the religious work in the hospital
and in the campus as a whole.
Wedding bells chimed for
Mr.
Mr.
John Abraham & Miss Sheeba John
Durairaj & Miss Vasanthi (Helper, MPHW Hostel)
God blessed.
Mr. John Kutty & Shiela with a baby boy
Mr. Vinod Mammen & Anies with a baby boy
Mr. Mohan & Mahadevi with a baby girl
Mr. Dhanushkodi & Ramani with a baby boy
Mr. Aron & Rita with a baby boy
Mr. Ramasamy with a baby girl(Cook, Hospital Kitchen)
On this occassion we would like to convey our
heartfelt gratitude to the ALM, KNH, CBM. WORLD
VISION OF INDIA, CASA and our personal friends here
in India and abroad who have contributed so much to
the work in this rural area.
WE WISH YOU ALL
A VERY HAPPY CHRISTMAS
AND A BLESSED AND PROSPEROUS NEW YEAR.
DR.
PRASAD CHERIAN
For C. F. C. H. C & C. E. H & D
SOCIETIES
AMBILIKKAI.
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